May 24, 2021

Background: It’s no surprise that unplanned, emergency intubations are significantly different from intubations in the operating room (OR). Unplanned intubations on the floors and in the ED and ICU settings are highly unlikely to be “physiologically optimized:” they have underlying shock, respiratory failure, metabolic acidosis, as well as other pathophysiological changes that can substantially increase the risks of adverse peri-intubation events.  Historically, we focused more on the anatomically challenging airway instead of the physiologically challenging airways. Fortunately for our patients, this has changed in recent years. There is increased attention on physiologic challenges including hypotension, hypoxemia, and metabolic acidosis.  Taking care of critically ill patients that require intubation can be a high stress situation with very little room for error.  Having a large evaluation of routine clinical practice and occurrence of adverse events could help establish which high-priority interventions could reduce risk in this already risky situation.

April 26, 2021

In emergency medicine, the standard of care is to place an advanced airway for ventilatory or oxygenation failure, impending airway compromise, or inability to protect the airway. A patient with significant cognitive impairment may have depressed gag and/or cough reflexes, putting them at risk for aspiration. The evaluation of a patient’s risk for aspiration can be highly subjective. One common adage states: “If the GCS is less than 8, then intubate”, offering a seemingly simple and more objective standard to guide airway management. Using the Glasgow Coma Scale (GCS) score of 8 or below to evaluate the need for intubation is promoted by the ATLS course and the East Association for the Surgery of Trauma (EAST) practice management guidelines.[1][2] This practice is also commonly applied to patients with non-traumatic causes of obtundation. However, the evidence behind this practice is not clear, prompting many to re-examine this oft-repeated lesson.

April 19, 2021

Background: Tension Pneumothorax (TP) can occur as a potentially life-threatening complication of chest trauma. With the risk of respiratory and cardiac arrest, an immediate temporizing intervention for this condition is required by direct Needle Decompression (ND). In 2018, the Advanced Trauma Life Support (ATLS) recommendations changed from the 2nd intercostal space in the midclavicular line (ICS2-MCL) to the 4th/5th intercostal space just anterior to the anterior-axillary line (ICS4/5-AAL), whereas the European Trauma Course (ETC) trauma guidelines and the guidelines from the Royal College of Surgeons of Edinburgh (RCSEd) in the UK still adhere to placement in the ICS2-MCL for the preferred location of ND. Both chest wall thickness of the patient and needle length both play a role in the success rate of ND.  Although it is well known that Chest Wall Thickness (CWT) increases with BMI, it is unknown if the optimal place for ND may vary with BMI.

February 26, 2021

Background: Cricothyrotomy is a high acuity low occurrence (HALO) procedure that is time critical.  It is the common final step in the cannot intubate cannot oxygenate (CICO) and/or cannot intubate cannot ventilate (CICV) situation. Due to the time critical nature of the procedure, any approach must include three facets:
  1. Be as simple and rapid as possible
  2. No special equipment required
  3. High success and low complication rate

January 18, 2021

Case: A 51-year-old woman, with no pertinent past medical history, presented to the Emergency Department (ED) complaining of right hand pain after a large fragment from a wooden cooking spoon penetrated her right palm approximately 1 week ago. She reported immediately removing the splinter and starting old, previously prescribed amoxicillin prior to her visit. She was prompted to visit the ED after her pain gradually increased, affecting her ability to flex and extend her right fourth digit.

On physical exam, the patient was afebrile with all other vital signs within normal limits. There was significant tenderness localized to the base of the right fourth digit near the proximal interphalangeal (PIP) joint, associated with edema, ecchymosis, and erythema. While the patients right hand remained neurovascularly intact, significant restrictions in passive motion, including flexion and extension, was noted to the right fourth digit. On visual inspection, no foreign bodies were appreciated.

A radiograph of the right hand was ordered, which was negative for any acute abnormalities, including foreign body. However, due to the patients clinical presentation and the potential radiolucency of the suspected foreign body, a point-of-care ultrasound was performed.