How to build a breathing, bleeding cricothyroidotomy simulator

Jean-Christopher Ozenne (@JCOzenne) of Gouvieux, France has generously published this great video on how to build “The Mustache” – a breathing, bleeding cricothyroidotomy simulator – using cheap and ubiquitous equipment.  Can’t wait to try this one out…I particularly like the artistic touch.  To paraphrase V himself:  A cric trainer without bleeding is not a cric trainer worth having.

The family in the ICU of adults. By Ana Bejarano

I believe that the first step is to understand that despite we are human beings we are not always humanized, because humanize is a mode of being, living, interacting, growing us, moving us and traveling to the inside, to experience life in another way. 

All of us want to be older, but we could have best moments, and create highlights for our patients.




What are the family needs?

  • Receiving clear information in terms that they can understand 
  • Having proximity with the patient 
  • Feeling that there is hope 
  • Having time to accompany their loved one
  • Being relieved
  • Perceiving that the patient receives care of high quality 
  • Trusting in the clinical skill of the team of health. 
  • Knowing that the ICU team is concerned by the patient 
  • Reassuring, giving support and protecting their loved one
  • Having some grade of comfort during the process
Specific role of the team when a family comes into the ICU: providing the medical report as soon as possible, accompanying to the family to the unit, explaining how it works, offering availability to ask.


Visitation policies. To define the enlargement of the visits, we should: 
  • Agreeing on a protocol with the institution
  • Knowing the wish of the patient 
  • Agreeing with all the ICU team
  • Defining with the patient, if is possible, what family member is suitable for accompanying
  • Creating a space of privacy and comfort to the family (Chairs, closed doors or place screens if it´s possible) 
  • Defining with the team if the family member is going to collaborate in the care 
  • Nursing participation in the report to the family to know the type of family and what relationship have between them 
  • What patients we are going to expand visits depending on the current diseaset (for example in isolates, infectious diseases, etc)
What can family do during the visit?
  • Participating in the early mobilization 
  • accompanying patient from bed to a chair or sitting 
  • accompanying and assisting in feeding patient 
  • Supporting with elements of sensory stimulation 
  • Performing skin care (for example, place moisturizers in lower limbs) 
  • Participating of the hygiene of the patient (hairstyle brushed teeth, nails cut) 
  • Being educated by nursing before the ICU discharge of the patient 
It´s important explain to the family don´t worry by alarms or drips, make them feel that we need them to tasks that although we can make us, the affection and love of a relative are irreplaceable.

What is the contribution of flexibilization visitation policies?


For patients: 
  • Decreases anxiety, confusion and agitation 
  • Reduces cardiovascular complications
  • decreases ICU stay
  • Makes the patient feeling more safe 
  • Increases the satisfaction of the patient 
  • Increases quality and security 
For families:
  • Increases satisfaction 
  • Decreases anxiety 
  • Promotes a best communication 
  • Contributes to a better understanding of the patient 
  • Allows more opportunities for the teaching of the patient / family , and is involves them in the care.
Myths to topple: visits stresses to the patient, interfering in the provision of care, are tyring for the patient and the family and contribute to infections.

Visits for 
children: If children are adequately prepared, they should be allowed as visitors to the ICU, because they present a positive behavior and less emotional changes in relation to children who do not visit their loved one.

Ana María Bejarano
Nursing ICU Head.
Director of Critical Nursing of SATI at Sanatorio La Entrerriana
Argentinean Society of Intensive Care Medicine

Critical Care Updates: Resuscitation Sequence Intubation – Hypoxemia Kills (Part 2 of 3)

Resuscitation Sequence Intubation - Hypoxemia Kills

This blog post is the second part of a series of 3, on a recent lecture I was asked to give  on Critical Care Updates: Resuscitation Sequence Intubation. This talk was mostly derived from a podcast by Scott Weingart (Twitter: @EMCrit) where he talked about the physiologic killers during preintubation and perintubation. In this podcast, Scott mentions the HOp killers: Hypotension, Hypoxemia, and Metabolic Acidosis (pH) as the physiologic causes of pre-intubation/peri-intubation morbidity and mortality. Taking care of these critically ill patients that require intubation can be a high stress situation, with little room for error.  In part two of this series we will discuss some useful strategies at the bedside to help us reduce pre-intubation/peri-intubation hypoxemia.

