Trouble with Trachs - Recannulating the Stenosed Trach Site

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Trouble with Trachs - Recannulating the Stenosed Trach Site

TracheOTOMY sites can close up rapidly (within hours).  Why is this?  Essentially, there is (usually) no missing tissue with this procedure.  Occasionally the procedure does involve cutting a small section of the tracheal ring out but this is much less common now that percutaneous techniques are more in vogue  The percutaneous technique involves, essentially, dilation of the skin, soft tissue, and trachea and, as such, these sites can close up very rapidly.

TracheOSTOMYsites are less of of problem as they do involve the removal of tissue.  If they are fresh, however, these sites can also close relatively quickly.

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A Crack in the Ice? An In-Depth Breakdown of the TTM Trial

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A Crack in the Ice? An In-Depth Breakdown of the TTM Trial

   Like many other Emergency Medicine residencies, we took the time in our last Journal Club to break down the Targeted Temperature Management Article.  There is tons out there in the #FOAMed space about this trial.  And, one of our 4th year residents, Dr. Trent Wray, took some extra time to break down the article in gory detail and put it into the context of the previously published literature.

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Lessons in Transport - Hypotensive Resuscitation

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Lessons in Transport - Hypotensive Resuscitation

Permissive Hypotensionis also known as hypotensive resuscitation or low volume resuscitation

What is it?

A resuscitation strategy in the critically ill trauma patient (primarily applicable to penetrating trauma but also adapted to blunt trauma) where we allow the systolic BP to remain as low as necessary to avoid exsanguination while still maintaining critical end organ perfusion. (typically defined as appropriate mental status & or the presence of a radial pulse)

The Thought Process:"Don't pop the clot"...

By allowing lower blood pressures we avoid the potential disruption of an unstable fresh clot and thus worsening bleeding caused by higher BP's. 

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Lessons in Transport - The Lethal Triad

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Lessons in Transport - The Lethal Triad

To successfully resuscitate the critically ill trauma patient we must have an understanding of and a respect for the LETHAL TRIAD of TRAUMA...

Bleeding causes acidosis, coagulopathy, and hypothermia... 

Acidosis and hypothermia causes more coagulopathy which causes more bleeding... and so begins a deadly cycle

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Lessons in Transport - TXA has Arrived!!

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Lessons in Transport - TXA has Arrived!!

To successfully resuscitate the critically ill trauma patient we must have an understanding of and a respect for the LETHAL TRIAD of TRAUMA...

Bleeding causes acidosis, coagulopathy, and hypothermia... 

Acidosis and hypothermia causes more coagulopathy which causes more bleeding... and so begins a deadly cycle

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Lessons in Transport - Therapeutic Hypothermia Part 3

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Lessons in Transport - Therapeutic Hypothermia Part 3

Common Issues in Therapeutic Hypothermia

1) Bradycardia: may occur during induced hypothermia (even to as low as 35 bpm) and except in rare cases, is NOT a reason to discontinue hypothermia.

  • If bradycardia is severe, associated with persistent hypotension, and is not responsive to fluid and vasopressor therapy, a decision in conjunction with medical control to discontinue hypothermia may be made.

2) Dysrhythmias: generally does not occur unless temperatures fall < 30*C and hypothermia related ventricular fibrillation is rare unless temperature is < 28*C.

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Transvenous Pacemaker Insertion - Part 3

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Transvenous Pacemaker Insertion - Part 3

We used Part 1 and Part 2 in this series to give you an in depth understanding of all the critical steps of the procedure.  After reading those posts you should have a good grasp of the indications for the procedure, the complications you may encounter, and you will have read, seen, and heard step by step instructions for placing a transvenous pacemaker in the ED. This final installment in the series should bring it all together for you.  Here you will see the placement of the transvenous pacemaker from start to finish from the point of view of the operator (Dr. J'Mir Cousar) all filmed in glorious HD.

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Letting the Cat out of the Bag after the Horse Has Already Left the Barn...

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Letting the Cat out of the Bag after the Horse Has Already Left the Barn...

