Trick of the Trade: IV-Push Antibiotics in the ED

IV_arm5 copyLimited intravenous access is a common conundrum in the Emergency Department, with heavy implications for medication administration. Of particular concern, are the profoundly septic patients that necessitate multiple timely therapies, which require tying up a line – fluids, pressors, several antibiotics, etc. The shift away from less central line (i.e. triple lumen) placement for initial resuscitation, may serve to further exacerbate this issue.

The Problem

Since most of these septic patients will require more than one antimicrobial for empiric coverage, the exact timing of therapy and desired order of administration are details that may not be adequately communicated. How many times have you noticed after ordering vancomycin and cefepime, that vancomycin has been administered first, allowing several hours to go by without having received that broad-spectrum, gram-negative coverage with cefepime?

Despite these challenges, the Surviving Sepsis Campaign (SSC) guidelines currently recommend administration of appropriate empiric antibiotics within 1 hour after recognition of severe sepsis [1]. This is largely based upon a retrospective analysis of 2,731 patients with septic shock, which demonstrated that administration of effective antibiotics within the first hour of documented hypotension was independently associated with increased survival to hospital discharge [2]. Currently however, a lack of guidance exists regarding the best way to achieve this important aspect of the resuscitation bundle.

 

Trick of the Trade – IV Push Antibiotics

Administration of antibiotics via intravenous push (IVP) may be one approach to hasten antibiotic administration without tying up lines. Additionally, while communicating the desired order of administration is still important, when faced with limited IV access, nurses may be more inclined to initiate the IVP antibiotic first, due to shorter administration times. Further, IVP administration of antibiotics may be a more economically beneficial alternative as compared to more common methods [3]. Through cost avoidance of both pharmacy preparation and nursing administration time, as well as eliminating the need for minibags and IV tubing, one study estimated savings of $184,000 per year [4].

Listed below are various antibiotics that have been shown to be safe when given as an IVP to adults: [5][6][7][8]

Antibiotic Concentration*, Diluent Rate of Administration Osmolality (mOsm/L)**
Cefazolin 1 g/10 mL, SWFI 1-2 min 340
Cefuroxime 750 mg/10 mL, SWFI 1-2 min 447
Cefoxitin 1 g/10 mL, SWFI 2-4 min 525
Cefotaxime 1 g/10 mL, SWFI 1-2 min 440
Ceftriaxone 1 g/10 mL, SWFI 1-2 min 423
Ceftazidime 1 g/10 mL, SWFI 1-2 min 435
Cefepime 1 g/10 mL, SWFI 2-4 min <400
Meropenem 1 g/10 mL, SWFI 3-5 min <500
Aztreonam 1 g/10 mL, SWFI 2-4 min 487

SWFI, sterile water for injection;

* The concentrations stated above do not necessarily represent recommended doses; these should be used to determine the volume required for higher/lower doses (e.g. cefepime 2 g/20 mL SWFI)

** Substances with an osmolality less than 600 mOsm/L are generally acceptable for administration via a peripheral line [9]

Important Considerations

  • When implementing IVP antibiotics in your ED, standardize the process. This may require substantial changes in nursing practice, updating policies and procedures, departmental education, adjustments to electronic order sets, adjustments to product stocking and inventory, as well as implementing oversight for unforeseen adverse effects
  • It is important to note, that the use of sterile water for injection (SWFI) is to help minimize osmolality; reconstituting with NS or D5W may produce significant phlebitis, and increase the risk for extravasation injury. Read more information (extravasation injuries PDF) on this topic.
  • As with any IV preparation, remember to properly label your syringe. Refer to Dr. Bryan Hayes’ post on The Art of Syringe Labeling in the ED.
  • Beta-lactam antibiotics are often administered as prolonged infusions in order to take advantage of their pharmacokinetic/pharmacodynamic profiles (T > MIC). However, this is usually employed for subsequent maintenance doses, and is also not practical for initiation in the ED. Moreover, time to administration of the initial dose is a more important factor in septic patients.
  • The literature used to support the aforementioned IVP antibiotics did not include pediatric patients. Therefore, the safety and feasibility of implementing this practice within the pediatric population is uncertain.

