Grand Rounds Recap - 6/15/16


Trends in Airway Management

  • We have seen some interesting changes in airway management described by the NEAR Database (Brown et al. Ann Emerg Med 2015)
  • Over the past 15 years, we are starting to increase our use of ketamine and propofol as induction agent while etomidate continues to be king.
  • The use of succinylcholine has decreased as the use of rocuronium has increased and now have reached parity
  • The use of the direct laryngoscope has decreases as the video laryngoscope has increased and are reaching equivalence

Rate of Decline in Oxygen Saturation at Various Pulse Oximetry Values with Prehospital RSI found that the level at which people seriously desaturate is 93%, which means this is where we should probably get nervous (instead of 90%). Above that,  no desaturations.

According to a recent study, the best device to use for pre-oxygenation is a bag-mask device to achieve 100% FiO2 and get full nitrogen washout of the lungs (Groombridge et al. Acad Emerg Med 2016)

Changes in Mnemonics

We use our mnemonics to evaluate for potential difficulty in every airway. There are some changes coming down the pipe:

  • LEMON - No change (Hagiwara AJEM 2015
  • MOANS --> ROMAN (Radiation/Restriction, Obesity/Obstruction/OSA, Mask seal/Male sex/ Mallampati, Aged >55, No teeth)
    • Highest risk ratio for failure to be able to successfully bag a patient was having had radiation therapy (probably because the disease process for which you got radiation made your airway difficult)
  • RODS (Restriction of mouth opening or ventilation/ Obesity/Obstruction, Distorted anatomy, Short thyromental distance)
    • What is the singe most predictive factor for difficult EGD use? Thyromental distance of course


The 7 P's: we're throwing out pretreatment except in the case of decreased cardiac reserve such that you worry about the increased sympathomimetic effect of intubation where you should give 3 mug/kg fentanyl. It has been replaced by pre-intubation optimization where we mitigate adverse effects of laryngoscopy, RSI drugs...

The Ancient Art of Blind Nasotracheal Intubation

The management of a difficult airway can be quite challenging, especially in the absence of sophisticated fiberoptic intubation equipment, a common limitation in developing countries.
— Arora, et. al.
Air Care is a developing country
— Steve Carleton


  • When oral intubation is not possible
    • angioedema of the tongue
    • limited mouth opening


  • suspected midface/skull base fracture
  • coagulopathy
  • incompatible nasal anatomy (deviated septum, occlusive nasal polyps)
  • suspected pharyngeal/laryngeal trauma

Pooled overall success rates from 4 studies was 76.1%, the success rate in trauma was 75.5%. (though this is in the hands of skilled operators)


  • Decongest nares
  • liberal topical anesthesia to nares +/- throat
  • lubricate nares and tube
  • soften tube with heat
  • coil tube congruent with natural curvature,
  • Endotrol (trigger) tube if available

ClInicopathologic case with drs. plash and hooker

Dr. Plash presents a patient with an LVAD who presents for fever and back pain...

LVAD numbers to know

  • Pump speed (RPM): usually fixed and based on echo settings and "ramping studies"
  • Power (Watts): varies patient to patient (Power spikes may indicate obstruction)
  • Pulsatility Index: tells you how much cardiac output is from the pump itself
  • Pump Flow

case follow up with dr. lagasse

Acute Aortic Emergencies - Spectrum of related entities characterized by an acute disruption of aortic integrity

Medical vs. Traumatic is the first major branch point. 

  • Within medical there is flap and nonflap
    • Flap (dissection)
    • Nonflap (penetrating atherosclerotic  ulcer or intramural hematoma)

They do share some of the same characteristics and there is some overlap in these processes


  • Pain control
  • Reduce aorta wall stress
    • HR < 60, SBP <120
    • Esmolol or labetalol, esmolol drip is probably the easiest to use
    • Can add nitroprusside or nicardipine drip to this

Surgical Management

  • Stanford Type A requires surgical management 
  • Standford Type B may get operative management 

update on Post-ROSC care with Drs. Gorder and thompson

Overall survival rate of OHCA is 9.5%

  1. The majority of OHCA are due to obstructive CAD
  2. Anoxic brain injury is the #1 cause of death in OHCA
  3. Emergent PCI for select patients and therapeutic hypothermia...


  • Insert advanced airway in patients who need it
  • Avoid hypercarbia and hypoxemia
  • Avoid hypocarbia (especially due to risk of cerebral edema)
  • Avoid hyperoxemia (due to free radicals and oxidative stress to neurons)


Which of these patients should go to the cath lab?