April 22, 2014

Needle Cricothyrotomy

April 22, 2014/ Mike Steuerwald

Circumstances rarely are such where we must perform a surgical airway emergently. When we do, it is always for the same indication: you have a patient that you can’t intubate AND can’t oxygenate. In most cases where a surgical airway is required, a traditional open or Seldinger technique is preferred.

In children, however, these approaches are contraindicated (most authors describe age less than 10 or so as the cut-off). Thus, the needle cricothyrotomy is a procedure that we must be prepared to perform as emergency providers as this can be done in pediatric patients.

April 18, 2014

Intubating (not in the SRU)

April 18, 2014/ Jeffery Hill, MD M.Ed

Logistics are pretty much everything. A focus on logistics is what helps UPS deliver 500,000,000 during the holiday season. A focus on logistics is what helped the Allies win World War II. But logistics doesn’t just happen on the global, macroscopic scale. Logistics plays a role in every procedure we do in the ED and in the prehospital environment. If you only focus on learning the mechanics of physically performing a procedure, you are neglecting crucial steps that will help ensure your success. In this our latest podcast in the Air Care and Mobile Care Online Flight MD Orientation, Dr. Steuerwald and Dr Hill discuss some of the complicating factors for prehospital airways, focusing on both some of the logistical issues that come into play and some of the mechanical/physical considerations.

April 14, 2014

So You Want to Tomahawk Somebody?

April 14, 2014/ Jeffery Hill, MD M.Ed

If you took a listen to our last podcast or inferred from our most recent post, the "challenging airway" that was described was managed by way of a tomahawk intubation. As we discussed in the podcast, there were a number of different ways we could have elected to manage that patient's airway including intubation from the back of the stretcher with the patient seated upright, awake fiberoptic intubation (both nasotracheal and oropharyngeal with the assistance of a Williams airway), tomahawk intubation, or, as was suggested by one of the residents (nice suggestion Dr. Cousar) after our simulation (on the same case), through a bronch adapter hooked to a LMA...

April 11, 2014

What Makes an Airway Difficult

April 11, 2014/ Jeffery Hill, MD M.Ed

What Makes an Airway Difficult? In short, a lot of different factors play into making an airway difficult. In general, they can be broken down into anatomic, physiologic, and logistic. We'll cover some of the logistical issues that can complicate intubations on a later post (mostly with regards to intubation in the HEMS and prehospital setting).

April 02, 2014

The Levy Cup Cometh...

April 02, 2014/ Jeffery Hill, MD M.Ed

On this day of #EMConf goodness, we tease the upcoming day of Grand Rounds competition known as The Levy Cup. In 3 weeks time, the residents will pair off into teams in a battle of wits and skills. A round robin competition of procedural relay stations, simulations, trivia game shows, Cash for Cases (where the less money you spend on the patient, the more points you get) and some surprises I don't want to spoil here will pair the field down to 2 teams that will compete in the finale. Think SimWars gone crazy!

March 31, 2014

Oxygen is Good, Methods for Delivery Often are Not

March 31, 2014/ Steven Carleton, MD PhD

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.

March 25, 2014

Pericardiocentesis

March 25, 2014/ Jeffery Hill, MD M.Ed

First, pericardiocentesis should be considered a temporizing procedure. In the setting of trauma, you are hoping that the pericardiocentesis will clear a small amount of blood from the pericardial space and remove any tamponade the might be present. It is likely, however, because of the mechanism of injury, that blood will again rapidly accumulate leading to recurrent tamponade physiology. Ultimately (but not on Air Care — DON’T do a clamshell), these patients will need a pericardial window, exploration, and repair of whatever injury is causing the accumulation of blood.

March 24, 2014

Look Before You Leap - Awake Fiberoptic Intubation

March 24, 2014/ Steven Carleton, MD PhD

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.

March 21, 2014

Awake Fiberoptic Intubation

March 21, 2014/ Jeffery Hill, MD M.Ed

Like all procedures, success in the performance of an awake fiberoptic intubation comes from proper preparation. Preparation for this procedure means so much more than proper preparation of the patient (preoxygenation, positioning, local anesthesia, etc.). To be fully prepared is to have a well practiced, working knowledge of your equipment and the options you have in setting it up. To be fully prepared is to be practiced in the motor skills necessary to drive the scope, advance the tube and troubleshoot as you go.

March 19, 2014

Lessons in Transport - Plasma? We Got That...

March 19, 2014/ Ryan Gerecht, MD

Why is Air Care starting to transport and infuse plasma? Multiple studies, many from military combat zones, strongly suggest that clinical outcomes are improved by administration of plasma alongside RBCs in a 1:1 ratio. (1,2) Furthermore, the concept of damage control resuscitation advocates for minimizing crystalloid infusion and maximizing early aggressive resuscitation with blood products in patients with life threatening hemorrhage. Recent unpublished analysis suggests that expanding these resuscitation principles to the prehospital environment via helicopter EMS was associated with improved outcomes.

March 18, 2014

Lessons in Transport - Your Friend and the Bleeding Patient's Friend: TXA in trauma

March 18, 2014/ Jeffery Hill, MD M.Ed

TXA… What can be said about TXA that hasn’t already been said. TXA is good for what ails you.

Nosebleed? No problem.

Menorrhagia? TXA can fix that.

Involved in a motor vehicle crash with multiple pelvic fractures, a busted up spleen, hemorrhaging internally? TXA has your back.

In this podcast, Dr. Hill, Dr. Steuerwald, and Dr. Gerecht sit down and talk through the indications for using TXA in the prehospital environment and briefly discuss some of the evidence for its use.

March 14, 2014

Lessons in Transport - Cognitive Biases in Critical Care Transport

March 14, 2014/ Ryan Gerecht, MD

As critical care transport professionals we are often perceived as an action oriented specialty. We frequently pride ourselves on procedural excellence and efficiency. (a difficult intubation, or fast scene-time etc.) However, the reality is that we spend the vast majority of our patient care time engaged in cognitive behavior... in THINKING rather than acting!

Because of this, it is imperative that we make every possible effort to understand how we think while caring for others. In addition, we should be aware of some of the cognitive biases that threaten our thinking processes, decision making, and thus the patients who place their trust in us.

March 13, 2014

Drill, Baby, Drill

March 13, 2014/ Jeffery Hill, MD M.Ed

You need access? You need access right now? Drill, baby drill.

The EZ-IO is pretty ridiculously easy to use. The only real decision points in its use are what site to choose (humeral vs tibial) and what needle to use (pink, blue, or yellow). There are a couple of other nuances which we will cover below and in the embedded video.

March 10, 2014

Ultrasound in HEMS

March 10, 2014/ Jeffery Hill, MD M.Ed

Critics out there may slight the use of ultrasound in the prehospital environment, saying it is just going to delay patient transfer and won’t add much to your decision making. However, when used properly, the ultrasound should never delay patient care and, when used in the correct patient population, it could help greatly in both decision making and treatment. Let’s first talk about when to use it. The logistics of this may be a bit tricky.

March 01, 2014

Finger Thoracostomy

March 01, 2014/ Jeffery Hill, MD M.Ed

We talked about needle thoracostomy a while back and when we did, we talked about the propensity for the needle to fail. There are a lot of reasons why the needle could fail to relieve a tension pneumothorax (or to only temporarily relieve a tension pneumothorax). The needle may be too short to enter the thorax in the first place* or the catheter could kink, allowing reaccumulation of air in the thorax.

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SRU (pronounced "shrew") = Shock Resuscitation Unit

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