Is Tamsulosin actually useful for renal stone expulsion? Anand Swaminathan does a deep dive evaluation of the literature. You don’t want to miss this!
Medical Expulsion Therapy with Tamsulosin in Ureteral Colic Read More »
Airway management is one of the most challenging and critical skills that the emergency medicine physician must master. This is particularly true in the setting of the trauma patient, where the ABCs of trauma evaluation begin with establishing the patency of the airway and ensuring adequate oxygenation and ventilation before moving through the remainder of the trauma algorithm. It is well known that delays in adequate airway management are one of the most common causes of preventable death in both the prehospital and emergency department setting.
Management of the Trauma Patient’s Airway – Pearls and Pitfalls Read More »
A 64 year-old woman with past medical history of diabetes mellitus type 2 that is well-controlled on insulin, hypertension, and asthma presents with 1 week of shortness of breath and cough productive of blood-tinged sputum. The shortness of breath became suddenly worse about an hour ago as she was walking into your emergency department for evaluation and at that time she had symptoms of pre-syncope. She is denying chest pain, palpitations, diaphoresis, nausea, recent travel, or surgery. The patient takes both a beta-blocker and a calcium channel blocker to control her hypertension. She took all of her medications this morning prior to presentation. The patient has no personal history of cancer and there is no significant family history. She denies the use of tobacco, alcohol, or any other drugs.
Outpatient Treatment of Pulmonary Embolism Read More »
Rapid Sequence Intubation (RSI) is one of the most critically important skills for an Emergency Medicine physician to be able to perform quickly and accurately. All airway management in the emergency department is performed on the unstable patient, often with unknown co-morbidities and a full stomach. In recent years, standard medication choices for induction were etomidate and succinylcholine. While other medications were proposed and tried, several were avoided for hypothetical side effects that have not borne out in recent research. Arguably, the modern combination of ketamine and rocuronium has less significant complications, and provides a superior alternative to etomidate and succinylcholine.
Ketamine and Rocuronium: The New Etomidate and Succinylcholine? Read More »
From the understanding of physostigmine’s mechanism of action and the above data, we would like to summarize key points and recommendations regarding the use of physostigmine.
Physostigmine for Management of Anticholinergic Toxidrome Read More »
Featured on #FOAMED REVIEW 28TH EDITION – Thank you to Michael Macias from emCurious for the shout out! Author: Joe Rogers, MD (Senior EM Resident, Rutgers-NJMS) // Editor: Alex Koyfman, MD & Justin Bright, MD The following is a compilation of helpful tips for managing the airway in the emergency department. **EAR TO STERNAL NOTCH POSITIONING** Why do it? -Position yourself (and your patient) for success! -Universal position for both ventilation and intubation – Facilitates maximal jaw distraction and mouth opening – Independent of age and size, though especially helpful in obese patients Of note: – Contraindicated in context of known or suspected cervical spine pathology Technique: – Horizontally align the sternal notch with the external auditory meatus – The facial plane should be parallel to the ceiling; hyperextending the neck may worsen your view – In adults, the head usually needs to be raised; in infants, the torso may need to be raised **NASAL OXYGEN** Why do it? – Administration of high-flow nasal oxygen during pre-oxygenation and after RSI improves arterial oxygenation during apnea – High-flow nasal oxygen saturates the nasopharynx with oxygen, patients inhale a higher percentage of oxygen, and the oxygen reservoir in the lungs increases prior to apnea – Oxygen saturation can be maintained without respirations if a continuous path of oxygen is supplied from the pharynx to the glottis because alveolar oxygen absorption continues during paralysis (“apneic oxygenation”) – “NO DESAT”: Nasal Oxygen During Efforts Securing A Tube Technique: – During pre-oxygenation apply high-flow nasal oxygen at 15 lpm as well as a face mask at 15 lpm – 3 minutes is an acceptable duration of pre-oxygenation – Leave on high-flow nasal cannula during intubation