I would like to access the supplementary material of following article; article itself is accessable through sci-hub. Thanks in advance!
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DOI/PMID/ISBN: https://doi.org/10.1016/S2213-2600(19)30246-2
Hi there! I would like to share a brief clinical case. 56-year-old patient. Not relevant clinical history. She was admitted after 10 days of COVID pneumonia. She was with a mask reservoir bag at 15 L / min. She made her condition worse so the assistant did a quick intubation sequence (difficult airway). At 2 hours, the pt has entered refractory hypoxemia. Physical examination revealed subcutaneous emphysema on the chest and face. The chest radiograph revealed pneumo-mediastinum (not PTX). Endoscopy showed a tracheal lesion on the posterior wall, near the carina.
What would you do in this case? What treatment do you choose, open or endoscopic surgery?
What equipment do you often use in a difficult airway? Here we have supraglottic devices, stylet and FBC. We do not have a video laryngoscope.
https://preview.redd.it/b0mxep9m4cf61.jpg?width=2977&format=pjpg&auto=webp&s=02807bce46ffbd171434f873f795b37d9f148760
Anyway be careful with the wire and stylet. Specially in women with low height
Grettings (sorry the english), chau!
Had a difficult airway the other day and tried every trick I knew and still was unsuccessful with intubation. MD used a fiber-optic bronchoscope with success.
Where can I find / what are some good resources on difficult tracheal intubation?
Thanks in advance!
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DOI: 10.1016/j.bja.2017.10.021.
Please note: I am aware that the article is accessable through Sci-Hub. The version on Sci-Hub, however, is a temporary manuscript without some crucial information. A final version with graphics and tables included would be greatly appreciated. Thanks in advance!
It may sound dumb but to evaluate tracheal stenosis in an intubated patient with MSCT.
Do I need to extubate him/her for more accurary. Provided that a physician is there to intubate him/her right away after the scan ?
Welcome!
This is a series I am going to be working on where I endeavour to cover various topics in physiology intermixed with clinical pearls to impart some knowledge that doctors of most specialties and grades will hopefully find useful when looking after acutely unwell patients. Join me as we dredge through the depths of anaesthetic exam revision to answer important questions like "why do CT ask for a pink cannula", "why frusemide is okay to give in AKI", "why is hypoxic drive a bunch of horse manure" and many more. Pick up some of this material and you'll be well on your way to becoming a pernickety anaesthetist, whether you like it or not!
Questions, comments, feedback, and suggestions are both encouraged and welcome.
Previous installments:
The physiology of ageing and illness, and its impact on critical care decision making
Decision making regarding escalation to critical care is often something that confuses and frustrates many, on both sides of the aisle. There is no hard and fast rule, no recipe to follow. This should serve more as an insight into the minds of intensivists and what we try to weigh up when deciding on what to do, as opposed to a rule book that rules in (or out) admission to intensive care. Perhaps the most important lesson to takeaway from this is that decision making is necessarily subjective. Truthfully, we don't know what we're doing, we're at best guessing, and ITU consultants frequently disagree with each other on admissions (other things too). If you genuinely think escalation to ITU is appropriate, refer away. I apologise in advance if you are (or have been) met with hostility or anger, I can't control other people! Ultimately I can't fault doctors for wanting what they think is the best care for their patients no matter how judgemental I end up being internally.
Physiology of ageing
This is an important thing to consider because age isn't just a number. Independent, fit and well Bernard at 70 is not the same as 40 year old Oliver, even if they have the same exercise tolerance. Whilst there is no age that makes you automatically ineligible for ITU, we do have to understand and appreciate that the body changes as it ages, and consequently your ability to deal with and recover from criti
... keep reading on reddit ➡What is your practice for intubation during arrest. At out institution we still do, although generally never pause for compressions.
It seems a move among a lot of ER blogs and ER, Nurse, RT tiktok influencers to say stop intubating. To my knowledge most of that data is for out of hospital arrest where EMS doesn’t have great rates of getting tracheal intubation on first try and pause for long times. In fairness its likely hard to intubate out of hospital. So I buy using and LMA. Though lots of rct have found no difference.
But there are very few in-hospital studies. No studies for zero pause compressions intubation with DL or VL.
To me the out of hospital isn’t necessarily able to be extrapolated, but makes me think more about how long we pause during intubation more than just saying “intubation bad.” It seems like the medical community lately is so willing to totally abandon practices in the face of like a handful of inconclusive data in order to be cutting edge. But is less willing to actually interpret data.
ER paramedic is intubated in the ICU currently. She’s in her fifties, healthy. Exercises daily, eats organic, takes herbal supplements. If she caught COVID, she’s healthy right? Who needs an “experimental” vaccine. She told people she’d take her chances with the virus.
The virus almost won yesterday. Shift change, we’re giving report when we notice on the monitor her sats are in the sixties and dropping. We run in emergently and begin lavaging and suctioning. We think it’s another mucus plug. Sats still dropping. We notice tracheal deviation. Call the offsite intensivist, he says draw an ABG. Not helpful. No cardiac arrest, but we call a code blue anyway to get a doctor at the scene. Put a stat X-ray in. It takes more than five minutes for them to arrive. No pneumothorax, thank god. But tracheal deviation to the left, insert chest tube and fluid pours out. Sats increase as fluid is released. Patient stabilized.