Take-Home Points

  • Various beta-lactam antibiotics may be safely administered via IVP.
  • IVP administration may be one strategy to help facilitate timely administration of antibiotics, and to prevent tying up multiple lines.
  • To date, no published literature exists to support the potential benefits (i.e. improved time to administration; improved outcomes) of IVP antibiotics in the Emergency Department; future studies are warranted.

References

  1. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International Guidelines for the Management of Severe Sepsis and Septic Shock: 2012. Crit Care Med. 2013;41:580-637. PMID: 23361625.
  2. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006 Jun;34(6):1589-96. PMID: 16625125.
  3. Ambrose PG, Bui KQ, Richerson MA, et al. Pharmacoeconomic analysis of intravenous push vs. slow infusion of beta-lactam antibiotics. Clin Drug Invest. 1999 May;17(5):407-410. PMID: 9161666.
  4. Garrelts JC, Smith DF, Ast D, et al. A comparison of the safety, timing and cost-effectiveness of administering antibiotics by intravenous bolus (push) versus intravenous piggyback (slow infusion) in surgical prophylaxis. Pharmacoeconomics. 1992 Feb;1(2):116-23. PMID: 10172048.
  5. Garrelts JC, Ast D, LaRocca J, et al. Postinfusion phlebitis after intravenous push versus intravenous piggyback administration of antimicrobial agents. Clin Pharm. 1988;7:760-5. PMID: 3233896.
  6. Nowobilski-Vasilios A, Markel Poole S. Development and preliminary outcomes of a program for administering antimicrobials by I.V. push in home care. Am J Health-Syst Pharm. 1999;56:76-9. PMID: 10048883.
  7. Garrelts JC, Wagner DJ. The pharmacokinetics, safety and tolerance of cefepime administered as an intravenous bolus or as a rapid infusion. Ann Pharmacother. 1999;33:1258-61. PMID: 10630824.
  8. Norrby SR, Newell PA, Faulkner KL, et al. Safety profile of meropenem: international clinical experience based on the first 3125 patients treated with meropenem. J Antimicrob Chemother. 1995 Jul; 36 Suppl A:207-23. PMID: 8543496.
  9. Intravenous Nurses Society. Position paper: midline and mid-clavicular catheters. J Intraven Nurs. 1997;20:175-178.
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Author information

Adam Spaulding, PharmD BCPS

Adam Spaulding, PharmD BCPS

Emergency Medicine Pharmacist,

Pharmacy Residency Program Director,

Waterbury Hospital Health Center,

Adjunct Assistant Professor - UCONN School of Pharmacy,

Contributor to Emergency Medicine PharmD Blog

The post Trick of the Trade: IV-Push Antibiotics in the ED appeared first on ALiEM.

In Criticism Of Praise

In Criticism of PraiseSometimes the most profound academic concepts haven’t come from the wonderful medical conferences or hundreds of academic articles I’ve read, but they come from arenas completely tangential to the medical field.  The topic of this article is a great example of this phenomenon.  It came from of all places, a Southwest Airlines magazine.  It’s titled “In Criticism of Praise” by Heidi Stevens.  Being an optimist with four children and many medical students under my wing, (yes I view them as my children) I was initially offended by the title and it of course, it drew me in.

Ms Stevens addresses the American addiction to immense praise irrespective of effort or outcome.   We just love to say “good job!”  She makes the important distinction of process oriented (“you got the pimp question right”) and outcome oriented praise. (“you worked really hard on that project”)  She points out research done by Carol Dweck, who gave students a hard test.  With test results, she told one group, “you must be smart. ” The others were told, “you must have worked hard.”  Later, she offered a choice of taking a hard or easy test.  90% of the “worked hard,” took the hard test while the majority of the “smart” group, chose the easy test.  Later that year, given the same test, the “worked hard” group, scored 30% higher and the “smart” group, 20% lower.

