"Sinuses are air pockets in your face."
(source: canned discharge instructions.)

"Sinuses are air pockets in your face."
(source: canned discharge instructions.)

"Death is a pretty worrying outcome."

Andy Neill



full context:

@rfdsdoc @mdaware death is a pretty worrying outcome - any reason? certainly hypotension common but usually related to inf speed

— Andy Neill (@AndyNeill) August 19, 2012

"Death is a pretty worrying outcome."

Andy Neill



full context:

@rfdsdoc @mdaware death is a pretty worrying outcome - any reason? certainly hypotension common but usually related to inf speed

— Andy Neill (@AndyNeill) August 19, 2012

New parrot toy for the dogs made unfortunate "polly wanna cracker" noise when squeezed.

Solution?

Laryngectomy.

New parrot toy for the dogs made unfortunate "polly wanna cracker" noise when squeezed.

Solution?

Laryngectomy.

I am not going to review or discuss the entire case of Rory Staunton. WhiteCoat did that very well, twice.

Briefly: previously healthy 12 year old scraped his arm in gym, goes to ED for fever and abdominal symptoms, discharged after evaluation (labs drawn but not resulted at the time showed elevated bands), and later came back with severe sepsis and unfortunately died. Jim Dwyer wrote an article about it in the New York Times that alleges that the sepsis was missed on the initial visit and shouldn't have been, and he names the ED doc who treated Rory on the initial visit.

What I will say is that while it's terrible that a healthy 12 year old kid died, from what we know about the case, this hardly seems like a "miss" or like it could have been avoided, unless we started admitting & antibiosing every febrile, tachycardic kid in every Pediatric ED. Which I think would cause many more problems than it solves. (What's the NNT for antibiotics for febrile/tachy kid?)

On WhiteCoat's second post on the subject, I made a comment ("Needle vs. haystack. Young healthy kids with non-dangerous viral infections can make bands, too.") and Jim Dwyer responded; for some reason my reply won't post.

So I emailed this to him directly (through the NYT website):

Mr. Dwyer, 

I tried to post a reply to your response on bands and infection, but for some reason it's not posting. 

You asked if the results (elevated WBC & high bands) were strongly  suggestive of a bacterial infection. They are not. While bands had previously been thought to be helpful in identifying serious bacterial infections, years of research have shown that they are a poor test, and are only indicative of a vigorous host response to infection or inflammation from any source, be it viral, bacterial, or non-infectious. 

There is a thorough review on the lack of utility of band counts here: 

Cornbleet PJ. Clinical utility of the band count. Clin Lab Med. 2002 Mar;22(1):101-36. 

Dr. Cornbleet reviews many studies, at least 18 of which are relevant here.

Some pertinent quotes from the paper are pasted below. 

The 84% false positive rate I quote from Cornbleet below demonstrates exactly what I meant by "needle in a haystack" -- of every 100 children with elevated bands, 84 of them do not have a serious bacterial infection. 

Seth Trueger
********@gmail.com
n.b. I am also posting this message to my website, mdaware.org

From Cornbleet:
Surprisingly, the clinical folklore of the band persists despite little mention of its diagnostic utility in current textbooks. Textbooks in internal medicine, hematology, and laboratory medicine do not recommend band counts for the diagnosis of infection, otherthan to mention that neutrophilia and left-shift typically accompany infection or inflammation.
Similarly, most pediatric textbooks do not advocate band counts for the diagnosis of infection in children over 3 months old.
...
The data indicate poor performance of the band count as a clinical laboratory test, with most positive likelihood ratios below 5 and most negative likelihood ratios above 0.2
...
Although Todd's initial study showed fairsensitivity and specificity for the algorithm, later studies by Morens and Rasmussen and Rasmussen
did not report good results. McCarthy and Dolan applied Todd's criteria to
hyperpyrexic children seen in the ED, but found an 84% false-positive rate.
...
Review of the literature provides little support for the
clinical utility of the band count in patients greater than 3 months of age.

