10 Tips from Nurses to Rock Your EM Clerkship

There are lots of ways to prepare for clerkship, like finding mentors, reading up, and making learning goals, as outlined in this past post. While those tips will help you maximize your skills building and demonstrate your professional competencies, it’s also important to use clerkship as an opportunity to learn how to work as part of an interdisciplinary team within a complex health care system. There is growing recognition that quality care and patient safety depend on teamwork, and evidence demonstrates that increased collaboration between physicians, nurses, and allied health professionals helps improve client outcomes [1]. With that in mind, here are tips from nurses to help you work with respect and synergy as part of the team.

10 Tips from Nurses to Rock Your EM Clerkship

Tip 1 – Be courteous

Often health care providers can be so focused on their patients and the endless tasks at hand that we can forget what it means to be courteous. Emergency departments can be hectic places full of people in crisis, but we can still take a few moments to exercise common courtesy with our colleagues. Start conversations with “hello” or “how are you?” and introduce yourself (#hellomynameis isn’t just for patient interactions). This allows us to build professional relationships from a place of trust and respect.

Other daily courtesies apply to workplace settings, too. Respectful and polite language, like saying “please” and “thank you”, sharing workspaces, returning supplies and charts when you’re finished with them, remembering to log off computers – all of these things help improve workflow and can make a sometimes chaotic environment just a little more pleasant. Other tips for being courteous in the workplace are available from the business sector here.

Tip 2 – Capitalize on other people’s expertise

There’s a reason that health care has interdisciplinary teams with specialties and sub-specialties – we can’t all know everything. Make the most of the variety and depth of knowledge that surrounds you. Nurses, especially, know the patients, staff, policies, and hospital well, and appreciate being recognized as a resource. We are (typically) with our patients for 8-12 hours at a time and are very familiar with their baseline status, so please trust us when we are worried, and listen to our concerns. This interesting paper takes a “pragmatic view of intuitive knowledge in nursing practice” and highlights the importance of a nurses’ intuition [2]. We’re also happy to show you what we know, especially if you’ll teach us something, too.

Tip 3 – Strategically pick your timing

Research shows that, like physicians, nurses also face many interruptions. One study showed that nurses are interrupted once every 6 minutes [3]. While it’s great to ask questions, solicit and give feedback, and have an open dialogue with colleagues, there are better and worse times for these discussions. Refrain from interrupting procedures, and wait until we have completed our assessment to start yours. Know that all health care providers are juggling a lot of competing priorities, and although we want to support your learning and attend to your patients, we may need to prioritize something else, so please be patient. Having said that, if you have immediate concerns about patient safety, speak up.

Tip 4 – Strategically pick your location

Pick your location wisely when questioning someone’s practice or debating a plan of care. Don’t do so in front of a patient, unless there is an immediate safety concern or bedside rounds are standard at your institution. Those conversations are probably best saved for the charting station, not the hallway, where patient confidentiality is easily compromised. When picking a location to do extra reading or learning, choose somewhere where you won’t be interrupted by people maneuvering around you for supplies or charts. When picking a location to watch a procedure, be mindful of sterile fields and introduce yourself to the patient and provider(s) rather than silently hovering.

Tip 5 – Practice Stewardship: Leave your patients, colleagues and the department how you found them or better

Nothing feels more disrespectful than someone leaving their mess for me to clean up. It’s definitely best practice to remove bedding, clothing, dressings and diapers to examine your patients, but please put them all back when you’re done. If there’s a complex wound, feel free to ask when the next dressing change is so that you can assess it then, or at least let the nurse know that you’ll have to remove a dressing so we can plan our care accordingly. Return or throw-out supplies when you’re finished a procedure, and dispose of all your sharps properly. If you don’t know where something goes, ask instead of putting it away in the wrong place. Ask your colleagues how you can help and what you can do to help make their job easier. Ask patients if there is anything they need before you leave the room.

Tip 6 – Take responsibility for patient safety

Little things make all the difference, even when you are a medical student. Leaving patients in better shape than you found them is also about patient safety. This means assuring that bed-rails are put back up and the call-bell is within reach. A significant number of patients experience adverse events in the hospital, especially falls [4]. Keep this in mind when mobilizing patients, and communicate fall risk with the rest of the healthcare team.

Tip 7 – WASH. YOUR. HANDS.

Hand hygiene is an important part of patient safety – so important that it warranted its own section. We all know that practicing hand hygiene is the number one way to reduce the spread of infection. But it’s incredible how few healthcare providers do it properly or as often as they should. Brush up on best practices and follow them.

Tip 8 – Do not touch things if you don’t know what they are

If you’re going to change or remove any tubes, pumps, IVs, or ventilator settings, please let us know. Unless you are totally familiar with how to use them, please do not touch them without asking first, as the nurse probably spent a significant amount of time setting them up, untangling them, and completing safety checks. If you’re curious about what a patient is hooked up to, just ask! Also, it’s best to keep your hands to yourself when observing a sterile procedure.

Tip 9 – Take care of yourself

Adjusting to long shifts can be physically and mentally exhausting. It’s harder to care for others if we’re not caring for ourselves. It’s your own responsibility to assure that you’re fed and watered and ready to learn. We are all doing what we can to take care of ourselves and our patients, so please don’t rely on others to take care of you, too. Remember, many of your nursing colleagues have had years of experience with working shifts. If you’re having trouble, reach out to them, as they will likely have some tried and true tips to share.

stolen foodTip 10 – Do not steal anyone’s snacks

Just trust me.

Acknowledgements: Thanks to my colleagues for their input on this post, including the nurses at BC Children’s Hospital and those who contribute to the online forums at reddit/r/nursing. Check out the great Reddit feed started by Claire for even more advice. 

This post was edited by Teresa Chan and Eve Purdy.

