Podcast #279: Sedation After Intubation

Author: Aaron Lessen, M.D.

Educational Pearls

  • Post-intubation care should always include pain control and adequate sedation.
  • Commonly used sedation agents include propofol, ketamine and versed.
  • However, too much sedation is harmful. Deep sedation (RASS -4 to -5)  is associated with worse long-term outcomes. RASS of 0 to -2 is ideal, as long as the patient is comfortable.

References: https://coreem.net/core/post-intubation/

Podcast #276: Angioedema

Author: John Winkler, M.D.

Educational Pearls

  • Angioedema is immediately life-threatening due to airway obstruction.
  • Mechanisms include allergic reaction (histamine-related) or bradykinin-related (ACE-inhibitor, C1 esterase inhibitor deficiency).
  • The bradykinin-related mechanism will not respond to the traditional meds used for anaphylaxis. Instead, use FFP to replace depleted factors.
  • If a patient displays signs of respiratory compromise, intubation is indicated. Anesthesia should be consulted as this will be a very difficult airway.

References: https://emcrit.org/pulmcrit/treatment-of-acei-induced-angioedema/

Podcast #274: Pediatric Sedation

Author: Aaron Lessen, M.D.

Educational Pearls

  • A recent prospective observational study was performed to examine the safety of different sedation medications in the pediatric ED.
  • This study included 6000 children, and looked at the rate of serious adverse events following administration of different sedatives.
  • Overall, the safest drug to use was ketamine alone, with an adverse event rate of about 1%.
  • Propofol, BZDs, and opiates had increased rates of adverse events.

References: https://lifeinthefastlane.com/pediatric-procedural-sedation-with-ketamine/

Podcast #208: Vocal Cord Dysfunction

Author: Martin O’Bryan M.D.

Educational Pearls:

  • Vocal cord dysfunction can mimic other causes of stridor, such as asthma and upper airway obstruction.
  • Patients are often very anxious because of the difficulty of inspiration.
  • The definitive diagnosis is laryngoscopy that must be done by a pulmonologist.
  • The treatment is general reassurance, asthma medications will not help. CPAP and heliox can be used to help with the stridor.
  • Benzodiazepines can be used to reduce the associated anxiety.

References: https://asthmarp.biomedcentral.com/articles/10.1186/s40733-015-0009-z

Podcast #170: Spice

synthetic-marijuana-plagues-southwest-floridaRun Time:  2 minutes

Author: John Winkler M.D.

Educational Pearls:

  • There are multiple synthetic marijuana alternatives that causes more amphetamine reaction. Known as Spice, K2, and many other names, they are made by changing the side branches of THC.
  • An overdose can cause a spectrum of reactions from general agitation to severe excited delirium to death.
  • Patients present physiologically with tachycardia, elevated blood pressure, elevated temperature, psychosis, and severe agitation.
  • It is important to make sure that the patient is kept calm and safe with multiple doses of sedating medication, end tidal CO2, and airway protection.
  • In New York City on 7/13/16 33 people had a suspected overdose on synthetic marijuana.
  • To make a synthetic marijuana illegal the exact chemical structure needs to be presented to the legislature, and can sometimes take up to 1 year. However, the frequency of changes in the chemical structure of synthetic marijuana hard to keep illegal.

Link to Podcast: http://medicalminute.madewithopinion.com/spice/

References: https://www.drugabuse.gov/publications/drugfacts/synthetic-cannabinoids

http://www.nytimes.com/2016/07/13/nyregion/k2-synthetic-marijuana-overdose-in-brooklyn.html?_r=0

Podcast #162: Jaw Infections

1e060aa3-b451-45a8-9b7c-7ff5fc99ee60Run Time:  3 minutes

Author: Suzanne Chilton M.D.

Educational Pearls:

  • Patient presentation: 2 weeks of mouth pain, no recent dentist visit, low grade fever, and muffled or hot potato voice.
  • Patient exam: swollen tongue that is located up and back in the mouth, edema under tongue, diffuse erythema, and rancid breath.
  • This patient has Ludwig’s Angina – a potentially life-threatening cellulitis of the lower jaw space.
  • The infection starts from a dental infection – most commonly between the 2nd & 3rd molar because roots of these teeth go into a space between the muscles of the head and neck that can reach down to the anterior neck.
  • The most serious complication for patients is maintaining their airway. Patients should be placed in a room with advanced airway management and a cricothyrotomy kit near by.
  • Treatment is broad spectrum antibiotics that targets anaerobes, and oral flora such as clindamycin or unasyn with flagyl.
  • Steroids will help with the swelling – patients have a 65% less chance of intubation if they are given steroids.