Lots of smart people (in addition to WhiteCoat) have responded to (or should I say, against) Mr Dwyer, and I will concede that the situation is a bit unfair for him: our medical knowledge & training makes physicians well-suited to criticize his journalism...

I am not going to review or discuss the entire case of Rory Staunton. WhiteCoat did that very well, twice.

Briefly: previously healthy 12 year old scraped his arm in gym, goes to ED for fever and abdominal symptoms, discharged after evaluation (labs drawn but not resulted at the time showed elevated bands), and later came back with severe sepsis and unfortunately died. Jim Dwyer wrote an article about it in the New York Times that alleges that the sepsis was missed on the initial visit and shouldn't have been, and he names the ED doc who treated Rory on the initial visit.

What I will say is that while it's terrible that a healthy 12 year old kid died, from what we know about the case, this hardly seems like a "miss" or like it could have been avoided, unless we started admitting & antibiosing every febrile, tachycardic kid in every Pediatric ED. Which I think would cause many more problems than it solves. (What's the NNT for antibiotics for febrile/tachy kid?)

On WhiteCoat's second post on the subject, I made a comment ("Needle vs. haystack. Young healthy kids with non-dangerous viral infections can make bands, too.") and Jim Dwyer responded; for some reason my reply won't post.

So I emailed this to him directly (through the NYT website):

Mr. Dwyer, 

I tried to post a reply to your response on bands and infection, but for some reason it's not posting. 

You asked if the results (elevated WBC & high bands) were strongly  suggestive of a bacterial infection. They are not. While bands had previously been thought to be helpful in identifying serious bacterial infections, years of research have shown that they are a poor test, and are only indicative of a vigorous host response to infection or inflammation from any source, be it viral, bacterial, or non-infectious. 

There is a thorough review on the lack of utility of band counts here: 

Cornbleet PJ. Clinical utility of the band count. Clin Lab Med. 2002 Mar;22(1):101-36. 

Dr. Cornbleet reviews many studies, at least 18 of which are relevant here.

Some pertinent quotes from the paper are pasted below. 

The 84% false positive rate I quote from Cornbleet below demonstrates exactly what I meant by "needle in a haystack" -- of every 100 children with elevated bands, 84 of them do not have a serious bacterial infection. 

Seth Trueger
********@gmail.com
n.b. I am also posting this message to my website, mdaware.org

From Cornbleet:
Surprisingly, the clinical folklore of the band persists despite little mention of its diagnostic utility in current textbooks. Textbooks in internal medicine, hematology, and laboratory medicine do not recommend band counts for the diagnosis of infection, otherthan to mention that neutrophilia and left-shift typically accompany infection or inflammation.
Similarly, most pediatric textbooks do not advocate band counts for the diagnosis of infection in children over 3 months old.
...
The data indicate poor performance of the band count as a clinical laboratory test, with most positive likelihood ratios below 5 and most negative likelihood ratios above 0.2
...
Although Todd's initial study showed fairsensitivity and specificity for the algorithm, later studies by Morens and Rasmussen and Rasmussen
did not report good results. McCarthy and Dolan applied Todd's criteria to
hyperpyrexic children seen in the ED, but found an 84% false-positive rate.
...
Review of the literature provides little support for the
clinical utility of the band count in patients greater than 3 months of age.

Lots of smart people (in addition to WhiteCoat) have responded to (or should I say, against) Mr Dwyer, and I will concede that the situation is a bit unfair for him: our medical knowledge & training makes physicians well-suited to criticize his journalism...

The final chapter in my discussion with Haney Mallemat on ultrasound-guided central access. Unfortunately the recording got cut off but 12 minutes made it!

A plethora of related links below.