References

  1. Martin, J. S., Ummenhofer, W., Manser, T., & Spirig, R. (2010). Interprofessional collaboration among nurses and physicians: making a difference in patient outcome. Swiss Med Wkly, 140, w13062.
  2. Billay, D., Myrick, F., Luhanga, F., & Yonge, O. (2007) A pragmatic view of intuitive knowledge in nursing practice. Nurs Forum ; 42(3): 147-55. (http://www.ncbi.nlm.nih.gov/pubmed/17661807)
  3. Kalisch, B. J., & Aebersold, M. (2010). Interruptions and multitasking in nursing care. Joint Commission Journal on Quality and Patient Safety36(3), 126-132. (https://www.researchgate.net/publication/42253476_Interruptions_and_multitasking_in_nursing_care)
  4. Hitcho, E. et al. (2004). Characterstics and circumstances of falls in a hospital setting. J Gen Int Med; 19(7): 732.789. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1492485/)

Author information

Eve Purdy
Medical Student Editor at BoringEM
Fourth year medical student at Queen's University-happily consuming, sharing, creating and researching #FOAMed

The post 10 Tips from Nurses to Rock Your EM Clerkship appeared first on BoringEM and was written by Eve Purdy.

Tiny Tip: HELLP Syndrome

If you train in a tertiary care center with obstetrical triage, you may not assess many pregnant women beyond the first trimester of pregnancy. However, in community emergency departments without a primary obstetrics triage department, you will often encounter pregnancy-induced hypertension (PIH; systolic pressure 140 mmHg, or diastolic pressure 90 mmHg), a common complication occurring in 7-9% of pregnancies. HELLP syndrome is an important subset of PIH that comes with its own built-in mnemonic to help remember its features[1].

The Mnemonic: HELLP Syndrome

HELPP syndrome is comprised four component parts [2]:

Haemolysis

Elevated

Liver enzymes

Low

Platelets

Applying the Mnemonic

If you encounter a pregnant woman with hypertension in the emergency department, be on the look out for signs of haemolysis (the peripheral blood smear and elevated LDH are your clues), elevated AST and ALT, and thrombocytopaenia. Clinical symptoms of acute hypertensive disease, including epigastric or right upper quadrant pain, headache, paraesthesias, and blurred vision may contribute to the clinical picture. Prolonged prothrombin time and low fibrinogen level are indicators of severity, and uric acid is used as an adjunct used for diagnosis in some centers.

The only cure for HELLP syndrome is delivery, but patients may be temporized with fluids, antihypertensive agents, and platelet transfusion, depending on the clinical picture. Consult obstetrics early.

 

 

Review by an Attending

Thank you very much for your piece. I enjoyed this review, and thought it represented the topic well. One thing I would suggest is that it is critical to consider the key differences between HELLP and other PIH-related entities.

Of note, within this recent update of the Society of Obstetricians and Gynecologists of Canada (SOGC) guidelines they state that:

“Definitions of severe preeclampsia vary, but most include multi-organ involvement. We modified our definition of severe preeclampsia to preeclampsia associated with one or more severe complications. Severe preeclampsia now warrants delivery regardless of gestational age. Our definition excludes heavy proteinuria and HELLP syndrome, which are not absolute indications for delivery, and includes stroke and pulmonary edema, which are leading causes of maternal death in preeclampsia.” – Pg 422, SOGC guidelines [2]

For Canadian learners, it is best to understand that there is controversy about definitions of severe preeclampsia internationally. The SOGC, however, is the main body that sets the national standards in Canada. Hence, it is worthwhile being familiar with what our Canadian experts have defined as Severe Preeclampsia – and with the 2014 guideline, it is noted that they excluded heavy proteinuria and HELLP syndrome from the definition for preeclampsia because these two diagnoses are not absolute indications for delivery.

That said, on page 421 they state that:

“HELLP syndrome is represented by its component parts (hemolysis, elevated liver enzymes, and low platelets), to which we react to by initiating delivery.”

This statement implies that usually a patient presenting with HELLP may very well require emergent delivery. As such, it is imperative, as you have stated, to alert obstetrics early and involve them in the decision making for this case.

One more note, the 125th recommendation urges practitioners to bear in mind the delay between ordering and receiving platelets (Level III-B) – and hence, if you are a first line practitioner with a patient whose platelets are low, it will be important to alert the obstetrical team and perhaps even begin ordering (+/- transfusing) platelets if the patient has HELLP syndrome (and particularly if the platelet count is < 20 x 109 /L as detailed in recommendation 126 (Level III-B). [2, p. 432]).

Addendum (Aug 14, 2014 12:03pm): Of note, the pregnancy-induced hypertension pathologies can occur in women in the postpartum period.  At the 6 week postpartum check up it is important to consider this critical diagnosis. (Thanks to Taylor Zhou for requesting this amendment as a post-publication peer review.)


 

References

1. Nabhan, A., & Elsedawy, M. (2011). Tight control of mild-moderate pre-existing or non-proteinuric gestational hypertension. The Cochrane Collaboration. Retrieved from http://onlinelibrary.wiley.com/store/10.1002/14651858.CD006907.pub2/asset/CD006907.pdf?v=1&t=hxvw2the&s=71494c9ecf58b33d930f62ee724ce5a38fff3029

2. Rey, E., Pels, A., von Dadelszen, P., Helewa, M., & Magee, L. (2014, May). Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: Executive summary. Retrieved from http://sogc.org/wp-content/uploads/2014/05/gui307CPG1405Erev.pd PMID: 21735406

Author information

Sarah Luckett-Gatopoulos
Sarah Luckett-Gatopoulos
Junior Resident Editor at BoringEM
Sarah is a resident at McMaster University. She has an interest in creative writing and health literacy.