What was the Premise of this Talk?

  • Resuscitate Before You Intubate
  • Hefner AC et al [1] and Kim WY et al [2] evaluated over 2800 patients requiring emergency intubation. In both trials the rate of cardiac arrest (CA) within 10 minutes of intubation ranged from 1.7% – 2.4%. Both trials listed pre-intubation hypotension (SBP ≤90mmHg) as a risk factor for cardiac arrest. Hefner AC et al also mentioned hypoxemia as a risk factor as well.

What are the Physiologic Killers Pre-intubation/Peri-intubation?

Hypoxemia Kills

  • The Basics:
    • Think NO DESAT (Nasal Oxygen During Efforts Securing A Tube)
    • NC at 15LPM + NRB at 15LPM (In all actuality you are turing the O2 all the way up, which may be more than 15LPM)
    • If you cannot get the O2 Saturation ≥95%, then consider the following:
      • Lung Shunt Physiology (i.e. Pulmonary Edema, Pneumonia, etc…).  These patients still need oxygen, but also need PEEP to recruit atelectatic alveoli to overcome the shunt
  • Intervention 1: NC 15LPM + BVM 15LPM + PEEP Valve 5 – 15cmH20
    • You don’t need to bag these patients, they need a tight seal and jaw thrust (i.e. Apneic CPAP Recruitment)
    • Bottom Line:  In critically ill patients in which you cannot get O2 Sats ≥95%, consider shunt physiology and use Apneic CPAP Recruitment
  • Intervention 2: Delayed Sequence Intubation (DSI)
    • Procedural sedation for the procedure of preoxygenation
      • Give 1mg/kg IV Ketamine -> Preoxygenate -> Paralyze the Patient -> Apneic Oxygenation -> Intubate
    • Evidence: Weingart et al Ann Emerg Med 2015 [1]
      • Observational trial with >150 intubations -> 62 patients uncooperative/combative
      • Mean O2 Saturation increased from 89.9% unto 98.8%
      • No Complications
    • Bottom Line:  In critically ill, agitated patients, who are hypoxemic, that need to be intubated, consider using DSI, which is procedural sedation for preoxygenation.
  • Intervention 3: Back Up Head Elevated (BUHE) Intubation [2]
    • 528 Intubations
    • Primary Outcome: Composite of Any Intubation-Related Complication (Difficult Intubation ≥3 Attempts or > 10 min, Hypoxemia <90% O2 Sat, Esophageal Intubation, or Esophageal Aspiration
    • Primary Outcome Results:
      • Standard Supine Intubation: 22.6%
      • BUHE Intubation 9.3%
    • Bottom Line: BUHE still needs prospective external validation in an ED setting, but seems to decrease intubation-related complications in comparison to standard supine intubation

Clinical Bottom Line:

  • Pre-Intubation Hypoxemia is a risk factor for Peri-Intubation Cardiac Arrest:
    Options to Improve Hypoxemia:
  • Start with NO DESAT (Nasal Oxygen During Efforts Securing A Tube) at 15LPM + NRB at 15LPM
  • If you don’t get the O2 Sats ≥ 95% think about shunt physiology and consider the following interventions:
    • Intervention 1: NC 15LPM + BVM 15LPM + PEEP Valve 5 – 15cmH20 (Apneic CPAP Recruitment)
    • Intervention 2: Delayed Sequence Intubation (DSI)
    • Intervention 3: Back Up Head Elevated (BUHE) Intubation
  • Many of these interventions can be done simultaneously to ensure no hypoxemia

Credit to Scott Weingart (Twitter: @EMCrit) for creating the HOp Killers mnemonic.

For More Thoughts on This Topic Checkout:

References:

  1. Weingart SD et al. Delayed Sequence Intubation: A Prospective Observational Study. Ann Emerg Med 2015; 65(4): 349 – 55. PMID: 25447559
  2. Khandelwal N et al. Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesth Analg 2016; 122(4): 1101 – 7. PMID: 26866753
  3. Mosier JM et al. The Physiologically Difficult Airway. WJEM 2015; 16(7): 1109 – 17. PMID: 26759664

Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)

The post Critical Care Updates: Resuscitation Sequence Intubation – Hypoxemia Kills (Part 2 of 3) appeared first on R.E.B.E.L. EM - Emergency Medicine Blog.