See also:

Prequel: Subclavian Ultrasound
8 min screencast on how to place a subclavian under US guidance

Episode 1: Questions for Haney on SCUS
My response to his SCUS video

Episode 2: Answers from Haney on SCUS
Haney's response to my response to his SCUS video

Matt Pirotte: Why you should never (rarely) do a femoral line

PHARM: Podcast 20 : Femoral Vein Access the root of all EVIL? with Dr Mathew Pirotte

EMCrit's central line tutorial (including the safe way to place a blind SC)

Dr G on FEAST: Fluid therapy in shocked children - NEJM article
One of many responses to the FEAST trial (Dr G's is a nice, brief overview but the formatting on his site is off; highlight the text to make it readable -- ctrl-A or command-a works)


note: nobody involved is sponsored by Skype, Vimeo, the makers of rocuronium, or anything else mentioned

The final chapter in my discussion with Haney Mallemat on ultrasound-guided central access. Unfortunately the recording got cut off but 12 minutes made it!

A plethora of related links below.

See also:

Prequel: Subclavian Ultrasound
8 min screencast on how to place a subclavian under US guidance

Episode 1: Questions for Haney on SCUS
My response to his SCUS video

Episode 2: Answers from Haney on SCUS
Haney's response to my response to his SCUS video

Matt Pirotte: Why you should never (rarely) do a femoral line

PHARM: Podcast 20 : Femoral Vein Access the root of all EVIL? with Dr Mathew Pirotte

EMCrit's central line tutorial (including the safe way to place a blind SC)

Dr G on FEAST: Fluid therapy in shocked children - NEJM article
One of many responses to the FEAST trial (Dr G's is a nice, brief overview but the formatting on his site is off; highlight the text to make it readable -- ctrl-A or command-a works)


note: nobody involved is sponsored by Skype, Vimeo, the makers of rocuronium, or anything else mentioned

can you believe how little most businessmen know about the practice of medicine?@drjonathan
-- Seth Trueger (@MDaware) August 12, 2012

see also: Patients Aren't Customers

can you believe how little most businessmen know about the practice of medicine?@drjonathan
-- Seth Trueger (@MDaware) August 12, 2012

see also: Patients Aren't Customers

Jeopardy! host Alex Trebek

Haney Mallemat responds to my response to his great screencast on placing subclavian central lines with US:

1) Doppler - This is a great point. Although most commercial point-of-care machines now have pulse wave Doppler, some older machines may not. My response?...get a new machine ;) , or use color Doppler which should work just fine. The only problem is when the vessels are very close and one vessel creates alterations of flow and color in the other vessel. To a person with a moderate amount of ultrasound experience this may not be a problem, but when I've taught folks with little to no U/S experience I find they have trouble with the color distinction. This is why I choose pulse wave Doppler; it allows you to put the interesting area in the middle of the sample volume (that thing that looks like an equals sign) and you get accurate information without the other "noise". Just a preference.

2) PTX in SC - True, the risk of PTX may be overblown and ultrasound might be like medical school (i.e., the more you know/see, the more paranoid you get...) However, I am a firm believer in that if I have the ability (and time) to do a procedure "un"blinded "and see anatomy, I will (and this logic goes for the puny, little radial arterial line too; I always try to use U/S). I'll will also play devil's advocate and ask, "should trainee's ditch the blind subclavian approach for U/S"? No, I think that would be a HUGE mistake as this line should be mastered blindly. The addition of ultrasound is just another trick up my sleeve that makes procedures safer and increases success when others can't get the line.  

3) Ultrasound Saves Time - I don't think that U/S adds time; I feel that's a perception and the U/S studies don't support that notion. 100% agree with you that U/S gets the line done sooner because it's done one time. I think people that argue against ultrasound are in the "generational" gap and don't want to learn something with a moderate learning curve. It might be cool if they just said that but I find it hard to believe (and argue) against people who state that they can do central lines WITHOUT U/S faster and with the same complications as U/S....the data doesn't support that. If true, however, those people should do a study and publish...that paper would be a "game changer"  

4) Femoral Lines - I'll insert your points with my comments in parenthesis:
Seth:Femoral lines are terrible in codes (Well...maybe not terrible, but not my first choice)
Seth: The vein collapses during hypotension, making it hard to find and harder to cannulate (Yes, I agree)
Seth: It can appear arterial (by palpation or US) as chest compressions push both ways (Yes, I agree)
Seth: Landmarks & anatomy are unreliable (Yes, I agree)
Seth: I'm not saying to never use place a femoral line, but if you do I really think you should absolutely use ultrasound (Yes, I agree. Always w/ ultrasound)
I personally wouldn't place an U/S guided IJ or SC during a code. My personal preferences in descending order are 1)IO 2)Fem w/ U/S 3)Blind Subclavian 4)Blind supraclavicular (one of my favorite procedures)

5) No Neck? - That left IJ is actually the subclavian I placed. We had to come anterior because the needle was not long enough and we went perpendicularly into the skin. The dialysis line was placed by IR during business hours. 

