To provide a fuller education, our curriculum should occasionally bend from the scientific and technical and include matters of the heart. This is a case from the early 1990s, a time in this fair land when ultrasound was not part of emergency practice, when RSI was still a relatively fresh concept, when the treatment of shock was non-systematic, and when consultation was a matter of pleading on the telephone.Read More
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.Read More
Thanksgiving is over, now it's now to relive Halloween. Take another airway lesson from Dr. Carleton and his IC Cordes course. This episode he takes us through a terrifying Air Care case through the lens of the Difficult Airway Algorithm in a case of a bloody airway courtesy of a bullet through the oropharynx.Read More
You just got done with the most precarious of intubations, but while patting yourself on the back, you note that beeping saturation tone is continuing its decline. Did the tube get dislodged? Was it ever in the cords? Take a step into the plight of oxygen and pulse oximetry with our physiologic guru Dr Steve CarletonRead More
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...Read More
Multiple casualties are brought to you from a house fire. There are four victims:
- A 5’11” 70 kg woman with a GCS of 8
- A 5’9” 140 kg man with circumferential burns of the chest and neck
- A 20 month-old with a pedi-GCS of 10
- 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.
How would you position each of these patients to optimize your chances of successful intubation on the first attempt?Read More
There can be some confusion with regards to the terminology surrounding laryngoscopy. The term "video laryngoscopy" can be used imprecisely without specific attention paid to the geometry of the blade containing the video camera. The geometry of the blade, however, is crucially important as the biomechanics of laryngoscopy differ substantially depending on whether a standard geometry (Macintosh or Miller) blade or a hyperangulated blade is used. Below you will find specific definition of terms with regards to laryngoscopy and a video demonstrating the differences between direct laryngoscopy, standard geometry video laryngoscopy, and hyperangulated video laryngoscopy.Read More
Our good friend Jim DuCanto visited us earlier this year. We spent several days sharing knowledge and perspectives.
Part of our time together was spent recording this podcast. It has been simmering and is finally available for listening. Within, we briefly go through the history of the extra-glottic device (EGD) in general, and then, we talk about the Laryngeal Mask Airway (LMA) and its “descendants” in great detail.
Jim really had a tremendous wealth of knowledge to share…Read More
Let the record show, this is not a debate for or against the use of video cameras on laryngoscopes. It’s not really a debate at all. It’s a plea. An honest plea…
The “DL vs. VL” debate has been had. It will continue to be had as our research evolves and our tools evolve (and we will participate). But, I beg of us as a community to pause and collectively consider a point of order: our discussion and debate, and worse our education of novice critical care providers, and even worse our research, is becoming marred by the fact that we aren’t all speaking the same language. We often throw around terms without RIGOROUS attention to detail.Read More
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.Read More
Recently, one of our FOAMed friends came to visit the University of Cincinnati. Jim Ducanto is well known for his innovations and general wealth of airway management knowledge. One wonderful thing that Jim shared with us during his visit was an airway mannequin that he “modified” to be able to puke…yes…puke. Not sort of puke…but REALLY PUKE!! Here is what Jim has to say regarding the motivation for building the device as well as lessons we learned while doing it’s “beta-test”.Read More
Emergency airway management is being revolutionized. Think about it…those of us who are in training now are being exposed to some very different core skills. The big culprit is the recent advent of video laryngoscopy – not much argument there.
With that said, I will argue that almost as significant as the advent of video laryngoscopy from a general “airway management revolution” perspective is the philosophical change of many pre-hospital providers in that it is becoming the norm for extra-glottic devices to be placed primarily, or at least considerably more often than in the past.
It is likely that the rate of field placement of extra-glottic devices will become more common. Thus, we will probably see many more patients present to the ED in whom EMS has placed an extra-glottic. As we recognize the power of extra-glottic devices, I think that even the most advanced airway managers will use extra-glottic devices with more frequency to facilitate rescue oxygenation and ventilation.
This begs the obvious question: should we remove these devices after they are in and working?Read More
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.Read More
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.Read More
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.Read More