Podcast #445: Hunting for the endotracheal tube

Author: Michael Hunt, MD

Educational Pearls:

  • Bedside transtracheal ultrasound to confirm proper endotracheal intubation is simple and effective
  • Review of 17 studies showed transtracheal ultrasound was was 98.7% sensitive and 97.1% specific
  • Curvilinear probe may be preferable as it provides a larger field of view

Editor’s Note: rather than explain what you’re looking for… just go here

References:

Gottlieb M, Holladay D, Peksa GD. Ultrasonography for the Confirmation of Endotracheal Tube Intubation: A Systematic Review and Meta-Analysis. Ann Emerg Med. 2018 Dec;72(6):627-636. doi: 10.1016/j.annemergmed.2018.06.024. Epub 2018 Aug 14. PubMed PMID: 30119943.

Summarized and edited by Erik Verzemnieks, MD

Podcast #444: Dyspnea in the intubated patient

Author: Aaron Lessen, MD

Educational Pearls:

  • Dyspnea can occur in up to 50% of intubated patients
  • Dyspnea is associated with prolonged mechanical intubation
  • Often goes undiagnosed as these patients have difficulty communicating
  • Expert opinion on reducing sensation of dyspnea
    • Reduce stimulation of respiratory drive like fever and acidosis
    • Give bronchodilators for patients with wheezing
    • Optimize the ventilator settings
    • Use medications for comfort (i.e. opioids, benzodiazepines)

References:

Decavèle M, Similowski T, Demoule A. Detection and management of dyspnea in mechanically ventilated patients. Curr Opin Crit Care. 2019 Feb;25(1):86-94. doi: 10.1097/MCC.0000000000000574. PubMed PMID: 30531366.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast #402: Rapid sequence intubation medications

Educational Pearls:

  • RSI includes induction agent (sedative) and a paralytic
  • Succinylcholine is a depolarizing paralytic of rapid onset and short duration with contraindications in hyperkalemic states and muscular dystrophy
  • Rocuronium and vecuronium are longer acting, non-depolarizing paralytic, more commonly
  • Common induction agents are etomidate and ketamine
  • Ketamine can be particularly beneficial for bronchodilator effects in those with reactive airway disease

References:

 

Stollings JL, Diedrich DA, Oyen LJ, Brown DR. Rapid-sequence intubation: a review of the process and considerations when choosing medications. Ann Pharmacother. 2014 Jan;48(1):62-76. doi: 10.1177/1060028013510488. Epub 2013 Nov 4. Review. PubMed PMID: 24259635.

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

Check out this episode!

Podcast #401: Foreign Body Aspiration

Author: Gretchen Hinson, MD

Educational Pearls:

  • Diagnosis can be difficult and often delayed
  • Asymmetric breath sounds, choking, stridor may be present, but children also present asymptomatically
  • Peak incidence around one to two years of age
  • Hot dogs, nuts, popcorn – round and smooth objects are most commonly aspirated

References:

Green SS. Ingested and Aspirated Foreign Bodies. Pediatr Rev. 2015 Oct;36(10):430-6. doi: 10.1542/pir.36-10-430. Review. PubMed PMID: 26430203.

Sink JR, Kitsko DJ, Georg MW, Winger DG, Simons JP. Predictors of Foreign Body Aspiration in Children. Otolaryngol Head Neck Surg. 2016 Sep;155(3):501-7. doi: 10.1177/0194599816644410. Epub 2016 Apr 12. PubMed PMID: 27071446.

 

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

Check out this episode!

Podcast #383: Prehospital Tubes

Author:  Sam Killian, MD

Educational Pearls:

  • Two high-quality randomized control trials published in 2018 demonstrated no difference in mortality or neurologic outcomes when using a supraglottic airway compared to endotracheal intubation in out of hospital cardiac arrest
  • These two trials enrolled over a combined 12000 patients
  • Supraglottic airways have a higher success rate than intubations

 

References:

Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H, South A, Stokes EA, Taylor J, Thomas M, Voss S, Wordsworth S, Rogers CA. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018 Aug 28;320(8):779-791. doi: 10.1001/jama.2018.11597. PubMed PMID: 30167701

Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JCJ, Aufderheide TP, Gray RE, Gray PC, Verkest M, Owens PC, Brienza AM, Sternig KJ, May SJ, Sopko GR, Weisfeldt ML, Nichol G. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2018 Aug 28;320(8):769-778. doi: 10.1001/jama.2018.7044. PubMed PMID: 30167699.

