In the spirit of roasts and fire-breathing dragons

You’re on a lovely amble through the backcountry when suddenly you see smoke rising nearby and catch a whiff of a familiar scent that throws you back to your med school OR days: burning flesh. You quickly find one obtunded, severely burned hiker who inadvertently set fire to his camp. After a quick airway assessmentRead more

Supplemental Oxygen: a cautionary tale.

You’re working in the Cardiac Room as a new PGY-2 and the triage nurse calls you to evaluate a patient. He’s about 40 years old, slightly overweight, known to the ED for chronic alcohol abuse, and appears to be intoxicated yet again.The nurse tells you that when she checked his vitals, his O2 sat wasRead more

Paper Review: Are we hurting patients via oxygen supplementation?

Bottom line up front: A recent large, high quality meta-analysis reported a significant mortality effect with the use of liberal, rather than conservative, oxygen supplementation. The number needed harm for 30-day mortality was 1 in 126. A modest but relevant NNH given how common oxygen supplementation is in the ER. Consider titrating all forms ofRead more

The Neuroprotective Intubation

Bottom line up front: (1) Intubating those with TBI or spontaneous ICH is dangerous. You want to prevent increased ICP that is caused by laryngoscopy. (2) Pre-treat with fentanyl if time and the pt’s BP allow. The dose of fentanyl is larger than we are used to, dose 3 mcg/kg (or ~150-200mcg). (3) It isRead more

Post-Intubation Care for the Critically Ill Asthmatic

Clinical Question – What is the best way to intubate and provide post-intubation care for the critically ill asthmatic? Case: 54M mhx asthma (hx of 2 intubations, last 2 months ago) presents to the cardiac room in respiratory distress. He fails nebs/steroids/mag and becomes obtunded after you trial bipap. A decision is made to intubate theRead more

High Flow

Clinical Question – Why use High Flow Nasal Cannula? When should you use it over BIPAP? HFNC offers several advantages compared to conventional oxygen therapy, including: Ability to deliver O2 at up to 60 LPMs at nearly 100% FiO2. This is huge compared to regular Nasal Cannula (1-6 LPMs, maxing out at 45% FiO2) and NRBRead more

Apneic Oxygenation: To do or not to do

Desaturation leading to hypoxemia during RSI is a familiar picture and apneic oxygenation was developed to prevent occurrence of oxygen desaturation during apneic period.  Does the latest evidence support this practice? ENDAO trial published in Acad Emerg Med is an RCT (first one!) conducted at an academic ED in NYC.   100 patients were randomized to noRead more

A Whole New World

We all love FOAM, and we all love airway. Today’s pearl will introduce you to a corner of FOAM you may not have come across, as well as a corner of airway management you might not know about. I’m a big fan of Jed Wolpaw’s Anesthesia and Critical Care Reviews and Commentary podcast. Many ofRead more

Oops…is that part important?

There you were, minding your own business when EMS brings you a sick-as-can-be patient, intubated in the field for who knows what. Someone gets overzealous with their trauma shears and cuts off the pilot balloon on the endotracheal tube. This happened to me twice in my PGY2 year. Obviously, this ETT will need to beRead more

Awake Intubation Topicalization

Compiled from a variety of sources from #FOAMed (specifically, NYSORA and the ACCRAC podcast) and inspired by morning report today with Taryn and Tina, here is a quick and dirty rundown for awake intubation. Firstly, we should be considering this method when the two Venn diagrams of “anatomically challenging” and “enthusiastically cooperative” overlap in theRead more