Author Archive for: Swami

Cricoid Pressure in Airway Management: The IRIS Trial

15 Nov
November 15, 2018

Background: Cricoid pressure is dead, right? Many have made this claim including a brilliant argument against its use by John Hinds here. Despite the many eulogies, we continue to hear about cricoid pressure so it makes sense that we dive in to the background prior to addressing the recent JAMA Surgery publication.

Cricoid pressure was first described by Dr. Sellick in the 1960’s though similar techniques were described as far back as the 1770s (Sellick 1961). The Sellick’s maneuver entailed the application of pressure over the cricoid cartilage with the thumb and 1-2 additional fingers.  The goal was to compress the cricoid cartilage against the esophagus in order to occlude the esophagus and prevent regurgitation of stomach contents into the upper airway. Initial studies on the maneuver suffered from a bevy of methodological flaws including small n, lack of blinding or randomization and selection bias. Despite this, Sellick’s maneuver was widely adopted and taught to hordes of anesthesia, critical care and emergency residents.

Studies investigating cricoid pressure in the last decade have demonstrated a number of issues with claims that it can prevent passive regurgitation. Check out this free chapter on EMRAP for an in depth discussion. Dynamic MRI studies demonstrate that application of pressure to the cricoid cartilage displaces the esophagus laterally instead of occluding it (Smith 2003, Boet 2012). An ultrasound study demonstrated similar findings: in 60% of patients the esophagus was lateral to the airway and cricoid pressure led to displacement rather than occlusion in all patients. (Tsung 2012).

Additionally, application of cricoid pressure decreases airway patency and increases the chance that your view of the airway will be obscured. (Allman 1995, Palmer 2000, Smith 2002, Oh 2013). Finally, no study to date has demonstrated a reduction in aspiration episodes with the application of cricoid pressure. A large observational study of pregnant patients undergoing C-sections found no difference in aspiration events and that the overall aspiration event rate was low (Fenton 2009). However, up until this point, there has not been a high-quality, randomized controlled trial performed. Read more →

Today I Learned: A Daily Dose of #FOAMed 1.0

12 Nov
November 12, 2018

In October 2016, I was exposed to the vast world of Free Open Access Medical Education and MedTwitter. I was astounded and inspired by the different educators who were trying to make learning easier. The Knowledge Translation (KT) gap was being vastly shortened by some very smart people who took to social media to educate the rest of the world. Although there were knowledge bombs in all areas of medicine, I was particularly drawn to the ones most relevant to emergency medicine and critical care.

Each day in 2017, I used Twitter to share a few pearls with the world as my contribution to #FOAMed. I included the hashtag #TodayILearned (Today I Learned) so I could keep track of them to use for future projects. Here are just a few of those pearls:

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Accidental Hypothermia

08 Oct
October 8, 2018

Definition:

  • Accidental hypothermia is an unintentional core body temperature of < 35°C when heat loss to surroundings is greater than heat generation
  • Most frequent cause is environmental exposure
  • Patient with impaired thermoregulation can develop hypothermia in relatively warm environments
    • Elderly, underlying illness, trauma, intoxication, or malnutrition (Brown 2012)

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LMWH in Cancer-Related VTE (CLOT Study)

20 Sep
September 20, 2018

Background: Venous thromboembolism (VTE) occurs frequently in patient with cancer. Treatment in this group entails a number of challenges including a higher rate of thrombosis recurrence and a higher risk of bleeding. Standard therapy in 2018 for both symptomatic and asymptomatic VTE is with low-molecular-weight heparin (LMWH) based on this study. Prior to 2003, patients were treated with warfarin after bridging with either unfractionated or LMWH. This approach requires frequent monitoring due to unpredictable anticoagulation levels associated with drug interactions, malnutrition and vomiting. Due to these issues, treatment with LMWH alone may be both more efficacious as well as preferred by patients. Read more →

(Dis)Utility of Procalcitonin in Lower Respiratory Tract Infections (ProACT Trial)

17 Sep
September 17, 2018

Background: The mis- and overuse of antibiotics continues to be a growing problem in medicine; the results of which are increased health-care costs, increased antibiotic resistance and, ultimately, patient harm. Unnecessary antibiotics are particularly prevalent in the treatment of lower respiratory tract infections (LRTIs) including asthma exacerbations and bronchitis. While it would be nice to simply stop using antibiotics when they’re not indicated, issues in stewardship abound. Amongst these are legitimate concerns by providers that the patient may have a bacterial infection causing their symptoms and, thus, benefit from a course of antibiotics.

Procalcitonin has been touted in recent years as a lab test that can help with this conundrum. Ideally, an elevated procalcitonin level would indicate the presence of a bacterial infection and, thus, suggest benefit from use of antibiotics while a low procalcitonin level would suggest a viral or non-bacterial etiology and suggest an absence of benefit from antibiotics. A recent Cochrane review showed potential for a procalcitonin approach but, there was minimal Emergency Department based evidence. Read more →