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....Read More
Despite decades of experience with endotracheal intubation, we continue to find approaches to improving the process of how we intubate. In today’s post we are not only going to talk about how to avoid post intubation cardiac arrest, but we are also going to cover 5 rather controversial topics in airway management including: Apneic oxygenation (ApOx), use of video laryngoscopy (VL) compared to direct laryngoscopy (DL), bougie 1st intubation, back up head elevated (BUHE) intubation, and finally bag valve mask ventilation (BVM) prior to intubation....Read More
Background: The two biggest keys to successful survival with good neurological outcome in out-of-hospital cardiac arrest (OHCA) are high-quality CPR and early defibrillation. Dispatcher-assisted (DA) CPR is a novel concept to not only improve the rate of CPR being performed, but also the quality of CPR. In DA-CPR, rescuers perform CPR under telephone guidance from trained dispatchers. In this study, the authors sought to see if DA-CPR improved the quality of chest compressions (Compression depth, compression rate, no-flow time, complete release of pressure between compressions, and hand location)....Read More
Background: Although the debate over balanced (i.e. lactated ringers, PlasmaLyte) vs unbalanced (i.e. 0.9% saline) crystalloids has not been settled, fluid resuscitation continues to be a fundamental therapy given to critically ill patients. 0.9% saline is one of the most common fluids given in resuscitation of patients but the high chloride content may contribute to the development of acute kidney injury (AKI) . Alternatives to 0.9% saline include crystalloids with electrolyte compositions that are more balanced and resemble that of plasma (i.e. Lactated Ringer’s Plasma-Lyte, etc). Theoretically use of more balanced crystalloids would result in less potential side effects when compared to 0.9% saline. The crux of the matter is does fluid choice affect any patient-oriented outcomes?...Read More
Every now and again someone raises the issue on social media about resuscitative thoracotomy. What are the indications (we have the EAST guidelines for that), what are the risks (highlighted in this important recent paper), and of course, whether EM or surgery should be doing it in the trauma bay (guess what – it’s in the curriculum for bothspecialties).
That’s not the point of this post. This post is about how I think you, as the emergency medicine physician (EP), working in a system where your surgeon is not in-house, but is available in a reasonable amount of time, should proceed when faced with the patient who meets the indications. You’ve gone through your HOTTT(T) algorithm and are now at that final “T” – you have to open the chest....Read More