The post Tiny Tip: HELLP Syndrome appeared first on BoringEM and was written by Sarah Luckett-Gatopoulos.

Boring Question: Dizzy, need a few HINTS?

The dizzy patient. If you haven’t seen a patient with this chief complaint, you either don’t work in an emergency department or you work in an imaginary emergency medicine utopia! Admit it, when you pick up the chart that reads “chief complaint…dizzy”, you look around inconspicuously, slowly replace that chart in the rack… and run quickly become preoccupied with some fascinating task from… oh… somewhere over there! But why? It is not because we do not like dizzy patients… It is because when the patient complains of ‘dizziness,’ it can mean so many things that it makes it hard for us to diagnose and solve the problem.

“Dizzy” is a vague problem that can be caused by a long list of diagnoses including critical or life-threatening diagnoses (e.g. posterior circulation infarction) that mimic benign causes of dizziness. Wouldn’t it be great if there was a blood test to rule-out serious pathology among dizzy patients? Unfortunately, we’re more likely to put humans on Mars than come up with such a test, so instead we are left to work up dizzy patients using our clinical skills and some focused diagnostic tests. 

This post will present the case of a dizzy patient and outline how the HINTS examination can be integrated into our evaluation.

CASE

A 72 year old woman presents after acute onset “dizziness” that has been continuous for 36 hours. She describes feeling nauseated (without vomiting) and unsteady while ambulating. She has a history of hypertension but no other relevant medical history. Her vital signs are normal and exam demonstrates slight difficulty walking and horizontal nystagmus on right lateral gaze. The remainder of neurologic exam is normal. You wonder if this could be a posterior circulation infarct or is it simply a benign case of vertigo? You can’t get an MRI easily for several days so the decision needs to be made now. While you are considering your super keen medical students asks if the HINTS exam can play a role in sorting out the diagnosis for this patient.

Boring Question: What is the role of the HINTS examination in the evaluation of the dizzy patient?

The Head Impulse Nystagmus Test of Skew (HINTS) exam is a promising bedside test designed to differentiate between peripheral and central causes of acute vestibular syndrome (AVS). AVS is characterized by acute onset vertigo with associated nausea/vomiting, nystagmus, unsteady gait and head motion that persist >24hrs [1]. In most instances, HINTS is used to differentiate between vestibular neuritis and a posterior circulation infarct. However it may also identify other important central causes of AVS including mass lesions or demyelinating syndromes [2].

The HINTS Test comprises 3 parts [2]

  1. Head impulse test (HIT) – the examiner performs rapid, passive head rotation of the patient while the patient fixates on the nose of the examiner; a peripheral etiology will cause a corrective saccade that is considered “abnormal” while a central cause of vertigo will lack any saccade thus considered “normal”. Bottom line is that “abnormal” is a good thing for the HIT and “normal” suggests a central etiology
  1. Nystagmus type – identification of nystagmus type by smooth pursuit of extra ocular movements:
    1. Central etiology = bilateral, direction-changing, horizontal nystagmus or primarily vertical nystagmus
    2. Peripheral etiology = nystagmus is unilateral, horizontal nystagmus
  1. Test of skew (alternate cover test) – in central causes of vertigo, covering of one eye results in subtle movement of the uncovered eye

This may be a bit overwhelming so I recommend watching this great video describing the HINTS exam [3,4]

HOW TO INTERPRET THE RESULTS OF HINTS?

 HINTS exam in peripheral vertigo

Unilateral “abnormal” head impulse test PLUS unilateral horizontal nystagmus without any skew deviation.

 HINTS exam in central vertigo

Any of, or combination of the following:

1)     bilateral “normal” HIT with any spontaneous or gaze-evoked nystagmus

2)     bilateral, direction-changing, horizontal gaze-evoked nystagmus

3)     skew deviation

Try using the mnemonic INFARCT to recall the findings in central vertigo. INFARCT = (Impulse Normal or Fast-phase Alternating or Refixation on Cover-Test) [7]

THE EVIDENCE FOR HINTS?

  • Very strong – several studies report HINTS to be highly sensitive (96-100%) and highly specific (85-98%) for identifying stroke among patients with AVS [2, 5]
  • Impressively, HINTS exam was also more accurate than MRI to diagnose stroke in patients with AVS within the first 48hrs of symptoms [2]
  • Most studies used HINTS to differentiate posterior stroke from peripheral causes of AVS but it can be broadly to differentiate between any central vs peripheral pathology [6]
  • A recent review highlights the impressive accuracy of HINTS in vertigo [6]

CONSIDERATIONS FOR HINTS EXAM

  1. It should ONLY be used for persistent and continuous vertigo. A patient without vertigo during the exam will have a “normal” head impulse test which is the same finding that will occur in a patient with central vertigo
  1. The few studies that exist have enrolled patients with vertigo >1hr since most patients present soon after the onset. So while AVS is technically defined as >24hrs, you can use the HINTS exam if it’s <24hrs as long as the symptoms are continuous
  1. Most of the studies required that patients had at least one risk factor for stroke. As a result the populations studied may have a higher risk of a central etiology. At this time it is unclear the accuracy of HINTS among lower risk populations (e.g. 40 year old male without any other risk factors)
  1. In one study patients were included if they had “vertigo” or “dizziness” plus the other components of AVS . So don’t necessarily exclude your patient because they don’t use the term “vertigo” [2]. However, do your best to establish that they’re experiencing the sensation of movement (either self- or external referenced)
  1. Finally, the majority of studies evaluating the utility of HINTS had highly trained clinicians performing the neurologic evaluations [2,5,8]. The data has not been externally validated among a general population of emergency physicians. So proceed with caution! We shouldn’t expect the same high sensitivity and specificity when used by non-expert clinicians.