Link to Podcast: http://medicalminute.madewithopinion.com/jaw-infections/

References: http://www.ncbi.nlm.nih.gov/pubmed/18952475

Podcast #146: Tracheal Foreign Bodies

65e2e5c6-4107-44ea-89c5-08a58ae3dc72Run Time: 7 minutes

Author: Aaron Lessen M.D.

Educational Pearls:

  • It is important to differentiate between an airway foreign body, which presents as more respiratory choking and difficulty breathing VS esophageal foreign body, patients often complain “I can’t swallow” or spit up what they try to drink /swallow.
  • 1-2 year old children are the most common patient to get airway foreign body, and the most common foreign bodies are food – grapes or hot dogs, round and smooth objects like balloons, and small toys.
  • Patients present with a history of choking, stridor, respiratory distress, wheezing, retractions, and increased work of breathing.
  • It is important to differentiate between a complete obstruction versus an incomplete obstruction.
  • Incomplete obstruction patients will be more awake, but in distress – the patient could decompensate and turn to a complete obstruction if there is too much intervention. Patients should be observed in the ER and move to the OR as soon as possible where peds ENT can perform a controlled removal of the foreign body.
  • With complete obstruction patients BLS measures are the first intervention techniques that should be taken – for a patient <1yo: 5 back blows followed by chest compressions, and for a patient >1yo the heimlich maneuver is recommended.
  • Laryngoscopic removal with magill forceps is the next intervention.
  • In more severe and rare cases where the foreign body is lodged at the trachea or below the vocal cords there are a few techniques that can be used: Needle transtracheal ventilation (you cannot cric a child under 8yo because they do not have a cricothyroid membrane), or possible endotracheal tube and try to advance the foreign body into the right mainstem bronchus so you can oxygenate the left lung until you can get the patient to the OR.

Link to Podcast: http://medicalminute.madewithopinion.com/tracheal-foreign-bodies/

References: http://journal.publications.chestnet.org/article.aspx?articleid=1080585

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2881610/

Podcast #88: Baby Botulism

6979447b-2690-45f1-a88e-b0d15a1c1addRun Time: 2 minutes

Author: Dr. Erik Verzemnieks

Educational Pearls:

  • Caused by inhalation of spores – most common source is soil and honey.
  • 50% of cases are in California followed by Pennsylvania – due to agricultural and industrial nature of the states.
  • Symptoms start as poor feeding, weakness, and constipation – eventually leads to paralysis, respiratory distress and arrest – rarely gets this far, 2% of cases end in fatalities.
  • Tested through stool cultures and treated with Baby botulism immune globulin (BabyBIG).

Link to Podcast:  http://medicalminute.madewithopinion.com/baby-botulism/

References:  https://www.nlm.nih.gov/medlineplus/ency/article/001384.htm

Podcast #69: Critical Airway Management

Run Time: 4 downloadminutes

Author: Dr. Aaron Lessen

Educational Pearls:

  • Over the last few years, general consensus has strayed away from pre-hospital intubation in the field. This is because it has been found that interruptions to CPR (namely intubation and airway management) decrease the success of the patient.
  • This was believed to be solved via the quick placement of a King Tube or a supraglottic device.
  • This was believed widely until there was a study done on the placement of supraglottic devices in pigs during cardiac arrest decreased carotid blood flow.
  • Multiple observational studies have shown patients have a higher rate of return of spontaneous circulation, greater rate of admission, and better neurological status upon discharge with endotracheal intubation in the field versus supraglottic device placement.

Link to Podcast:  http://medicalminute.madewithopinion.com/critical-airway-management/

References:  http://www.ncbi.nlm.nih.gov/pubmed/26006743

Podcast #60: RSI Drugs

5ac33960-5ec3-4472-b49f-c334a35287c5Run Time: 4 minutes

Author: Dr. Brent Levy

Educational Pearls:

  • Etomidate: longer acting and causes less hemodynamic instability, but causes adrenal suppression – not good for septic patients.
  • Propofol: quick acting, but causes hemodynamic instability – not good for hypotensive patients.
  • Ketamine: does not suppress the breathing drive, but increases HR – not good for card patients.
  • Succinylcholine: short acting paralytic, but not good for burn patients or hyperkalemia patients or patients with a history of malignant hypothermia.
  • Rocuronium: longer acting paralytic, and is okay to give to the patients with the conditions described above.
  • Delayed Sequence Intubation: good for patients who do not have adequate preoxygenation – normally a sedative is given prior to preoxygenation – may even avoid intubation all together.

Link to Podcast:  http://medicalminute.madewithopinion.com/rsi-drugs/

References:  http://emcrit.org/wp-content/uploads/preox-deox-dsi-in-the-ed.pdf