Posts Tagged intubation

Placing the Intubating Laryngeal Airway

My favorite supraglottic airway is the Cookgas Air-Q; it was created by an anesthesiologist, Dr. Daniel Cook (As always, I have no conflicts of interest). He just created a new device that allows the placement of an esophageal blocker through the laryngeal airway. I gave him a call to hear about the new product and in the course of that conversation, he gave me a ton of tips on the placement of laryngeal airways in general. Sorry about the audio quality, his cell phone was probably AT&T : ).

[Click Here to Read More and to Hear the Episode]

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Interview with EMS Physician, Cliff Reid

I was able to cajole Cliff Reid of the amazing blog, resus.me on to the EMCrit program. Cliff is truly a doc after my own heart as you will hear from the cast.

He is currently an EMS physician and Director of Training at the New South Wales Ambulance Service.

Cliff’s blog, resus.me is an incredible collection of timely articles on emergency medicine, ems, critical care and resuscitation.

Cliff and I discuss prehospital intubations, helicopters for EMS, and upstairs care, outside the walls of the hospital.

[Click here to read more and hear the podcast]

photo by mad scientist

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Delayed Sequence Intubation (DSI)

The Case

You have a 50 y/o male with bad bilateral pneumonia. BP 108/70, HR 96, RR 28. He is delirious, agitated, and looks sick, sick, sick! Saturation is 70% on a nasal cannula; when you try to place the patient on a non-rebreather (NRB) he just swats your hand away and rips off the mask. It is obvious to everyone in the room that this patient needs intubation, but the question is how are you going to do it?

Your first impulse may be to perform RSI, maybe with some bagging during the paralysis period. This is essentially a gamble. If you have first pass success, you (and your patient) may just luck out, allowing you to get the tube in and start ventilation before critical desaturation and the resultant hemodynamic instability. However, the odds are against you: bagging during RSI predisposes to aspiration, conventional BVM without a PEEP valve is unlikely to raise the saturation in this shunted patient, and if there is any difficulty in first-pass tube placement your patient will be in a very bad place.

Is There a Better Way???

[Read and Listen to the DSI Podcast]

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Extubation in the Emergency Department

If you can put an ET tube in, I think you should be able to remove it as well. In this podcast, I discuss extubating patients in the ED. Specifically, I deal with patients who have only been intubated for a few hours in distinction to extubation of the patient who has been lingering in your ED for 2-3 days. The best patients for this short-term extubation are those intox folks with a low GCS and signs of trauma, overdoses, or endoscopy cases.

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Open Cricothyrotomy in Many Different Flavors

Ok, Ok, I promise this is the last airway episode for at least a little while. I am perhaps a bit obsessed. Had this show in the works for a while. The cric is the last barrier between a failed airway and death. EM docs need to be able to perform this procedure without hesitation. This requires training and practice until you can perform the procedure in < 30 seconds literally with your eyes closed!

In EMCrit Podcast # 24, we discuss numerous ways to perform an open cricothyrotomy including interviews and videos from Darren Braude and Seth Manoach.

[Click Here to Read More and Hear the Podcast]

Photo from wikipedia

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The Awake Intubation Video

Awake intubation can save your butt!

In EMCrit Podcast 18, we discuss RSI’s less popular sibling: awake intubation. It requires forethought and humility–you must be able to say to yourself, “I am not sure I will be able to successfully intubate this patient.” However, the payoff for this thought process is enormous. You can attempt an intubation on a difficult airway with very few downsides. If you get it, you look like a star, if you don’t you have not made the situation worse.

It all comes down to what is best for our patients. If the airway is predicted to be difficult and you perform RSI or even worse, a sedation-only intubation and you fail, then the morbidity/mortality that ensues was preventable.

Two of my critical care resident specialists, Raghu Seethala and Xun Zhong, volunteered to intubate each other awake. The purpose of this was to let them gain experience, understand what their patients would feel during the procedure, and to prove that awake intubation can be done without complicated nerve block injections or fragile equipment, such as a bronchoscope.

[Click Here to See the Video and Read More]

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