BACK TO THE CASE

Symptomatic relief using anti-nausea medications results in some symptomatic improvement of the patient but the symptoms do not entirely resolve. You perform the HINTS exam on the patient. She has a “normal” head impulse test without any saccade. She has unilateral, gaze-evoked nystagmus without any vertical or bidirectional nystagmus. And there is no skew deviation. Based on these findings you’re concerned there is a central cause for her vertigo. She is referred and admitted to the neurology team. An MRI the following day confirms a cerebellar infarct.

CONCLUSION

  • The HINTS exam has an important role in the evaluation of AVS based on existing data
  • It is highly accurate in identifying central causes of AVS, perhaps superior to MRI in early stages
  • These impressive results we however comes from one centre where highly trained experts performed the exam so if there is any uncertainty do not rely exclusively on HINTS for diagnosis

This post was edited by Teresa Chan (@TChanMD)

References

1. Hotson, J. R., & Baloh, R. W. (1998). Acute vestibular syndrome. New England Journal of Medicine339(10), 680-685. DOI: 10.1056/NEJM199809033391007

2. Newman‐Toker, D. E., Kerber, K. A., Hsieh, Y. H., Pula, J. H., Omron, R., Saber Tehrani, A. S., … & Kattah, J. C. (2013). HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Academic Emergency Medicine20(10), 986-996. Link

3. EMCrit http://emcrit.org/misc/posterior-stroke-video/ and the original source of the videos is http://novel.utah.edu/Newman-Toker/collection.php

4. Newman-Toker D. 3-Component H.I.N.T.S. battery. (2009). Retrieved at: http://content.lib.utah.edu/cdm/singleitem/collection/ehsl-dent/id/6

5. Chen, L., Lee, W., Chambers, B. R., & Dewey, H. M. (2011). Diagnostic accuracy of acute vestibular syndrome at the bedside in a stroke unit. Journal of neurology258(5), 855-861. DOI: 10.1007/s00415-010-5853-4

6. Cohn, B. (2014). Can Bedside Oculomotor (HINTS) Testing Differentiate Central From Peripheral Causes of Vertigo?. Annals of emergency medicine. In Press. DOI: 10.1016/j.annemergmed.2014.01.010

7. Newman-Toker D. Acute Vestibulary Syndrome (n.d.) Retrieved at: http://content.lib.utah.edu/utils/getfile/collection/ehsl-dent/id/7/filename/5.pdf

8. Kattah, J. C., Talkad, A. V., Wang, D. Z., Hsieh, Y. H., & Newman-Toker, D. E. (2009). HINTS to diagnose stroke in the acute vestibular syndrome three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke40(11), 3504-3510. DOI: 10.1161/​STROKEAHA.109.551234

Author information

Andrew Petrosoniak
Andrew Petrosoniak

The post Boring Question: Dizzy, need a few HINTS? appeared first on BoringEM and was written by Andrew Petrosoniak.

KT: High Five (strategies to effectively use online resources), Bro

Before we get too focused on research papers in the Knowledge Translation section, I thought I would highlight a relevant article from the Education/Resident’s perspective in the Annals of Emergency Medicine.  (Boring Disclosure: Two of BoringEM’s Editors, Brent Thoma and Teresa Chan, were authors of this paper.)

The Paper:
Five Strategies to Effectively Use Online Resources in Emergency Medicine (PMID: 24962889)

Why this paper is important?

Because it is a very practical article with tips and tricks relevant to newcomers and well-seasoned FOAMites. The lessons learned might also help connect you with that special article or topic that inspires you to write for BoringEM. It is also a good resource to share with colleagues just starting out online.

Catching up

There is a near-infinite amount of information that health professionals to learn, and an exponentially growing body of resources to help do so (PMID: 24554447). Numerous digital tools can be used to help organize an overwhelming amount of information. Testing those waters can be tricky and take time so these authors provide pro tips.

Bottom Line

Authors highlight 5 strategies to make the most of online resources.

STRATEGY 1: Use a Simple Syndication Reader (RSS)

RSS readers allows you to get information from all different blogs in one location instead of having to surf the web for hours.

STRATEGY 2: Use a Podcast Application

The same idea as an RSS reader but to organize and centrally locate podcasts.

STRATEGY 3: Use Compilations to Find Quality Resources

Use pre-selected, curated and collated content lists to stay up to date. Consider creating lists of your favourite resources to share with your learners and colleagues.

STRATEGY 4: Use Social Networks to Connect with Content Producers and Peers

Learning is social and online learning need not be any different. Being active on different social platforms allows you to stay up to date and also engage, not just with content, but with producers too.

STRATEGY 5: Use Custom Search Engines to Find resources When They are Needed

A custom search engine FOAMSearch only pulls hits from specific sites that are relevant to emergency medicine and critical care clinicians. It makes finding the information that you need, easier.

For more top tips give the article a read!

Eve Purdy (@purdy_eve)
MD Candidate, 2015
Medical Student Editor, BoringEM

Author information

Eve Purdy
Medical Student Editor at BoringEM
Fourth year medical student at Queen's University-happily consuming, sharing, creating and researching #FOAMed

The post KT: High Five (strategies to effectively use online resources), Bro appeared first on BoringEM and was written by Eve Purdy.

Basic Airway Assessment: It’s as easy as… 1-2-3?

In medical school, many multiple-choice questions in the setting of an acutely ill patient have an option of “managing the ABC’s” and it is always the correct answer.  Unfortunately, saying “I would manage the ABCs as my first priority” is very different from actually knowing how to assess an airway, let alone managing abnormalities during a trauma resuscitation.

If you think this is going to be some crazy airway blog post, think again.  This isn’t a sexy topic on cool, cutting-edge airway interventions…. It’s a bread and butter BoringEM topic that deserves attention. Read on for an approach to basic airway assessment.