Jeopardy! host Alex Trebek

Haney Mallemat responds to my response to his great screencast on placing subclavian central lines with US:

1) Doppler - This is a great point. Although most commercial point-of-care machines now have pulse wave Doppler, some older machines may not. My response?...get a new machine ;) , or use color Doppler which should work just fine. The only problem is when the vessels are very close and one vessel creates alterations of flow and color in the other vessel. To a person with a moderate amount of ultrasound experience this may not be a problem, but when I've taught folks with little to no U/S experience I find they have trouble with the color distinction. This is why I choose pulse wave Doppler; it allows you to put the interesting area in the middle of the sample volume (that thing that looks like an equals sign) and you get accurate information without the other "noise". Just a preference.

2) PTX in SC - True, the risk of PTX may be overblown and ultrasound might be like medical school (i.e., the more you know/see, the more paranoid you get...) However, I am a firm believer in that if I have the ability (and time) to do a procedure "un"blinded "and see anatomy, I will (and this logic goes for the puny, little radial arterial line too; I always try to use U/S). I'll will also play devil's advocate and ask, "should trainee's ditch the blind subclavian approach for U/S"? No, I think that would be a HUGE mistake as this line should be mastered blindly. The addition of ultrasound is just another trick up my sleeve that makes procedures safer and increases success when others can't get the line.  

3) Ultrasound Saves Time - I don't think that U/S adds time; I feel that's a perception and the U/S studies don't support that notion. 100% agree with you that U/S gets the line done sooner because it's done one time. I think people that argue against ultrasound are in the "generational" gap and don't want to learn something with a moderate learning curve. It might be cool if they just said that but I find it hard to believe (and argue) against people who state that they can do central lines WITHOUT U/S faster and with the same complications as U/S....the data doesn't support that. If true, however, those people should do a study and publish...that paper would be a "game changer"  

4) Femoral Lines - I'll insert your points with my comments in parenthesis:
Seth:Femoral lines are terrible in codes (Well...maybe not terrible, but not my first choice)
Seth: The vein collapses during hypotension, making it hard to find and harder to cannulate (Yes, I agree)
Seth: It can appear arterial (by palpation or US) as chest compressions push both ways (Yes, I agree)
Seth: Landmarks & anatomy are unreliable (Yes, I agree)
Seth: I'm not saying to never use place a femoral line, but if you do I really think you should absolutely use ultrasound (Yes, I agree. Always w/ ultrasound)
I personally wouldn't place an U/S guided IJ or SC during a code. My personal preferences in descending order are 1)IO 2)Fem w/ U/S 3)Blind Subclavian 4)Blind supraclavicular (one of my favorite procedures)

5) No Neck? - That left IJ is actually the subclavian I placed. We had to come anterior because the needle was not long enough and we went perpendicularly into the skin. The dialysis line was placed by IR during business hours. 

Haney Mallemat (EM/IM/CCM@UMEM) just put together a great screencast on subclavian ultrasound for CVC placement. Definitely worth the ~8 min watch.

I had a few questions for Haney and some opinions of my own so I figured I'd put it here instead of in discrete, 140-character (minus @tags) snippets.

To be clear: I think this is a great talk about a simple way to improve a procedure; these are just little bits around the edges.

1) Doppler

You describe how to use doppler to identify the vein vs artery. I think that's a great idea (and I do it occasionally, mostly to ID the IVC when assessing fluid responsiveness) but it can be a little technically difficult, particularly since some machines (including one of my current ones) can't do it.