Praise the Process

There is power in the subtleties of our words!  When we teach and praise outcomes by mostly rewarding a test score or right answer, we increase anxiety of wrong answers, hide learning gaps, lessen the desire to tackle hard problems and lose trust.  Praising the process of persevering through a tough exercise, develops determination, excites creativity, deepens trust and promotes learning from mistakes, just to name a few.  I’m proud of you for taking the time to think carefully about this article and hope it criticizes the way we praise.

References:

  1. In Criticism of Praise by Heidi Stevens

Post Peer Reviewed By: Salim Rezaie (Twitter: @srrezaie)

The post In Criticism Of Praise appeared first on R.E.B.E.L. EM - Emergency Medicine Blog.

Intern Report 8.25

internreport

Case Presentation by Jonathan Najman, MD

History of Present Illness:

12-yo boy presents to the ED with sudden onset of abdominal pain and vomiting for 1 day. The patient states that he woke up suddenly early in the morning with severe abdominal pain and subsequently had multiple episodes of non-bloody and non-bilious emesis. The pain is intermittent in nature, sharp, radiates to his groin, is the worst pain he has ever felt and seems to be worsening with time. The patient’s mother states that he has been afebrile at home.  The patient denied feeling any symptoms the day prior as well as any recent trauma, urinary symptoms, sexual activity or masturbation, or any sick contacts.  Denied sexual activity.  There is no change in urination, no burning with urination, and reported skin changes.  He was well yesterday.

PMH: no known medical problems or hospitalizations

PSH: none
FH: no sick contacts
SH: lives at home with mother and father, denied sexual activity

Physical Exam:

Vital Signs: BP 108/68, HR 101, RR 20, T 37.9, 98% on RA

General: uncomfortable, with intermittent moments of extreme pain and discomfort

HEENT: NCAT, no pharyngeal erythema, no cervical lymphadenopathy palpated

Cardiovascular: RRR, normal S1 and S2, no murmurs noted

Respiratory: Clear to auscultation bilaterally

GI: Abdomen is mildly tender to palpation over the suprapubic region, otherwise it is soft, nondistended and nontender, with +BS

GU: Mild scrotal tenderness to palpation. There is slight swelling of the left testicle noted with significantly tenderness to palpation. Lifting the testicle does not seem to reduce the pain. The left testicle appears to be higher than the right. Cremasteric reflex is intact bilaterally. Negative blue dot sign bilaterally. There are no rashes or bruises noted over the genitalia.  There is no discharge from the penis.

MSK: moving all extremities

Neurological: Alert and conversational, moving all four extremities spontaneously.

Skin: intact, no rashes or bruises noted

The following ultrasound was obtained:

8.25

Questions:

1) What does the patient most likely have?

  a) Varicocele

  b) Epididymitis

  c) Testicular torsion

  d) Hydrocele

2) How would you treat this patient?

  a) Manually detorse testicle in a clockwise fashion, if successful, DC home

  b) Consult urology for emergent surgical repair

  c) Ceftriaxone and Doxycycline

  d) Levofloxacin

3) What is the most common cause of epididymitis in prepubertal patients?

  a) Idiopathic

  b) E. coli

  c) C. trachomatis

  d) Ureaplasma


Filed under: Uncategorized

Apneic ventilation using pressure-limited ventilation

 
Introduction

Noninvasive ventilation (i.e. BiPAP) is arguably the most powerful approach to optimize oxygenation and ventilation before intubation, given its ability to provide 100% FiO2, PEEP, and ventilatory support.  The only way to improve upon this is to extend the administration of positive pressure ventilation throughout sedation and paralysis, right up until the moment of intubation.  Either a mechanical ventilator or some BiPAP machines can easily be set to deliver ventilator-triggered breaths after the patient becomes apneic.  This is similar to manually bagging the patient, but using a machine improves precision and safety.  Although unnecessary for most patients, apneic ventilation may be useful for patients at high risk of hypoxemia or acidosis. 