Podcast #380: Oxygen for the kill

Author:  Ryan Circh, MD

Educational Pearls:

 

  • Review of 25 randomized control trials encompassing 16,037 acutely ill hospitalized patients
  • Patients given oxygen with saturations > 94% on room air were found to have associated increased mortality in-hospital, at 30-days, and at long-term follow up
  • It may seem intuitive, but do not give oxygen to patients that do not need it

 

References:

Chu DK, et al (2018). Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 391(10131):1693-1705

Podcast # 348: Steakhouse Syndrome

Author: Don Stader, MD

Educational Pearls:

  • Steakhouse syndrome is an impacted esophageal food bolus.
  • Occurs because they have an esophageal stricture (schatzki ring, scarring, esophagitis).
  • Classic treatments have consisted of effervescents, glucagon, and/or sublingual nitroglycerin (NTG).
  • Recent case series has shown oral 400mcg tablet of NTG dissolved in 10cc tap water was 100% successful.
  • Complications of NTG are hypotension and headache.

 

References

Kirchner GI, Zuber-Jerger I, Endlicher E, et al. (2011) Causes of bolus impaction in the esophagus. Surgical Endoscopy. 25:3170.

Willenbring BA, et al. (2018). Oral Nitroglycerin Solution May Be Effective for Esophageal Food Impaction. Journal of Emergency Medicine. 54(5):678-680.

Podcast # 337: Airway Burn Inhalation

Author: John Winkler, MD

Educational Pearls:

  • Singed nasal hairs, soot around mouth, hoarse voice, drooling, and burns to head/face are signs suggestive of inhalation injury.
  • Early intubation is critical for these patients as the airway changes rapidly.
  • With inhalation injuries, the upper airway is burned while the lower airway is damaged by inhaled chemicals in the soot and can cause ARDS.
  • Carbon monoxide (CO) and cyanide (CN) poisoning can occur with inhalation injuries.
  • Treatment for CO poisoning is 100% oxygen and possible hyperbarics. Treatment for CN poisoning is cyanocobalamin.

 

References

Rehberg S, Maybauer MO, Enkhbaatar P, et al. Pathophysiology, management and treatment of smoke inhalation injury. Expert Rev Respir Med 2009; 3:283.

Woodson CL. Diagnosis and treatment of inhalation injury. In: Total Burn Care, 4 ed, Herndon DN (Ed), 2009.

Podcast #325: Vaping and Pneumonia

Author: Sam Killian, MD

Educational Pearls:

  • Being exposed to E-cigarette vapor may increase risk of pneumonia.
  • Recent study has shown e-cigarette vapor increases quantities of Platelet-activating-receptor factor in epithelial cells, which may aid pneumococcal bacteria in entering pneumocytes.

References:

Miyashita L, et al. (2018). E-cigarette vapour enhances pneumococcal adherence to airway epithelial cells. The European Respiratory Journal. 7;51(2).

Podcast #315: Retropharyngeal Infections in Pediatrics

Author: Dr. Karen Woolf, MD

Educational Pearls:

  • Anatomy : base of skull to posterior mediastinum, anteriorly bounded by middle layer of deep cervical fascia and posteriorly by the deep layer, communicates to lateral pharyngeal space bounded by carotid sheath. Lymph node chains draining nasopharynx, sinuses, middle ear, etc. run through it.
  • Epidemiology & Microbiology: most common kids 2-4, (neonates too). Polymicrobial (GAS, MSSA, MRSA, respiratory anaerobes).
  • Signs and symptoms can include pharyngitis, dysphagia, odynophagia, drooling, torticollis, muffled voice, respiratory distress, stridor, neck swelling, and trismus.
  • Exam may show drooling, posterior pharyngeal swelling, anterior cervical LAD, or a neck mass.
  • Imaging: Get CT neck w/IV contrast!
  • DDx: epiglottis, croup, bacterial tracheitis, peritonsillar abscess, trauma, foreign body, angioedema, cystic hygroma, meningitis, osteomyelitis, tetanus toxin.
  • Tx: Unasyn, if not responding add Vancomycin or Linezolid; surgical drainage if airway is compromised.
  • Complications: airway obstruction, sepsis, aspiration pneumonia, IJ thrombosis, carotid artery rupture, mediastinitis.

References:

Craig FW, Schunk JE. Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management. Pediatrics 2003; 111:1394.

Fleisher GR. Infectious disease emergencies. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.783.

Goldstein NA, Hammersclag MR. Peritonsillar, retropharyngeal, and parapharyngeal abscesses. In: Textbook of Pediatric Infectious Diseases, 6th ed, Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL (Eds), Saunders, Philadelphia 2009. P.177