attempts **BIMANUAL LARYNGOSCOPY** Why do it? -External laryngeal manipulation by the laryngoscopist is the easiest, fastest, and most effective modification to improve view Of note: This is not B.U.R.P or cricoid pressure (both of which are done by an assistant, neither of which are helpful) Technique: – Manipulation is most effective at the thyroid cartilage, where vocal cords attach anteriorly – Once the view is optimized, an assistant can maintain pressure at the right location, freeing the right hand to place the tube **HEAD ELEVATION** Why do it? – Improves visualization by enlarging space beneath tongue and epiglottis – Less force required for full laryngeal exposure – After bimanual laryngoscopy, head elevation is the second easily performed manipulation to improve laryngeal view Of note: – Like ear to sternal notch positioning, head elevation is contraindicated in context of known or suspected cervical spine pathology Technique: – Performed while holding the laryngoscope with the left hand – Lift the patient’s head at the occiput with the right hand, keeping the face parallel to the ceiling – When ideal view is achieved, release the right hand – If possible, briefly suspend the head with the laryngoscope and attempt intubation – If the head is too heavy, have an assistant support the patient’s head and shoulders **STRAIGHT-TO-CUFF STYLET SHAPE** Why do it? – Narrower long-axis dimension allows greater visibility – Better maneuverability within the hypopharynx Technique: – Ideal shape of styletted tracheal tube is straight to the proximal cuff, then ≤ 35 degree angle bend at the proximal cuff (> 35 degrees increases likelihood of mechanical impaction) – Use far right corner of mouth to insert and pivot tube – Tube stays below the line of sight until tracheal insertion – Keep tip visible as it approaches target – If tube catches on tracheal rings after insertion, rotate clockwise and advance tube **EPIGLOTTOSCOPY** Why do it? – The epiglottis is the first reliable anterior landmark at the top of the laryngeal inlet Technique: – Prepare suction to maximize anatomical clarity – Slide blade gently and slowly down tongue – Once the epiglottis is in view, move the tongue to the left and lift epiglottis edge off the posterior pharynx – If the epiglottis is not seen, blade may be too deep: slowly pull back until epiglottis drops into view – Advance blade fully into the vallecula – Create anterior pressure at the hyoepiglottic ligament, causing the ligament to pull the epiglottis forward to expose the glottis – Optimize glottic view with bimanual laryngoscopy and/or head elevation **PREDICTORS OF DIFFICULT AIRWAY IN ED** Most Helpful – Thyroid-to-hyoid less than two fingers Somewhat Helpful – Hyoid-to-mental less than three fingers – Airway obstruction – Poor neck mobility, cervical collars, spinal immobilization – Trauma, facial distortion, secretions, mandibular injury – Obesity – Large tongue, large teeth – Grade 4 Cormack and Lehane score – Correlates to hyoid-mental distance, thyroid-hyoid distance Not Helpful – Mallampati classification not practical in ED setting Bottom line: – Beware the short fat neck – Mallampati not helpful – “LEON” – Look externally – Evaluate 3-3-2 – Obstruction – Neck mobility **PEDIATRIC AIRWAY ANATOMY** The unique features of the pediatric airway persist until about age 8 or 9 years, then become more adult-like: Occiput – The head and occiput in children are proportionally larger than in adults – In supine position may cause neck flexion and airway obstruction – To achieve ear to sternal notch positioning, a blanket may be placed under the shoulders and torso Tongue – Child’s tongue is relatively larger – Lower muscle tone increases risk of passive airway obstruction; MCC airway obstruction in children – Can be managed by better positioning or use of an adjunct device such as oropharyngeal airway or nasopharyngeal airway Larynx – Larynx is more anterior and cephalad in children, C4 vs. C6 in adults – Vocal cords slant anteriorly – Bimanual laryngoscopy more likely necessary to visualize the cords; alternatively, the fifth finger of the left hand can be used to improve glottic visualization – Also may be helpful to lower oneself to below the level of the patient and look up at an angle when intubating Epiglottis – The pediatric epiglottis is floppy, long, and narrow – A straight blade (Miller) can more easily pick up the epiglottis to facilitate intubation in
Novel Tips for Airway Management Read More »