Nuts & bolts

Apneic ventilation using a BiPAP machine with Spontaneous/Timed mode (S/T Mode)


Some newer BiPAP machines (e.g. Phillips BiPAP Vision and Phillips Respironics V60) can be set in a "spontaneous/timed" mode (S/T mode).  As long as the patient is breathing at a rate higher than the set rate, S/T mode is identical to BiPAP.  However, if the patient's respiratory rate drops below the set rate, machine-triggered breaths will be delivered (functioning identically to a traditional mechanical ventilator set on pressure-controlled ventilation).  Apneic ventilation can also be performed by connecting a facemask to a traditional mechanical ventilator set to provide pressure-controlled ventilation.

Transitioning from spontaneous breathing to machine-triggered ventilation

The transition onto ventilator-supported breathing may be seamless.  While the patient is breathing spontaneously, the machine can be set at a rate 5-10 breaths/minute below the patient's respiratory rate.  This will have no effect until apnea occurs, when the machine will immediately begin providing pressure-controlled ventilation.  At this point, the respiratory rate may be increased to the optimal rate for machine-triggered ventilation (e.g. 30 breaths/minute, as discussed below). 

Keep the airway open

Whether performing apneic oxygenation or apneic ventilation, nothing works if the airway is occluded (e.g. due to the tongue falling backwards after paralysis).  One advantage of apneic ventilation is that it provides a continuous monitor of whether the airway is open.  The machine will display the tidal volumes that the patient is receiving.  Following paralysis, the tidal volumes will fall, but they shouldn't fall to zero.  If the tidal volumes fall very low, this suggests airway occlusion.  Usually, patient positioning (i.e. ear to sternal notch) plus simple airway maneuvers (i.e. head tilt and chin lift) may open the airway.  

Machine settings to optimize oxygenation

Physiology of recruitment: Understanding transpulmonary pressure

When we think about using positive pressure to recruit the lungs, we generally think about PEEP.  However, PEEP is only part of the story.  For example, let's imagine a woman with severe ARDS who is placed on BiPAP 15cm/5cm.  The pressure which is opening her alveoli is the transpulmonary pressure, which equals the difference between her alveolar pressure and pressure in her pleural cavity.  This is equal to the positive pressure from BiPAP mask minus the pressure generated by her diaphragm (1):


In this scenario, lung recruitment only occurs during inspiration, when her transpulmonary pressure is +30cm.  During exhalation, her transpulmonary pressure is -3cm, which will de-recruit her lungs.  Thus, the primary factors opening up her lungs are actually the peak pressure of the BiPAP machine (+15cm) and negative pressure produced by her diaphragm (-15cm), not the PEEP. 

The single most important number influencing her recruitment may be her mean transpulmonary pressure.  For example, if she spends most of her time during inspiration, then her mean transpulmonary pressure will be closer to +30cm.  Alternatively if she has a lower respiratory rate and is taking shorter breaths, then her mean transpulmonary pressure will be closer to -3cm. 
  

Now let's imagine that she is paralyzed prior to intubation.  While apneic, her trans-pulmonary pressure may be stable at around 5cm.  (Note that if she were obese, her diaphragm would compress her lungs during apnea, producing a transpulmonary pressure <5cm).  We have just taken away her inspiration, which was recruiting her lungs with a pressure of +30cm.  Without these bursts of pressure during inspiration, her lungs may collapse before intubation. 

How to set the BiPAP machine during apnea to optimize trans-pulmonary pressure

The transpulmonary pressure may be approximated using the equations below (2).  The driving pressure is equal to the Peak Pressure minus the PEEP, which is the pressure differential that drives gas into the lungs with each breath (thus determining how large each tidal volume is).


The peak pressure must be limited to avoid gastric insufflation.  This establishes a tradeoff between the PEEP and the driving pressure: the higher the driving pressure is, the lower the PEEP must be.



For a patient with severe hypoxemia, we generally want to maximize the transpulmonary pressure even if this occurs at the cost of reducing ventilation.  This may be achieved by increasing the PEEP.     

The other approach to improve transpulmonary pressure is to increase the percent of the time that the patient will spend during inhalation.  This may be done either by increasing the respiratory rate, or by increasing the inspiratory time of each breath.  The best way to do this is to increase the respiratory rate, because this will simultaneously improve oxygenation and ventilation.  A respiratory rate of 30 breaths/minute with a one-second inspiratory time will cause half of the time to be spent during inspiration (Inspiration : Expiration ratio of 1:1).  This is the highest fraction achievable with a Respironics BiPAP machine (3). 