I use color doppler rather liberally to ID vessels -- arteries give you big, colorful, pulsatile bursts; veins smolder.

2) PTX in SC

You mention the risk of pneumothorax with SC, and I love the picture of the proximity of the pleura to the vein we generally stab at blindly. However, is the risk overblown? We know how to recognize & treat pneumothoraces, and Scott Weingart contends that with proper technique (needle stays parallel to floor the entire time) the risk is minimized.

3) Ultrasound Saves Time

People who are reluctant to use US often cite the extra time needed to use US when placing a line (you allude to this, too, despite your clear preference for US!).

My feeling* is that US saves time for central lines. Maybe not for the simple, 1&done easily placed lines.

But a lot of them aren't that simple. There's probably some bimodal distribution of lines: some go in right away and another big chunk involve rooting around in soft tissue and kinking the heck out of wires for 20-30 minutes. Facility with US really helps minimize the second group, increase the 1&dones, really adds only a minute to wheel over the machine and place a probe cover, and is not difficult at all. (And you can do all of this alone.) And it shows you exactly where to go.

I really think that once you get mediocre at US-placed lines, then it saves time on every line.

4) Femoral Lines

I don't want to rehash Matt's great femoral line argument with Minh, and I recently got in a twitter fight with @talesfromtheer et al on some of this, but some bullets:

• femoral lines are terrible in codes
• the vein collapses during hypotension, making it hard to find and harder to cannulate
• it can appear arterial (by palpation or US) as chest compressions push both ways
• landmarks & anatomy are unreliable

*I don't have evidence or data. I didn't even look it up.

Haney Mallemat (EM/IM/CCM@UMEM) just put together a great screencast on subclavian ultrasound for CVC placement. Definitely worth the ~8 min watch.

I had a few questions for Haney and some opinions of my own so I figured I'd put it here instead of in discrete, 140-character (minus @tags) snippets.

To be clear: I think this is a great talk about a simple way to improve a procedure; these are just little bits around the edges.

1) Doppler

You describe how to use doppler to identify the vein vs artery. I think that's a great idea (and I do it occasionally, mostly to ID the IVC when assessing fluid responsiveness) but it can be a little technically difficult, particularly since some machines (including one of my current ones) can't do it.

I use color doppler rather liberally to ID vessels -- arteries give you big, colorful, pulsatile bursts; veins smolder.

2) PTX in SC

You mention the risk of pneumothorax with SC, and I love the picture of the proximity of the pleura to the vein we generally stab at blindly. However, is the risk overblown? We know how to recognize & treat pneumothoraces, and Scott Weingart contends that with proper technique (needle stays parallel to floor the entire time) the risk is minimized.

3) Ultrasound Saves Time

People who are reluctant to use US often cite the extra time needed to use US when placing a line (you allude to this, too, despite your clear preference for US!).

My feeling* is that US saves time for central lines. Maybe not for the simple, 1&done easily placed lines.

But a lot of them aren't that simple. There's probably some bimodal distribution of lines: some go in right away and another big chunk involve rooting around in soft tissue and kinking the heck out of wires for 20-30 minutes. Facility with US really helps minimize the second group, increase the 1&dones, really adds only a minute to wheel over the machine and place a probe cover, and is not difficult at all. (And you can do all of this alone.) And it shows you exactly where to go.

I really think that once you get mediocre at US-placed lines, then it saves time on every line.

4) Femoral Lines

I don't want to rehash Matt's great femoral line argument with Minh, and I recently got in a twitter fight with @talesfromtheer et al on some of this, but some bullets:

• femoral lines are terrible in codes
• the vein collapses during hypotension, making it hard to find and harder to cannulate
• it can appear arterial (by palpation or US) as chest compressions push both ways
• landmarks & anatomy are unreliable

*I don't have evidence or data. I didn't even look it up.