Misconceptions about the “A” of ABC

The biggest misunderstanding is around the A of the ABC’s: Airway. In the trauma room I regularly hear the statement, ‘They are talking, so their airway is patent’.  This is inaccurate.  Patency is our primary concern in airway assessment, but the patient who can talk does not necessarily have a PATENT airway.  Think about a patient with bad airway edema from a laryngeal fracture, or a patient with an inhalational injury.  They can talk, but their airway may be closing nonetheless.  The ability to talk usually implies a PROTECTED airway, not a patent airway.  Lack of airway protection is a less urgent matter than patency.

PATENCY is assessed through the presence/absence of obstructive symptoms (stridor, secretions, snoring, etc.), or findings suggesting an airway that may become obstructed (singed nasal/facial hair, carbonaceous sputum, stab to neck with risk of expanding hematoma).

Managing the Airway

The next issue is that the indications for definitive airway management involve both airway and breathing, so just because the airway is patent and protected, it doesn’t mean the patient won’t need to be intubated.

In general, the indications for intubation are (Walls et al., 2012):

  1. Failure to oxygenate
  2. Failure to ventilate
  3. Failure to maintain airway patency
  4. Anticipated clinical course: going for imaging/OR (airway or breathing)

1 and 2 relate to breathing issues, 3 is about airway patency, and 4 is about airway protection.

Look before you Leap:  Assess the airway for difficulty of potential interventions

From here, there is confusion about assessing the airway for PATHOLOGY (patency and protection issues) versus INTERVENTIONS such as: Bag-Valve Mask ventilation (BONES or BOOTS), difficult Laryngoscopy & Endotracheal Intubation (LEMON), difficult Laryngeal Mask Airway (RODS) and difficult Surgical Airway (SHORT).

Deciding that something is wrong with the airway SHOULD be the easy part, and simple interventions will deal with the most immediate airway issue of obstruction. (These simple interventions being:  suction, jaw thrust, oral-pharyngeal airway, supplemental O2).

Deciding if a definitive intervention (i.e. intubation) is required and how to go about that takes a lot more experience and training. The table below contains mnemonics for assessing a patient for intubation, bag-malve-vask ventilation, LMA placement, and cricothyrotomy.

Airway mnemonics modified from the STARSTM Manual & Walls et al. (4th edition)

Difficulty Endotracheal Intubation Difficult Bag-Mask-Valve (BMV)
L   Look externally
E   Evaluate 3-3-2
M  Mallampati*
O  Obstruction/Obesity
N  Neck Mobility**
B Beard
O Obstructed/Obese/OSA
N Neck Stiffness / Neck Mass
E Expecting (Pregnant)
S Stridor / Snores (OSA)**
Difficult Laryngeal Mask Airway (LMA) Difficult Cricothyrotomy
R  Restricted Mouth Opening
O  Obstruction
D  Distorted airway anatomy
S  Stiff Lungs / Neck
S  Surgery
H  Hematoma, Have Infection (Abscess)
O  Obesity
R  Radiation
T  Trauma, Tumor

* this is of limited use in non-elective intubations (e.g. Trauma)
** technically, can add an extra “S” behind all these mnemonics, since Stiff Lungs always makes any positive pressure ventilation strategy more difficult.

A suggested approach to basic airway assessment

My approach to airway assessment for PATHOLOGY is to assess the “S’s” in 3 steps:

The S’s of Airway Pathology

Step 1: Is there evidence of airway OBSTRUCTION now – is it complete or partial?

Complete Obstruction:
Silence without chest rise or
See-Saw Chest movement (chest down, abdo up with attempted respiration – resulting from diaphragmatic excursion with a closed glottis/obstructed tongue)

*Complete airway obstruction needs immediate intervention – cardiac arrest is likely within seconds to minutes of complete airway obstruction.

Partial Obstruction
Stridor – airway swelling/compression by hematoma
Secretions – saliva, blood
Snoring – tongue relaxation
Smash – risk of teeth/blood in the airway

Interventions:
SIMPLE = jaw thrust, suction, OPA, supplemental Oxygen, BVM
ADVANCED = Definitive airway management

Step 2: Is there a risk of ANTICIPATED airway obstruction?

Singe or Sputum (carbonaceous) – risk of delayed airway swelling from inhalational burn
Stab or Swelling neck – risk of delayed airway compression from expanding hematoma or neck mass

Interventions:
Frequent re-assessment, early intervention (if skilled), early consultation with experts

Step 3: Is there a risk of Aspiration from failure to PROTECT their airway?

Sleepy (low GCS)

Interventions:
Definitive airway management if decreased LOC (impaired gag reflex) is going to be prolonged, is not easily reversible, is deteriorating, or if intubation will facilitate further investigations (ie CT Scan).

The level of consciousness can always change and along with it the ability to protect the airway from aspiration, however aspiration is not an immediate event the second your GCS hits 8 or less.  GCS < 8 is not an absolute indication for intubation.  Many intoxicated patients and post-ictal patients live with a GCS or 5 or 6 and wake up a few hours later.  They don’t usually aspirate, and can be managed without definitive airway protection. Alternatively the head-injured trauma patient with a GCS of 12 at presentation that is a 10 now probably needs definitive airway management.

Conclusion

Always assess the S’s of the Airway.  If they are all normal, you can be confident that you are NOT dealing with an immediate or impending airway issue of patency or protection.  If there are abnormalities in the S’s, simple airway interventions will temporize the situation until more experienced providers can assist with definitive airway interventions. The table below summarizes the three steps and nine S’s. This approach is illustrated in 3 cases below.