Therefore:

Machine settings to optimize ventilation

Less commonly than hypoxemia, we encounter patients with severe metabolic acidosis and a compensatory respiratory alkalosis (e.g. diabetic ketoacidosis or salicylate intoxication).  These patients are at risk of acidosis in the peri-intubation period because we are taking away their compensatory respiratory alkalosisand potentially replacing it with a respiratory acidosis.  Intubation of such patients should be avoided if possible (discussed previously on the post about DKA).  However, sometimes it is unavoidable.  In such situations, all efforts must be made to maintain the PaCO2 as low as possible throughout the peri-intubation period.

Often such patients have normal lungs, in which case the ventilator settings can be set to maximize ventilation.  This may be achieved by maximizing the driving pressure and decreasing the PEEP to zero (4).

Therefore:

Safety and maximal peak pressure

Interposing ventilation between paralysis and intubation is controversial.  Some would argue that true rapid sequence intubation (RSI) involves no ventilation, with any ventilation increasing the aspiration risk.  However, for a patient at high risk of desaturation it may be safer to perform apneic ventilation up-front in a controlled fashion, thereby extending the safe apnea time and increasing the likelihood of first-pass success.  Providing no ventilation up-front often results in the patient desaturating and requiring urgent manual bagging.  With eitherapproach, apneic ventilation occurs; it's simply a matter of timing and control.  Pressure controlled ventilation has been shown to result in lower peak pressures compared to manual ventilation, implying greater safety (Goedecke 2004).

The maximal pressure that may be safely applied without insufflating the stomach and causing regurgitation is unclear.  Previous studies based on auscultating the stomach have suggested that pressures <20-25cm are safe.  A recent prospective, randomized, double-blind study using ultrasonography to evaluate gastric insufflation found that 15cm provided the ideal balance between avoiding gastric insufflation and providing adequate ventilation (Bouvet 2013)(6).  The safety and efficacy of apneic ventilation using pressure-limited ventilation with a peak pressure of 15cm has been validated in elective surgical patients (Joffe 2010).

Advantages of pressure-limited ventilation

In general, mechanical ventilation can either be volume-limitedor pressure-limited.  With volume-limited ventilation, the tidal volume is set by the practitioner and the pressure will vary depending on the lung compliance.  Alternatively, with pressure-limited ventilation, the peak pressure is set by the practitioner and the volume will vary depending on the lung compliance.  Similar results can generally be achieved with either mode.  However, for the purpose of apneic ventilation, pressure-limited ventilation has some unique advantages:

Pressure-limited ventilation guarantees a safe inspiratory pressure.

Using a pressure-limited mode, as long as the inspiratory pressure is set at a safe level (i.e., 15 cm), this will guarantee that unsafe levels of pressure never occur.  Alternatively, if volume-limited ventilation is used, then high pressures can occur.  Volume-limited ventilation requires close monitoring with adjustment of tidal volumes to avoid dangerous pressures, a complex task requiring ongoing attention. 

The trade-off here is that the tidal volume is not guaranteed, so some patients may receive low tidal volumes.  Choosing pressure-limited ventilation thus prioritizes safety over efficacy.  Given that a normal minute ventilation is not mandatory during apnea, and that aspiration can be a major problem, this is a sensible trade-off. 

Pressure-limited ventilation maximizes the efficiency of inspiration.

Compared to volume-limited ventilation, pressure-limited ventilation will maximize the tidal volume for a given peak pressure (e.g. 15 cm).  With volume-limited ventilation, the airway pressure only reaches the peak pressure at the very last moment (figure below).  In contrast, with pressure-limited ventilation the airway pressure is equal to the peak pressure throughout inspiration.  Since pressure-limited ventilation maximizes the driving pressure throughout the entire breath, it will achieve a higher tidal volume compared to volume-limited ventilation with the same peak pressure (5). Seet 2009 confirmed this, demonstrating that pressure-limited ventilation achieved the same tidal volume as volume-limited ventilation despite using a lower peak pressure. 


