June 6, 2019

Mechanical Ventilation is a modality commonly used in the critically ill, but many providers, may not have a strong understanding of the basics of mechanical ventilation. Emergency Medicine and Critical Care Physicians need to have a firm grasp of the basic concepts of mechanical ventilation because without it, we can do serious harm to our patients. Airway management is not complete once the endotracheal tube is placed through the cords, and the proper selection of both the ventilator mode and initial settings is essential to ensure your patient has the best possible outcomes. You should not simply rely on the respiratory therapist to know your patients physiology. Clear communication with your therapist about the patient’s physiology and initial ventilator setting is crucial.

May 29, 2019

Take Home Points on Tracheostomy Emergencies

  • Track is mature in 7 days - don't blindly replace before then because concern for false track creation
  • All bleeding needs to be taken seriously and should be evaluated by surgery
  • If not ventilating through trach - go through it systematically to find malfunction

May 15, 2019

Essentials of Emergency Medicine 2019 is taking place at the Cosmopolitan Hotel/Casino in Las Vegas, NV. I was asked to give five lectures on varying topics and wanted to share what was discussed at each of these sessions.  If you haven't been to Essentials of Emergency Medicine, you need to add this conference to your list of conferences to attend.  The organizers pride themselves in discussing the latest practice-changing research and have meticulously designed content to maximize enjoyment and retention. In my humble opinion this conference is the quintessential medutainment extravaganza that applies learning theory principles, with amazing speakers, to provide you with the latest and greatest for clinical practice.

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.

February 11, 2019

Background: Syncope, defined as a transient loss of consciousness with a complete recovery, is a common ED presentation. There are numerous causes of syncope ranging from the relatively benign (eg vasovagal syncope) to the potentially life-threatening (eg dysrhythmia, ectopic pregnancy, aortic dissection). Among the life-threatening diagnoses is pulmonary embolism (PE). PE is a common cause of sudden, unexpected, non-traumatic death and, syncope in the setting of PE portends poor 30-day outcomes (Roncon 2018). What is not well known is how often ED presentations of syncope are the result of PE. A study in 2016 demonstrated a 17.3% rate of PE in first time syncope presenting to the ED but, had numerous significant biases and limitations (Prandoni 2016). Ultimately, this study is unlikely to reflect the reality of ED syncope cases and lacks external validity. Incorporating the PESIT trial data into clinical assessment would lead to a profound increase in PE evaluation without adding significant benefit. Additional clinical data demonstrating the true prevalence of PE in syncope patients is needed to confirm these suspicions.