  Step 1: Is there evidence of airway obstruction now? Step 2: Is there a risk of anticipated airway obstruction? Step 3:Is there a risk of Aspiration from failure to PROTECT their airway?
Signs Symptoms Complete Obstruction
Silence without chest rise
or
See-Saw Chest movementPartial Obstruction
Stridor – airway swelling/compression by hematoma
Secretions – saliva, blood
Snoring – tongue relaxation
Smash – risk of teeth/blood in the airway
Singe or Sputum (carbonaceous) – risk of delayed airway swelling from inhalational burnStab or Swelling neck – risk of delayed airway compression from expanding hematoma or neck mass  Sleepy (low GCS)

Cases

Case 1

44 y o male, assaulted to head/face with baseball bat.  Brought to ED in sitting position in c-spine precautions, normal Vital Sign, GCS 15.

Airway Assessment for Pathology:
Deformed nose bleeding into pharynx, difficulty opening mouth/sore jaw, spitting up blood continuously.  No trauma to neck, no stridor, no singed hairs or carbonaceous sputum, no see-saw respirations.

Q: What is going on with this patient’s airway?  What should you do immediately?
A: Partial airway obstruction from blood.  Awake and protecting airway.  Manage this airway with suction +/- supplemental O2, upright positioning.

Airway Assessment for Intervention:
History of Sleep Apnea, Obese, Beard, Unable to open mouth (likely from mandible fracture), and no neck mobility (c-spine collar).

Q: How should you proceed?
A: This person is a predicted difficult BVM, Laryngoscopy, LMA and Surgical Airway!  If you do need to intervene for a drop in GCS or loss of patency you would need additional airway experts to definitively manage this airway safely. 

Case 2

36 y o female single vehicle rollover on highway, brought in c-spine precautions.  GCS initially 15/15 by EMS, no signs of external head injury/trauma, complaining of abdominal pain.  Initial Vitals: HR 115, BP 92/68, RR/O2 sats normal.  On arrival to hospital, GCS now 11, HR 130, BP 68/40 with a distended abdomen (not pregnant).

Airway Assessment for Pathology:
Snoring respirations. No secretions, stridor, see-saw resps, singe or stab/swelling to neck.

Q: What is going on with this patient’s airway?  What should you do immediately?
A: This patient has a partial obstruction from her tongue due to decreased LOC and should be treated with jaw thrust/OPA/supplemental O2. Additionally, she may fail to protect her airway due to a low GCS secondary to hypovolemic shock.  Her ability to protect her airway is likely to correct with blood transfusion.

Airway Assessment for Intervention:
This patient has no predictors of difficult airway intervention except for a c-spine collar.

Q: How will you proceed?
A: Don’t just do something… Stand there!  Intubation comes with a significant risk of hypotension, both from the drugs given as well as the effect of positive pressure ventilation on pre-load.  You would NOT want to intubate this patient until their BP improved, or you might end up running a code.  If their BP improves, it is likely that their LOC will as well, so you probably won’t need to intubate at all.

Case 3

14 y o male flipped his quad, with quad landing on his head, brought in c-spine precautions.  EMS reports the helmet to be split in two.  GCS 12 (E4, V3, M3) with blood draining from both ears.  No visible trauma to chest/abdo or extremities.  HR 55, BP 177/94, RR/O2 sats normal.

Airway Assessment for Pathology:
Low and declining GCS. No see-saw resps, snoring, secretions, stridor, smash, stab, singe.

Q: What is going on with this patient’s airway?  What should you do immediately?
A:  This patient is at risk of failing to protect airway and has obvious signs of skull fracture for which they will need a CT scan.  Although the GCS is more than 8, it is deteriorating.  Also, the most predictive aspect of the GCS is the motor score.  As this patient is demonstrating flexor posturing and early Cushing’s response (hypertension/bradycardia), there is a high likelihood of intra-cranial injury.  This patient will likely need to be intubated.

Airway Assessment for Intervention:
There are no predictors of difficult airway intervention in this patient except for c-spine collar.

Q: How will you proceed?
A:  You need to get definitive control of this patient’s airway.  Hypoxemia and hypotension contribute to secondary brain injury, so management of this airway should pay close attention to these issues.  You would want to use apneic oxygenation as part of your RSI to mitigate the risk of hypoxemia, and choose a sedative agent that will maintain their blood pressure.

Case 4

56 yo female trapped in a housefire, no traumatic injuries.  Wheezy and SOB on scene once extricated from hospital, treated with Salbutamol nebulizer en route to hospital by EMS.  Wheeze/SOB settled upon ED arrival. Normal vital signs, GSC 15.

Airway Assessment for Pathology:
Black soot at the back of the throat, singed eyebrows.  No stridor, secretions, snoring, see-saw respirations, stab.

Q: What is going on with this patient’s airway?  What should you do immediately?
A: There is an impending loss of airway patency from airway edema.  Consider early intubation before airway before the swelling makes passing an Endotracheal tube difficult or impossible.

Airway Assessment for Intervention:
No predictors of difficulty for airway intervention.

Q: How will you proceed?
A:  Early definite airway management under the auspices of impending airway loss.  It’s impossible to know if she will swell in her airway or not, but if she does it could be life threatening.  Early management is the usual approach if there is reasonable suspicion for inhalational burn, although at times it is an unnecessary intervention.

Author information

Rob Woods
Rob Woods
Program Director at University of Saskatchewan
Rob Woods is the Program Director of the University of Saskatchewan Emergency Medicine Residency Program

The post Basic Airway Assessment: It’s as easy as… 1-2-3? appeared first on BoringEM and was written by Rob Woods.

Basic Airway Assessment: It’s as easy as… 1-2-3?

In medical school, many multiple-choice questions in the setting of an acutely ill patient have an option of “managing the ABC’s” and it is always the correct answer.  Unfortunately, saying “I would manage the ABCs as my first priority” is very different from actually knowing how to assess an airway, let alone managing abnormalities during a trauma resuscitation.