When should apneic ventilation be considered? 

Although apneic ventilation is a useful tool for the toolbox, it is only occasionally needed.  Patients who may benefit the most include those with profound hypoxemia, severe metabolic acidosis, or morbid obesity.

For a patient requiring intubation who is already on a BiPAP machine capable of delivering apneic ventilation, this should be considered.  The primary drawback of apneic ventilation is the logistics of connecting the patient to noninvasive ventilation.  In this situation, apneic ventilation can be accomplished by pushing a few buttons on the BiPAP machine. 


  • Ventilatory support up until the moment of intubation may be easily provided using more sophisticated BiPAP machines (which can be set to provide backup respirations as soon as the patient stops breathing) or a mechanical ventilator.
  • Continuing ventilator support until intubation improves oxygenation and ventilation during paralysis.  This may be useful for patients at high risk of hypoxemia (due to lung collapse) or acidosis (due to metabolic acidosis).
  • Expert mask-ventilation technique is critical to maintain an open airway after paralysis. 
  • Use of pressure-limited ventilation during apnea guarantees avoidance of high inspiratory pressures that could cause gastric distension and aspiration. 
  • Patients with hypoxemia may benefit more from PEEP, whereas patients at risk from hypercapnia may benefit more from higher driving pressures.  The following is a rough guide to setting up apneic ventilation for different types of patients: 



Disclosures: I have no conflicts of interest nor any relationship with drug or device manufacturers.  

Notes

(1) Please note that in general exhalation is usually a passive process with no diaphragmatic activity.  However, in the setting of respiratory distress it may become an active process.  Also note that this patient's diaphragmatic pressures cannot be measured, and these are simply what I am imagining they might be.  Finally, note that this is a simplification which assumes zero airway resistance (such that alveolar pressure is equal to airway pressure).   

(2) Note again that this ignores any passive pressure exerted by the diaphragm to compress the lungs during apnea, for example due to pregnancy or obesity. 

(3) In theory, the respiratory rate could even be increased further, to achieve inverse ratio ventilation (inspiratory time > expiratory time), similar to the concept of airway pressure release ventilation (APRV).  However, the Respironics BiPAP machines will not allow inverse ratio ventilation (in most routine situations, inverse-ratio ventilation would result from an operator error and would be undesirable).  Using a complete mechanical ventilator, inverse ratio ventilation could be used to further improve oxygenation (although this benefit might occur at the cost of impaired ventilation).

(4) The ideal respiratory rate to maximize ventilation is unclear.  Minute ventilation is proportional to respiratory rate, so in general increasing respiratory rate is beneficial.  However, if respiratory rate is increased too much, then there will be insufficient time for the lungs to fill and empty with each breath, causing the tidal volume to fall.  A respiratory rate of about 30 breaths/minute may be a reasonable compromise.  

Note also that typical recommendations for respiratory rate during manual bagging (i.e. limiting the respiratory rate to 10-12 breaths/minute) are designed to take into account that manual bagging is a volume-limitedprocess with a risk of progressive accumulation of excess gas in the chest (which may cause the intrathoracic pressure to spiral out of control).  Using pressure-limited mechanical ventilation, it is impossible for this to happen. 

(5) For intubated patients, minimizing the peak pressure doesn't matter so much (because the plateau pressure is more important than the peak pressure).  However, for mask ventilation of non-intubated patients, the peak pressure is critically important to avoid gastric insufflation.  Therefore, the lower peak pressures achievable with pressure-limited ventilation becomes a significant advantage. 


(6) Note that there has been no evidence directly linking the level of pressure to clinical aspiration.  It is possible that a minimal amount of gastric insufflation (e.g. as detected by ultrasound) may be clinically irrelevant.  Thus, it is possible that higher pressures (e.g. 20-25cm) are safe.  Unfortunately it is unlikely that a study relating pressure to clinical aspiration will be done, because this would require a very large sample size. 


