June 17, 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.

June 10, 2019

Airway management as the first priority has been the backbone of resuscitation for years. “Address A first, before moving to B and C,” is what we are taught and what we go on to teach successive generations of learners. For appropriately trained clinical teams, either in- or prehospital, the completion of “A” may well mean performing a rapid sequence intubation (RSI) From its inception in the 1970s, there has been continued evolution in how we approach RSI (and airway management in general) in the physiologically threatened patient – this post will focus on the trauma patient. You can revisit some really well-done blogs and podcasts over the last few years that have highlighted various approaches to prevent peri- and post-intubation problems. Like cardiac arrest.

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 23, 2019

Background: The clinical importance of immediate coronary angiography, with subsequent percutaneous coronary intervention (PCI) in OHCA patients without STEMI is a matter of debate.  We have already covered the COACT trial on REBEL EM, but this is a second study, the pilot phase of the DISCO trial, assessing immediate vs delayed coronary angiography in patients with OHCA and without STEMI on ECG.

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