Rabin, E., K. Kocher, et al. "Solutions To Emergency Department 'Boarding' And Crowding Are Underused And May Need To Be Legislated." Health Affairs. 2012 Aug; 31(8): 1757-1766.
doi: 10.1377/hlthaff.2011.0786Health Aff August 2012 vol. 31 no. 8 1757-1766

It's like your paper was boarding, too RT @mdaware after 366 days of peer review, our crowding/boarding article is out: content.healthaffairs.org/content/31/8/1...
-- borborygmi (@nickgenes) August 6, 2012

Rabin, E., K. Kocher, et al. "Solutions To Emergency Department 'Boarding' And Crowding Are Underused And May Need To Be Legislated." Health Affairs. 2012 Aug; 31(8): 1757-1766.
doi: 10.1377/hlthaff.2011.0786Health Aff August 2012 vol. 31 no. 8 1757-1766

It's like your paper was boarding, too RT @mdaware after 366 days of peer review, our crowding/boarding article is out: content.healthaffairs.org/content/31/8/1...
-- borborygmi (@nickgenes) August 6, 2012

sadly too many MDs graduate with the personability of Dr. House and the vocabulary of Dr. Seuss@medschooladvice @inpatientmed #fb

— Seth Trueger (@MDaware) August 8, 2012

sadly too many MDs graduate with the personability of Dr. House and the vocabulary of Dr. Seuss@medschooladvice @inpatientmed #fb

— Seth Trueger (@MDaware) August 8, 2012

Minh Le Cong & I discuss some points on acute-on-chronic pain management in the ED, drug seekers, and diverters.


PHARM Podcast 31 : ED chronic pain management

Minh Le Cong & I discuss some points on acute-on-chronic pain management in the ED, drug seekers, and diverters.


PHARM Podcast 31 : ED chronic pain management

Minh Le Cong interviewed me on:

• A little bit on why I'm doing health policy
• Transition from resident to attending
• Not torturing intubated patients
• Critical airway case discussion
• My first intubation as attending
• Human factors tips for airway & team management
• My love for ETCO2
• A little rehash of our cricoid pressure debate

Minh Le Cong interviewed me on:

• A little bit on why I'm doing health policy
• Transition from resident to attending
• Not torturing intubated patients
• Critical airway case discussion
• My first intubation as attending
• Human factors tips for airway & team management
• My love for ETCO2
• A little rehash of our cricoid pressure debate

Don't do this.

Scott Weingart has another great but unfortunately sad post about post-intubation sedation.

The fact that this needs to be discussed at all makes me sad, which inspired me to share some pearls.

Not sure which of these I learned from Scott Weingart specifically (most likely: all of them). Special thanks to Scott for teaching me to fix patients without torturing them.

(nb - I'm going to use the terms "sedation" and "sedative" even though the first line should be analgesia. see EMCrit 21)

Here are 3 simple things that I do to not torture my patient:

1. Sedation is an RSI med

Ask for your sedative the same time you ask for your RSI meds.

If you're planning on intubating a patient, it should be no surprise to you that very soon you will have an intubated patient that requires sedation.

This is easy.

Sample interaction:

"Can you please get me 100 mg of roc, 100 mg of ketamine, and a fentanyl drip?"


2. Paralysis is NOT sedation

Just because your patient is sitting there calmly does not mean they are comfortable, particularly if you have given them a paralytic. This is relevant in 2 ways.

a) If you used roc to intubate, your patient is paralyzed for some time, so remember to sedate them.

b) Don't use paralytics as post-intubation sedation.

"10 of vec" is NOT a sedative. Don't use it. Forget that it exists. It makes your life easier but is unequivocally terrible.

I won't say "never" because there are a few RARE circumstances where paralysis may be necessary in the intubated patient. Namely, this is at the very end of the algorithm for the ultra-severe asthmatic, and certain special circumstances of ventilator-dyssynchrony. But in both of these cases, your patient should be sedated FIRST and DURING paralysis.

If you're not really sure what I'm talking about here (and even if you do) then make sure you talk to an intensivist before you use paralytics here; or (more likely): NEVER use paralytics for the already-intubated patient.


3. Don't use pain as a pressor

see: EMCrit - Pain and Terror as Effective Pressors

The ETT comes with sedative, period. Treat the blood pressure as you would anyone else -- resuscitate, add pressors, or dial down PEEP (you actually have one more option than in the non-intubated patient).