Airway Pearls from The CRASH Airway Course – Part 1

I was lucky enough to show up at the CRASH Airway Workshop at The Crashing Patient Conference by the Airway Guru "Ken Butler" at The University of Maryland, Baltimore held in October 2014. It was an amazing trip where I got an opportunity to meet some great people. 

Today, I am going to share three big "Airway Pearls" that I learned form the course:
   
1. Positioning is the key (often ignored in the ED):

For every ED Airway - Make sure that the Ear and Sternal Notch are in the same horizontal plane when you position the patient. To achieve this, you need to support the occiput with some sheets OR in obese you may need to elevate the head end (ramped up position - Reverse Trendelenberg position) and support the occiput as well as the shoulders. Bottom line is take a look from the side to bring EAR and STERNAL NOTCH in the same horizontal plane.


Ear --> Sternal Notch
Ramped up position can be achieved this way in trauma
when you can't mobilise the neck

This position maximizes the upper airway patency and improves the mechanics of ventilation. In morbidly obese this position also lengthens the apneic time period to critical hypoxia + shortens the time needed with BMV to return back to normal oxygen saturation.



2. Apneic Oxygenation OR Nasal Oxygen during efforts securing a tube  (NODESAT)

Apnoeic oxygenation is the application of high flow oxygen via nasal prongs at 10-15L/minute during intubation (during laryngoscopy!). Keep the O2 flow at 4L/min to start with and once you push the induction agent, go upto 15L/min. Continue to provide O2 via nasal prongs  until you pass the tube inside. With this, you will be blowing some oxygen into the lungs, that will diffuse into the bloodstream (it works because even when they are paralysed, blood is still flowing in their body), and buys you some time before the sats start to  drop (extends your safe apnea time). And 30 more seconds of safe apnea time is a lot during the heat of resuscitation. In adddition, again this also shortens the time needed with BMV to return to normal oxygen saturation. 


Apneic Oxygenation

Some high risk groups for desaturation are Obese, Paediatrics, Pregnant and those with a lung pathology. 



One of my anecdotes with apneic oxygenation, Recently I remember bagging a sick hypoxic patient to get the sats up, the maximum I could reach was 97% but then with apneic oxygenation I witnessed the sats going from 97-->100% during laryngoscopy!! 

So make it a part of your Intubation checklist and use it for every ED intubation.

3. Bimanual Laryngoscopy (Using both your hands during the procedure)
This one is my favourite. When we use both our hands during laryngoscopy, that gives a great view without applying too much force. Lets see how it is done:


Bimanual Laryngoscopy (This image in only for demonstration purpose, Always use full PPE)

With scope in your left hand, enter inside the mouth and move in, step by step and the first structure to be visualised is the epiglottis (epiglottoscopy), following which the tip of the blade should be placed in the valeculla (Don't go too far). Now, with your right hand optimise the view using ELM (External Laryngeal Manipulation), once you get an optimal view, take off your hand and ask your assistant to maintain the pressure 


OR

To start with, ask you assistant place his hand over the larynx and give pressure on top of your assistant's hand to get an optimal view (see the image below). This keeps the pressure exactly at the same spot. Bimanual Laryngoscopy dramatically improves the view of the cords.


Bimanual Laryngoscopy with an assistant to start with 
(This image in only for demonstration purpose, always use your full PPE)


Stay tuned.. I will be back next week with Airway Pearls - Part 2


Thanks


One game changer paper on Airway, that is worth reading is:
Weingart SD, Levitan RM. Preoxygenation and Prevention of Desaturation During Emergency Airway Management Ann Emerg Med. 2012 Mar;59(3):165-75.


Special note of thanks to Dr. Azhar and the authorities of Simulation Lab, Apollo Health City, Hyderabad

Minör Aciller: Pseudonöbet

Giriş Yaygın kabul gören isimlendirme psikojenik nonepileptik nöbet (PNES); diğer kullanılan isimler psikojenik nöbet, nonepileptik nöbet, psikojenik pseudonöbet, histerik nöbet Acil servislerde sık görülen ve iyi ayırıcı tanı gerektiren klinik bir d… Read more →