REMI 2036. Ecografía para comprobar la intubación endotraqueal





Artículo originalDirect ultrasound methods: A confirmatory technique for proper endotracheal intubation in the emergency department. Abbassi S, Farsi D, Zare M, Hajimohammadi M, Rezai M, Hafezimoghadam P. Eur J Emerg Med 2015; 22: 10-16. [Resumen] [Artículos relacionados]
      
Introducción: Una de las situaciones más estresantes para los médicos que trabajamos en cuidados intensivos o en urgencias, es la del paciente con dificultades para la intubación y los riesgos que ello comporta. La ecografía cada vez nos ayuda en más situaciones con nuestros pacientes y también puede ser de ayuda en este campo.
      
Resumen: Se realiza un trabajo prospectivo en pacientes de urgencias que requieren intubación, sobre la utilidad de la ecografía como método de visualización de intubación apropiada en el momento de la introducción del tubo traqueal y de confirmación de dicha intubación. Usan un ecógrafo con una sonda lineal del 7,5-10 MHz observando a nivel de cartílago cricoides el paso del tubo traqueal y posteriormente realizan ecografia a nivel supraesternal y torácica para intentar identificar la profundidad de intubación y de desplazamiento pulmonar con la ventilación. Se estudia prospectivamente en 60 pacientes del área de urgencias. Se excluyen, entre otros, pacientes en parada cardiaca, trauma cervical y vía aérea anómala. Describen diferentes signos ecográficos para la visualización de la correcta intubación (“signo de la tormenta de nieve” cuando pasa el tubo a la traquea a nivel de la membrana cricotiroidea, el “signo de la bala”: cuando se “abre” la glotis al paso del tubo traqueal, visión de la interfases mucosa-aire para ver si el tubo está en traquea o esófago, etc..), dando unos valores del 98 al 100% en sensibilidad y especificidad para correcta intubación traqueal.
        
Comentario: El estudio referido tiene las limitaciones de ser realizado en un único centro, por un médico formado en ecografía de urgencias más de 2 años y no incluyendo pacientes con eventual mayor dificultad para la intubación. En cualquier caso, muestra otro nuevo campo en el que la ecografía aparece como una herramienta útil. Cada vez se hace más necesaria la formación en ecografía de los médicos de cuidados intensivos y que atienden pacientes críticos.
   
Antonio García Jiménez
Hospital Arquitecto Marcide, Ferrol, A Coruña.
© REMI, http://medicina-intensiva.com. Marzo 2015.
      
Enlaces:

  1. A feasibility study on bedside upper airway ultrasonography compared to waveform capnography for verifying endotracheal tube location after intubation. Adi O, Chuan TW, Rishya M. Crit Ultrasound J 2013; 5(1): 7. [PubMed]
  2. Real-time tracheal ultrasonography for confirmation of endotracheal tube placement during cardiopulmonary resuscitation. Chou HC, Chong KM, Sim SS, Ma MH, Liu SH, Chen NC, Wu MC, Fu CM, Wang CH, Lee CC, Lien WC, Chen SC. Resuscitation 2013; 84: 1708-1712. [PubMed]
  3. Ultrasonography for confirmation of endotracheal tube placement: A systematic review and meta-analysis. Chou EH1, Dickman E2, Tsou PY3, Tessaro M2, Tsai YM4, Ma MH5, Lee CC6, Marshall J2. Resuscitation 2015. [PubMed]
Búsqueda en PubMed:
  • Enunciado: Ultrasonidos durante la intubación traqueal
  • Sintaxis: intubation, intratracheal[mh] AND ultrasonography[mh] 
  • [Resultados]
                   

Episode 25 – Skin and Skin Structure Infections

(ITUNES OR LISTEN HERE) The Free Open Access Medical Education (FOAM) We review the post by Bryan Hayes, PharmD, FAACT on Academic Life in Emergency Medicine,  Sulfamethoxazole-Trimethoprim for Skin and Soft Tissue Infections: 1 or 2 Tablets BID? The Take Home: Most abscesses do not need antibiotics after incision and drainage.  If the patient has systemic signs […]

Syncope Sunday 2: reflex syncope

Neurally mediated syncope is a heterogenous group of autonomic disorders resulting in orthostatic intolerance. It peaks in toddlers and adolescents.

There are two main groups – reflex and postural orthostatic tachycardia syndrome (or autonomic failure). In this post, we will discuss reflex syncope.

This post is part of our Syncope Sunday series – you can read Post 1 here.

What is reflex syncope?

Reflex syncope is a sudden failure of the autonomic nervous system to maintain vascular tone during orthostatic stress.

There is hypotension and bradycardia; along with cerebral hypoperfusion and loss of consciousness. An individual may have an event characterised by a primary vasodepressor, cardioinhibitory, or a mixed response.

In reflex syncope there is a clear provoking factor.

Vasovagal syncope is the most common type of reflex syncope in children, but what exactly is it?

This is a benign reflex event.

There is depression of sympathetic vasomotor tone (‘vaso’) and associated parasympathetic mediated bradycardia (‘vagal’).

In vasovagal syncope there is clear provocation – tiredness, hunger, heat, dehydration

Often there is a prodromal sensation with short-lasting loss of consciousness and quick complete recovery.

So, what are reflex anoxic seizures?

There are non-epileptic paroxysmal events in infants and pre-school aged children provoked by pain or surprise.

8/1000 of pre-schoolers are affected.

Sudden vagal excitation following the trigger leads to a short period of asystole.

A better term to use is reflex asystolic syncope. This describes the event exactly and removes the confusion by using the word seizure – this is not a seizure

Asystole! That sounds awful...

The classic presentation of reflex asystolic syncope is:

  • Sudden and distressing stimulus such as injury or shock – child is described as deathly pale and lifeless.
  • A period of asystole that typically lasts 5 – 30 seconds.
  • Can have a brief convulsive phase.
  • The child comes around confused and distressed.

The convulsive phase may be dystonic posturing with asymmetrical or symmetrical jerking and occasionally incontinence which can increase diagnostic confusion for the physician. There may even be a short post-ictal phase.

This diagnosis falls in the hinterland between neurology and cardiology. It is generally managed by a general paediatrician.

The history is vital in diagnosing this. Clues include: provocation, deathly white, then collapse. Ask the family if this happened before – note that recurrent attacks may have no provocation but a previous episode will help give clues.

The post Syncope Sunday 2: reflex syncope appeared first on Don't Forget the Bubbles.

ECG of the Week – 2nd March 2015

These ECG's are from a 20 yr old female who presented to the Emergency Department following an episode of chest pain. At review she was pain free and all vital signs were normal. Her serial ECG's are below, there is ~30 mins between each ECG.




ECG 1
Click to enlarge

ECG 2
Click to enlarge
Things to think about


  • What are the key features on each ECG ?
  • What are the differential diagnoses for these features ?
  • How would you investigate this patient ?