 If you are just now finding this site, you'll see there's a fair degree of stuff on here already.  This is an educational blog edited by Dr. Bill Hinckley and Dr. Jeff Hill, both physicians dedicated to education in the Department of Emergency Medicine at the University of Cincinnati.  The content of the blog is by nomeans only ours.  In fact, this site is best thought of as a funnel for all the great educational content our faculty and resident's churn out.  We look forward to interacting in this digital space with our colleagues locally and from across the globe.  Feel free to reach out to us on twitter, Facebook, or through the blog itself.

   For now take a listen to our introductory podcast for some more background on the genesis of the site and the site name by clicking here

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Lessons in Transport - To Cool or Not to Cool?

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Lessons in Transport - To Cool or Not to Cool?

To COOL or NOT To COOL that is the question...

(Read each of the following scenarios & honestly ask yourself if this is a patient suitable for therapeutic hypothermia)

Scenario 1: 67 yo male scene STEMI, witnessed Vfib arrest with ROSC, GCS 3T, stable vitals

Scenario 2: 24 yo female MVC, ejected, hypotensive for EMS, 10 minute cardiac arrest with ROSC, GCS 3T

Scenario 3: 2 yo female cardiac arrest suspected choking, ROSC after removing food from her airway. GCS 4T (1T2)

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Transvenous Pacemaker: Part 2 - A Procedural Slide Set

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Transvenous Pacemaker: Part 2 - A Procedural Slide Set

worked to create a video walkthrough of the procedure.  The video walkthrough is divided into two separate videos.  The first, embedded below is a narrated procedural slide set, designed to be a cognitively unloaded approach to learning the procedure.  In a later post we'll see a full, start to finish video of the procedure filmed from the first person viewpoint.

In addition to the video being posted here, Dr. Cousar has constructed a checklist that will be placed on the pacemaker generator which will have a QR code to link to this narrated slide set.

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Transvenous Pacemaker Placement - Part 1: The Walkthrough

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Transvenous Pacemaker Placement - Part 1: The Walkthrough

If you are interested in seeing the placement of a Transvenous Pacemaker after reading this post check out Part 2 (Procedural Slide Set) and Part 3 (the first person view of the procedure)

Reasons to Pace in the First Place

Hemodynamically unstable+

1. Sinus Bradycardia - seen in 17% of acute MI patients (especially inferior or anterior wall MI) [1,2]

2. AV Block - may be due to ischemia (15-19% of all Acute MI) [2,3]

3. Drug Overdose - with the goal of maintaining adequate hemodynamics while your medical therapy/dialysis has an opportunity to work.

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Lessons in Transport - Post-Intubation Checklists

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Lessons in Transport - Post-Intubation Checklists

Post-Intubation Checklists

Making a checklist can help cognitively unload you in high stakes and high pressure situations.  Post-intubation consider the following important points:

Protecting the Tube

  • Continuous wave form ETCO2... each and every time

  • Secure Endotracheal Tube at the appropriate depth (See LIT week 6)

  • Analgesia and Sedation

  • Restraints... Do you know where the soft restraints are stored?

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Snake Envenomations Podcast

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Snake Envenomations Podcast

This podcast, our first, focuses on the care of patients who have been bitten by snakes, primarily North American Crotalids.  The discussion revolves around a case of envenomation we ran recently during a Grand Rounds simulation.  In the podcast, we focus on clinical assessment of the bites including determining the severity of local and systemic symptoms, the initial care and management of envenomations, and some of the complications associated with administration of antivenin.

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The Basics of Evidence Based Clinical Practice - Asking Good Questions

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The Basics of Evidence Based Clinical Practice - Asking Good Questions

Evidence Based Clinical Practice (EBCP) is a way to bring the sometimes obtuse world of evidence based medicine to the bedside.  Instead of getting lost in p-values, ANOVA, student t-tests, multivariate logistic regressions, EBCP approaches evidence based medicine always through the lens of a patient under a clinician's care.  It is a process that starts with asking carefully crafted questions and efficiently searching for answers to those questions.  Subsequent analysis of the articles found in the clinician's searching seeks to answer: are the results valid? what are the results? and finally, how can one apply the results to patient care?

In this short video, we go through the crucial initial step of the process: asking a question.  Success in asking answerable, well crafted questions begets successful search strategies.

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