If you think this is going to be some crazy airway blog post, think again.  This isn’t a sexy topic on cool, cutting-edge airway interventions…. It’s a bread and butter BoringEM topic that deserves attention. Read on for an approach to basic airway assessment.

Misconceptions about the “A” of ABC

The biggest misunderstanding is around the A of the ABC’s: Airway. In the trauma room I regularly hear the statement, ‘They are talking, so their airway is patent’.  This is inaccurate.  Patency is our primary concern in airway assessment, but the patient who can talk does not necessarily have a PATENT airway.  Think about a patient with bad airway edema from a laryngeal fracture, or a patient with an inhalational injury.  They can talk, but their airway may be closing nonetheless.  The ability to talk usually implies a PROTECTED airway, not a patent airway.  Lack of airway protection is a less urgent matter than patency.

PATENCY is assessed through the presence/absence of obstructive symptoms (stridor, secretions, snoring, etc.), or findings suggesting an airway that may become obstructed (singed nasal/facial hair, carbonaceous sputum, stab to neck with risk of expanding hematoma).

Managing the Airway

The next issue is that the indications for definitive airway management involve both airway and breathing, so just because the airway is patent and protected, it doesn’t mean the patient won’t need to be intubated.

In general, the indications for intubation are (Walls et al., 2012):

  1. Failure to oxygenate
  2. Failure to ventilate
  3. Failure to maintain airway patency
  4. Anticipated clinical course: going for imaging/OR (airway or breathing)

1 and 2 relate to breathing issues, 3 is about airway patency, and 4 is about airway protection.

Look before you Leap:  Assess the airway for difficulty of potential interventions

From here, there is confusion about assessing the airway for PATHOLOGY (patency and protection issues) versus INTERVENTIONS such as: Bag-Valve Mask ventilation (BONES or BOOTS), difficult Laryngoscopy & Endotracheal Intubation (LEMON), difficult Laryngeal Mask Airway (RODS) and difficult Surgical Airway (SHORT).

Deciding that something is wrong with the airway SHOULD be the easy part, and simple interventions will deal with the most immediate airway issue of obstruction. (These simple interventions being:  suction, jaw thrust, oral-pharyngeal airway, supplemental O2).

Deciding if a definitive intervention (i.e. intubation) is required and how to go about that takes a lot more experience and training. The table below contains mnemonics for assessing a patient for intubation, bag-malve-vask ventilation, LMA placement, and cricothyrotomy.

Airway mnemonics modified from the STARSTM Manual & Walls et al. (4th edition)

Difficulty Endotracheal Intubation Difficult Bag-Mask-Valve (BMV)
L   Look externally
E   Evaluate 3-3-2
M  Mallampati*
O  Obstruction/Obesity
N  Neck Mobility**
B Beard
O Obstructed/Obese/OSA
N Neck Stiffness / Neck Mass
E Expecting (Pregnant)
S Stridor / Snores (OSA)**
Difficult Laryngeal Mask Airway (LMA) Difficult Cricothyrotomy
R  Restricted Mouth Opening
O  Obstruction
D  Distorted airway anatomy
S  Stiff Lungs / Neck
S  Surgery
H  Hematoma, Have Infection (Abscess)
O  Obesity
R  Radiation
T  Trauma, Tumor

* this is of limited use in non-elective intubations (e.g. Trauma)
** technically, can add an extra “S” behind all these mnemonics, since Stiff Lungs always makes any positive pressure ventilation strategy more difficult.

A suggested approach to basic airway assessment

My approach to airway assessment for PATHOLOGY is to assess the “S’s” in 3 steps:

The S’s of Airway Pathology

Step 1: Is there evidence of airway OBSTRUCTION now – is it complete or partial?

Complete Obstruction:
Silence without chest rise or
See-Saw Chest movement (chest down, abdo up with attempted respiration – resulting from diaphragmatic excursion with a closed glottis/obstructed tongue)

*Complete airway obstruction needs immediate intervention – cardiac arrest is likely within seconds to minutes of complete airway obstruction.

Partial Obstruction
Stridor – airway swelling/compression by hematoma
Secretions – saliva, blood
Snoring – tongue relaxation
Smash – risk of teeth/blood in the airway

Interventions:
SIMPLE = jaw thrust, suction, OPA, supplemental Oxygen, BVM
ADVANCED = Definitive airway management

Step 2: Is there a risk of ANTICIPATED airway obstruction?

Singe or Sputum (carbonaceous) – risk of delayed airway swelling from inhalational burn
Stab or Swelling neck – risk of delayed airway compression from expanding hematoma or neck mass

Interventions:
Frequent re-assessment, early intervention (if skilled), early consultation with experts

Step 3: Is there a risk of Aspiration from failure to PROTECT their airway?

Sleepy (low GCS)

Interventions:
Definitive airway management if decreased LOC (impaired gag reflex) is going to be prolonged, is not easily reversible, is deteriorating, or if intubation will facilitate further investigations (ie CT Scan).

The level of consciousness can always change and along with it the ability to protect the airway from aspiration, however aspiration is not an immediate event the second your GCS hits 8 or less.  GCS < 8 is not an absolute indication for intubation.  Many intoxicated patients and post-ictal patients live with a GCS or 5 or 6 and wake up a few hours later.  They don’t usually aspirate, and can be managed without definitive airway protection. Alternatively the head-injured trauma patient with a GCS of 12 at presentation that is a 10 now probably needs definitive airway management.

Conclusion

Always assess the S’s of the Airway.  If they are all normal, you can be confident that you are NOT dealing with an immediate or impending airway issue of patency or protection.  If there are abnormalities in the S’s, simple airway interventions will temporize the situation until more experienced providers can assist with definitive airway interventions. The table below summarizes the three steps and nine S’s. This approach is illustrated in 3 cases below.