2 options to maintain MAP in the hypotensive intubated patient:

a) no pressor, no sedative, yes torture

b) yes pressor, yes sedative, no torture

If you're not sure which of these is a better idea then... well I don't have a polite way to end this sentence.

Don't do this.

Scott Weingart has another great but unfortunately sad post about post-intubation sedation.

The fact that this needs to be discussed at all makes me sad, which inspired me to share some pearls.

Not sure which of these I learned from Scott Weingart specifically (most likely: all of them). Special thanks to Scott for teaching me to fix patients without torturing them.

(nb - I'm going to use the terms "sedation" and "sedative" even though the first line should be analgesia. see EMCrit 21)

Here are 3 simple things that I do to not torture my patient:

1. Sedation is an RSI med

Ask for your sedative the same time you ask for your RSI meds.

If you're planning on intubating a patient, it should be no surprise to you that very soon you will have an intubated patient that requires sedation.

This is easy.

Sample interaction:

"Can you please get me 100 mg of roc, 100 mg of ketamine, and a fentanyl drip?"


2. Paralysis is NOT sedation

Just because your patient is sitting there calmly does not mean they are comfortable, particularly if you have given them a paralytic. This is relevant in 2 ways.

a) If you used roc to intubate, your patient is paralyzed for some time, so remember to sedate them.

b) Don't use paralytics as post-intubation sedation.

"10 of vec" is NOT a sedative. Don't use it. Forget that it exists. It makes your life easier but is unequivocally terrible.

I won't say "never" because there are a few RARE circumstances where paralysis may be necessary in the intubated patient. Namely, this is at the very end of the algorithm for the ultra-severe asthmatic, and certain special circumstances of ventilator-dyssynchrony. But in both of these cases, your patient should be sedated FIRST and DURING paralysis.

If you're not really sure what I'm talking about here (and even if you are) then make sure you talk to an intensivist before you use paralytics here; or (more likely): NEVER use paralytics for the already-intubated patient.


3. Don't use pain as a pressor

see: EMCrit - Pain and Terror as Effective Pressors

The ETT comes with sedative, period. Treat the blood pressure as you would anyone else -- resuscitate, add pressors, or dial down PEEP (you actually have one more option than in the non-intubated patient).

2 options to maintain MAP in the hypotensive intubated patient:

a) no pressor, no sedative, yes torture

b) yes pressor, yes sedative, no torture

If you're not sure which of these is a better idea then... well I don't have a polite way to end this sentence.

This is adapted from an email I sent to the incoming EM residents as I graduated a few weeks ago. Of course, no monetary conflicts of interests of any kind, and these recommendations are just personal tips:


As outgoing academic chief, one thing I cannot stress enough is that you really need to read during residency.

This is adapted from an email I sent to the incoming EM residents as I graduated a few weeks ago. Of course, no monetary conflicts of interests of any kind, and these recommendations are just personal tips:


As outgoing academic chief, one thing I cannot stress enough is that you really need to read during residency.

There's been some online chatter about IOs recently, and that got me thinking about a lot of the pearls I have picked up.

Some background: I think we should probably do more IOs, particularly on the non-sick patients. Ever placed a triple-lumen CVC on a patient just because you couldn't get an IV even with an ultrasound? That patient should get an IO instead. Fewer complications, easier & faster to place. My theory is that while drilling into bone is painful, that lasts a second or less, and poking around in a healthyish patient to place a TLC has to be worse.

Complications do happen, but if you do IOs right, the complication rate is low.

This is not a comprehensive list of everything you need to know before you IO. Just some tips that make IOs easier & safer.

n.b. this mostly assumes a powered device, such as the EZ-IO*


IO Pearls:

Placement should just feel right -- it's hard to describe but the tactile sensation when you drill in just feels right (or wrong) as you get through the cortex into the medulla.

Spin before the skin -- otherwise, the skin gets all caught up in the spinning bit.

