Anatomy of a Procedure - Subclavian Cannulation

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Anatomy of a Procedure - Subclavian Cannulation

The subclavian central line, whether using an infraclavicular or supraclavicular approach can strike fear in the novice proceduralist. Big needles traversing near and seemingly towards a patients lung apex is not exactly a comforting vision. However, like with most procedures, a firm understanding of the anatomy at play will give the operator confidence as they approach what is a critical central venous access procedure particularly in crashing patients.

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Surrounded by Mysteries We Cannot Hope to Understand

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Surrounded by Mysteries We Cannot Hope to Understand

I.C. Cordes submissions arise spontaneously whenever I have something on my mind.  Usually they are concrete lessons in airway management, but recently I have done a lot of airway training and that tank is a little dry.  Hence, this is another foray into metaphysics as I stumble toward the twilight and navigate Erikson’s 8th stage of psychosocial development.

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The Anatomy of Femoral Vascular Access

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The Anatomy of Femoral Vascular Access

Prior to the widespread availability of point-of-care ultrasonography, invasive medical procedures were performed by the “landmark method”.  Landmark methods are based on surface anatomy, palpation, and sometimes trigonometry, and are fraught with the potential for error.  Complications, while unquantified in the misty past, were likely much more common than in the current era of readily available bedside imaging.  Vascular access procedures are inarguably safer and more successful when guided by sonography, but interpretation of ultrasound images still requires an understanding of both surface and deeper anatomy to relate the two-dimensional screen image to three-dimensional reality.  Further, there are circumstances where either the urgency of the resuscitation, or compromised access to the patient, requires that vascular access be obtained using landmarks rather than real-time imaging.  In such cases a detailed understanding of regional anatomy is critical to maximize procedural success and minimize complications.

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Airways, like Martinis, are Best "Dry"

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Airways, like Martinis, are Best "Dry"

Have you ever looked down the blade of a laryngoscope and said to yourself, “Damn!  This airway is just too dry!”  I thought not.  Rather, we often look down the blade into a mucky swamp of secretions that drip from the pharyngeal walls like drool from a big, sloppy dog, and often obscure familiar landmarks and goop-up our optical and video adjuncts.  Is there no solution?  There is!  Let us review an illustrative case...

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Favorite Positions!

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Favorite Positions!

Multiple casualties are brought to you from a house fire.  There are four victims:

  1. A 5’11” 70 kg woman with a GCS of 8
  2. A 5’9” 140 kg man with circumferential burns of the chest and neck
  3. A 20 month-old with a pedi-GCS of 10
  4. An elderly, 5’6” 65 kg man with no burns, but a history of severe CHF and complaining of chest pain and dyspnea

You determine that they all require intubation for various indications.  You choose RSI as the method for all except the morbidly obese patient, who you intend to intubate awake, with sedation and topical airway anesthesia.

Question:

How would you position each of these patients to optimize your chances of successful intubation on the first attempt?

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Nobody Expects the Spanish Inquisition! (or, for that matter, the Cormak-Lehane Grade 4 Laryngoscopic View!)

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Nobody Expects the Spanish Inquisition! (or, for that matter, the Cormak-Lehane Grade 4 Laryngoscopic View!)

A 68 year-old man presents by squad with shortness of breath.  He is noted to have a nearly quiet chest with very poor air movement, to be using accessory respiratory muscles, and to be slightly lethargic.  Quick perusal of old records discloses a history of severe COPD, steroid and O2 dependence, HTN and ulcer disease.  The squad reports that his O2 sat was 86% at the scene, improving to 92% on a NRBM and two nebs.

His vitals are:  p 138, r 22 and labored, bp 156/96, O2 sat 92% on a high-flow NRBM.  His POC renal returns with a pCO2 of 88.  His estimated weight is about 175 lbs.

A decision is made to intubate. 

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Oxygen is Good, Methods for Delivery Often are Not

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Oxygen is Good, Methods for Delivery Often are Not

An elderly patient with steroid and oxygen dependent COPD, and NYHA Class IV CHF, presents with dyspnea.  The patient is alert but looks somewhat desperate, confused, and exhausted.  Exam reveals accessory muscle use, grunting expirations, poor air movement, and cool clammy skin.  The patient speaks in two-word phrases.  Attempts to improve the situation are made with Lasix, nebulizers, and non-invasive ventilatory support.  The patient cannot tolerate BiPAP due to anxiety.

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Look Before You Leap - Awake Fiberoptic Intubation

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Look Before You Leap - Awake Fiberoptic Intubation

Look Before You Leap, Drive Your Ferrari Like it is a Wheelchair, Harken Ye to the Wicked Witch of the West!

A 37 year-old woman presents with stridor, drooling, tachypnea and accessory respiratory muscle use.  She has an adequate blood pressure, but is tachycardic to 120.  Her oxygen saturation on room air is a reassuring 97%.  She cannot answer questions, appears to have an altered mental status though she follows commands, and suddenly has a brief period of either myoclonus or seizure with unresponsiveness.  No post-ictal period is noted after this episode.

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The Decision to Intubate

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The Decision to Intubate

The I.C. Cordes College of Airway Knowledge, written by Dr. Steven Carleton, is known to many who have passed through our doors.  Today, however, we begin to set them free to the #FOAMed world starting off with I.C. Cordes #1 - The Decision to Intubate.  I felt like I had found a mint copy of the Amazing Fantasy Introducing Spiderman comic book or a Honus Wagner baseball card receiving these collected cases by email from Dr. Carleton earlier today. - Jeffery Hill, MD

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