  Step 1: Is there evidence of airway obstruction now? Step 2: Is there a risk of anticipated airway obstruction? Step 3:Is there a risk of Aspiration from failure to PROTECT their airway?
Signs Symptoms Complete Obstruction
Silence without chest rise
or
See-Saw Chest movementPartial Obstruction
Stridor – airway swelling/compression by hematoma
Secretions – saliva, blood
Snoring – tongue relaxation
Smash – risk of teeth/blood in the airway
Singe or Sputum (carbonaceous) – risk of delayed airway swelling from inhalational burnStab or Swelling neck – risk of delayed airway compression from expanding hematoma or neck mass  Sleepy (low GCS)

Cases

Case 1

44 y o male, assaulted to head/face with baseball bat.  Brought to ED in sitting position in c-spine precautions, normal Vital Sign, GCS 15.

Airway Assessment for Pathology:
Deformed nose bleeding into pharynx, difficulty opening mouth/sore jaw, spitting up blood continuously.  No trauma to neck, no stridor, no singed hairs or carbonaceous sputum, no see-saw respirations.

Q: What is going on with this patient’s airway?  What should you do immediately?
A: Partial airway obstruction from blood.  Awake and protecting airway.  Manage this airway with suction +/- supplemental O2, upright positioning.

Airway Assessment for Intervention:
History of Sleep Apnea, Obese, Beard, Unable to open mouth (likely from mandible fracture), and no neck mobility (c-spine collar).

Q: How should you proceed?
A: This person is a predicted difficult BVM, Laryngoscopy, LMA and Surgical Airway!  If you do need to intervene for a drop in GCS or loss of patency you would need additional airway experts to definitively manage this airway safely. 

Case 2

36 y o female single vehicle rollover on highway, brought in c-spine precautions.  GCS initially 15/15 by EMS, no signs of external head injury/trauma, complaining of abdominal pain.  Initial Vitals: HR 115, BP 92/68, RR/O2 sats normal.  On arrival to hospital, GCS now 11, HR 130, BP 68/40 with a distended abdomen (not pregnant).

Airway Assessment for Pathology:
Snoring respirations. No secretions, stridor, see-saw resps, singe or stab/swelling to neck.

Q: What is going on with this patient’s airway?  What should you do immediately?
A: This patient has a partial obstruction from her tongue due to decreased LOC and should be treated with jaw thrust/OPA/supplemental O2. Additionally, she may fail to protect her airway due to a low GCS secondary to hypovolemic shock.  Her ability to protect her airway is likely to correct with blood transfusion.

Airway Assessment for Intervention:
This patient has no predictors of difficult airway intervention except for a c-spine collar.

Q: How will you proceed?
A: Don’t just do something… Stand there!  Intubation comes with a significant risk of hypotension, both from the drugs given as well as the effect of positive pressure ventilation on pre-load.  You would NOT want to intubate this patient until their BP improved, or you might end up running a code.  If their BP improves, it is likely that their LOC will as well, so you probably won’t need to intubate at all.

Case 3

14 y o male flipped his quad, with quad landing on his head, brought in c-spine precautions.  EMS reports the helmet to be split in two.  GCS 12 (E4, V3, M3) with blood draining from both ears.  No visible trauma to chest/abdo or extremities.  HR 55, BP 177/94, RR/O2 sats normal.

Airway Assessment for Pathology:
Low and declining GCS. No see-saw resps, snoring, secretions, stridor, smash, stab, singe.

Q: What is going on with this patient’s airway?  What should you do immediately?
A:  This patient is at risk of failing to protect airway and has obvious signs of skull fracture for which they will need a CT scan.  Although the GCS is more than 8, it is deteriorating.  Also, the most predictive aspect of the GCS is the motor score.  As this patient is demonstrating flexor posturing and early Cushing’s response (hypertension/bradycardia), there is a high likelihood of intra-cranial injury.  This patient will likely need to be intubated.

Airway Assessment for Intervention:
There are no predictors of difficult airway intervention in this patient except for c-spine collar.

Q: How will you proceed?
A:  You need to get definitive control of this patient’s airway.  Hypoxemia and hypotension contribute to secondary brain injury, so management of this airway should pay close attention to these issues.  You would want to use apneic oxygenation as part of your RSI to mitigate the risk of hypoxemia, and choose a sedative agent that will maintain their blood pressure.

Case 4

56 yo female trapped in a housefire, no traumatic injuries.  Wheezy and SOB on scene once extricated from hospital, treated with Salbutamol nebulizer en route to hospital by EMS.  Wheeze/SOB settled upon ED arrival. Normal vital signs, GSC 15.

Airway Assessment for Pathology:
Black soot at the back of the throat, singed eyebrows.  No stridor, secretions, snoring, see-saw respirations, stab.

Q: What is going on with this patient’s airway?  What should you do immediately?
A: There is an impending loss of airway patency from airway edema.  Consider early intubation before airway before the swelling makes passing an Endotracheal tube difficult or impossible.

Airway Assessment for Intervention:
No predictors of difficulty for airway intervention.

Q: How will you proceed?
A:  Early definite airway management under the auspices of impending airway loss.  It’s impossible to know if she will swell in her airway or not, but if she does it could be life threatening.  Early management is the usual approach if there is reasonable suspicion for inhalational burn, although at times it is an unnecessary intervention.

Author information

Rob Woods
Rob Woods
Program Director at University of Saskatchewan
Rob Woods is the Program Director of the University of Saskatchewan Emergency Medicine Residency Program

The post Basic Airway Assessment: It’s as easy as… 1-2-3? appeared first on BoringEM and was written by Rob Woods.