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

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