September 16, 2019

Background: Rapid sequence intubation (RSI) involves the use of an induction agent followed by a neuromuscular blocking (NMB) agent to obtain optimal intubating conditions.  Administration of a NMB results in apnea which, in turn, can lead to oxygen desaturation.  Oxygen desaturation during rapid sequence intubation may lead to serious adverse events including dysrhythmias, hypotension, and cardiac arrest.  Preoxygenation helps extend the duration of safe apnea and has 2 major goals:
  1. Attempt to achieve an O2 saturation of 100%
  2. Maximize oxygen storage in the lungs by denitrogenation of the residual capacity of the lungs (Approximately 95% of oxygen reservoir)
Preoxygenation is assessed in the ED but usually through pulse oximetry which is inadequate.  In the operating room, anesthesiolgists use gas analyzers to quantify and optimize preoxygenation with ETO2.  In critically ill patients, preoxygenation should be performed to achieve an ETO2 ≥85% based on the response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society [2].

September 5, 2019

Background: Working in the emergency department means frequently performing painful procedures on patients, often we turn to procedural sedation to make these procedures more tolerable for patients, families and clinicians alike.  Ketamine is often used for this purpose, particularly in pediatrics, however, many clinicians are reluctant to use this agent due to concerns for recovery agitation or the dreaded “emergence phenomenon.” Clinicians often turn to the co-administration of various agents, including benzodiazepines and antipsychotics, to blunt this effect.  The definition of recovery agitation and the means by which it is measured are inconsistent in the previous literature, leading to a dearth of evidence as to whether the practice of co-administration of medications is effective in reducing recovery agitation.

August 1, 2019

You are working an ED shift with an experienced EM resident. As the resident prepares to intubate a 100kg patient with pneumonia you suggest that the head of the bed be elevated to aid in first pass success and avoidance of peri-intubation hypoxia. The resident thanks you for your kind suggestion and states ‘I just read an article in Annals of EM suggesting there was no benefit to non-supine position in ED patients.’ This is news to you. You give the resident the benefit of the doubt and ask them to send you a copy of their evidence.

May 23, 2019

Background: Predicting a challenging airway is important to assist in the most optimal approach to airway management during RSI.  Two such tools include the Mallampati and LEMON scores and were derived in the pre-operative setting. Major limitations of these scores include the requirement of patients to be awake and cooperative and they don’t incorporate physiologic factors into them. The HEAVEN criteria is a recently developed tool thought to be more relevant and feasible for emergency airway assessment.  Each letter of HEAVEN stands for the difficult airway characteristic:
  • Hypoxemia - ≤93% at the time of initial laryngoscopy
  • Extremes of size – Pediatric patient ≤8 years of age or clinical obesity
  • Anatomic challenge – any structural abnormality that is anticipated to limit laryngoscopic view
  • Vomit/blood/fluid – Clinically significant fluid noted in the pharynx or hypopharynx prior to laryngoscopy
  • Exsanguination – Suspected anemia raising concerns about limiting safe apnea times
  • Neck mobility issues – Limited cervical range of motion

May 9, 2019

Background Information: The sequential administration of a sedative and neuromuscular blocking agent (NMBA) to facilitate the passage of an endotracheal tube is a common method of intubating in both the emergency department (ED) and intensive care unit (ICU). In fact, 85% of ED intubation and 75% of ICU intubations are performed using RSI. 1 It has been shown that the NMBA not only provides muscle relaxation to improve laryngeal view but has also reduced intubation associated complications, ultimately improving the likelihood of intubation success.2-4 While the early use of a sedative leads to hypoventilation and apnea, the patient has an increased risk of hypoxemia and delaying optimal intubation conditions.1 Use of an NMBA was associated with a lower prevalence of hypoxemia, however the order of its administration before the sedative remains controversial for fear of patient awareness and its use has been limited to the operating room (OR) setting. 1,2 The authors of this study sought to identify whether the order of RSI drugs was associated with increased apnea time during intubation. They defined this interval as the time elapsed from administration of the first RSI drug to the end of a successful first intubation attempt.
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