One shot per bone -- the main danger of IO is extravasation (leading to soft tissue damage), and no matter how poor your first attempt, you probably popped a hole in the cortex. If you then place a working IO, it will leak out that hole, and badness will ensue.

BM is great but not necessary -- successful aspiration of a small amount of bone marrow "confirms" placement but is not 100% sensitive (NPV is poor); even if aspiration doesn't work, you should try flushing. Pay close attention to any sign of leak (and monitor those compartments...) -- maybe ultrasound is useful for checking for leaks? (I have no idea; someone should look into that).
24 hour limit -- IOs should be removed as soon as possible (i.e. after alternate access achieved) but should be taken out before a full day.

To remove: pull straight out -- you can twist even though they're not threaded but:

Do NOT rock on removal -- rocking evidently causes bone cracks and kills puppies. Big no-no.

Tips from Matt:

The stylet is the worst sharp -- the stylet from the IO needle is basically the sharpest needle in the world, with teeth. BE CAREFUL.

Lido isn't perfect -- understand that even after infusion of lido injection is going to be very painful. would be difficult to use in a patient you were going to keep awake.

Pressors are OK -- remember that is is relatively safe for pressors, probably better than a bad peripheral.

"I have had a few residents ask me about sternal IOs, these are military items mean to be placed with no drill. They are a paddle like mechanism and are designed so that body armor can be opened and the IO can be placed. EZ IO drills are not for sternums under any circumstances. Does not seem like something that would need stating but I've been asked multiple times."

How-to Video:

This video is from Dena Asaad Reiter's excellent EMProcedures page:






*I don't get money from them (really)

There's been some online chatter about IOs recently, and that got me thinking about a lot of the pearls I have picked up.

Some background: I think we should probably do more IOs, particularly on the non-sick patients. Ever placed a triple-lumen CVC on a patient just because you couldn't get an IV even with an ultrasound? That patient should get an IO instead. Fewer complications, easier & faster to place. My theory is that while drilling into bone is painful, that lasts a second or less, and poking around in a healthyish patient to place a TLC has to be worse.

Complications do happen, but if you do IOs right, the complication rate is low.

This is not a comprehensive list of everything you need to know before you IO. Just some tips that make IOs easier & safer.

n.b. this mostly assumes a powered device, such as the EZ-IO*


IO Pearls:

Placement should just feel right -- it's hard to describe but the tactile sensation when you drill in just feels right (or wrong) as you get through the cortex into the medulla.

Spin before the skin -- otherwise, the skin gets all caught up in the spinning bit.

One shot per bone -- the main danger of IO is extravasation (leading to soft tissue damage), and no matter how poor your first attempt, you probably popped a hole in the cortex. If you then place a working IO, it will leak out that hole, and badness will ensue.

BM is great but not necessary -- successful aspiration of a small amount of bone marrow "confirms" placement but is not 100% sensitive (NPV is poor); even if aspiration doesn't work, you should try flushing. Pay close attention to any sign of leak (and monitor those compartments...) -- maybe ultrasound is useful for checking for leaks? (I have no idea; someone should look into that).
24 hour limit -- IOs should be removed as soon as possible (i.e. after alternate access achieved) but should be taken out before a full day.

To remove: pull straight out -- you can twist even though they're not threaded but:

Do NOT rock on removal -- rocking evidently causes bone cracks and kills puppies. Big no-no.

Tips from Matt:

The stylet is the worst sharp -- the stylet from the IO needle is basically the sharpest needle in the world, with teeth. BE CAREFUL.

Lido isn't perfect -- understand that even after infusion of lido injection is going to be very painful. would be difficult to use in a patient you were going to keep awake.

Pressors are OK -- remember that is is relatively safe for pressors, probably better than a bad peripheral.

"I have had a few residents ask me about sternal IOs, these are military items mean to be placed with no drill. They are a paddle like mechanism and are designed so that body armor can be opened and the IO can be placed. EZ IO drills are not for sternums under any circumstances. Does not seem like something that would need stating but I've been asked multiple times."

How-to Video:

This video is from Dena Asaad Reiter's excellent EMProcedures page:






*I don't get money from them (really)