Coworkers watch on in horror as they fear they about to lose one of their own. They’re friend. Someone who has worked at the hospital for over a decade.
This virus is not a joke people. It does not discriminate against the young or old. Healthy or sick. Get fucking vaccinated. Spare your loved ones that dreaded call.
During the delivery of an infant who has an estimated gestational age of 42 weeks, you note that the amniotic fluid looks like pea soup and contains thick particles of meconium.
Of the following, the MOST important initial step in the resuscitation of the infant is to
A. aspirate the gastric contents
B. determine the Apgar score
C. initiate tracheal intubation
D. provide positive pressure ventilation
E. suction the hypopharynx
A?
Whilst I'm trying not to be a broken record, I do think the point needs underlining. Especially to those who don't think there's risk of our jobs and roles being eroded by these ANP/ACP types.
https://doi.org/10.1016/j.ienj.2020.100879
> Productivity of Advanced Clinical Practitioners in Emergency Medicine: A 1-year dual-centre retrospective analysis > > ACP roles are increasingly prevalent in UK Emergency Medicine. > > There is currently little evidence evaluating their overall impact. > >This study of ACP productivity demonstrated rates of 1.03–1.53 PPH. [patient per hour]
https://www.magonlinelibrary.com/doi/abs/10.12968/bjon.2021.30.8.470
> Evaluation of the safety of inter-hospital transfers of critically ill patients led by advanced critical care practitioners > > This quality improvement project provides an example of safe and effective advanced practice in an area that is traditionally a medically led domain. ACCPs can provide an alternative process of care for critically ill adults who require external transfer, and a benchmark for audit and quality improvement.
https://twitter.com/DentonGavin/status/1276940954059132930/
> Our ACCP team meet with ICS transfer guidelines and are at least at parity in efficacy and safety with Dr led transfer.
https://journals.sagepub.com/doi/full/10.1177/1751143718772957
> Can Advanced Critical Care Practitioners provide safe advanced airway management? > > This audit of ACCP delivered tracheal intubation, qualified ACCPs working within a framework of appropriate clinical supervision, were found to be able to perform tracheal intubation to a comparable standard to doctors working in intensive care or emergency medicine.
RCEM are actively involved in supporting ACPs in EM. As demonstrated by the vice president of RCEM himself:
https://twitter.com/RCEMPolicyVP/status/1396462443736469508
> 2/2 RCEM ,unlike many Royal Colleges, is defined by the specialty 'Emergency Medicine,' not the profession (so not Royal College of Emergency Physicians) We embrace and value our ACP colleagues, who compliment our hard pressed workforce.
https://twitter.com/RCEMACPChair/status/1377696058340470792
> 8th July RCEM are holding a virtual study day on developing & sustaining an ACP service. Topics covered - pearls and pitfalls from well established services, governance issues , supporting trainee in difficult, role of supervisor and much more. Spread the word.
https://t
... keep reading on reddit ➡Hi everyone!
I have a question I was thinking about that I wanted to try to get some input on. I am an RN but have no experience in trauma/ER (all labor and delivery and newborns here!) and recently I learned about a friend's family who got in a very severe car accident. As a result of the accident, a child around 10 years old had a trachea laceration from what I understand. Thankfully a nurse witnessed the accident and was able to provide help until EMS arrived and last I am aware the child has survived and is responsive even after a couple of strokes although there may be other long-term complications.
This situation got me thinking that I really would not have known what to do in that situation. I tried to do an internet search for guidance and everything brought up intubation/trach/etc, however, obviously, that is not something I could do. So, if I was in that nurse's place above what is the best thing I could do for the person while waiting for paramedics?
This is my thought process... apply pressure to the wound with whatever I have available to try to limit bleeding and sealing the outside wound as best as possible to allow for the patient to breathe assuming no other head/neck injuries and they are breathing spontaneously. I'm thinking this gives the best chance for oxygenation even with the risk of aspiration from the blood.
However, I was also thinking if there is other significant facial/neck trauma and the possibility no air exchange was occurring from the nose or mouth, would it be better to try to keep the tracheal lac clear to allow for breathing almost like a trach (assuming the patient is spontaneously breathing)?
I realize this is probably something that is going to be exceedingly rare to ever actually encounter, but, I would rather feel prepared and know what to do to give the patient the best chance possible. If this isn't allowed here, please let me know and I'll delete it, but I thought since y'all work in the field, y'all would be the best ones to help me with guidance and my thought process. Thanks!
I don't want to step on anybody's toes here, but the amount of non-dad jokes here in this subreddit really annoys me. First of all, dad jokes CAN be NSFW, it clearly says so in the sub rules. Secondly, it doesn't automatically make it a dad joke if it's from a conversation between you and your child. Most importantly, the jokes that your CHILDREN tell YOU are not dad jokes. The point of a dad joke is that it's so cheesy only a dad who's trying to be funny would make such a joke. That's it. They are stupid plays on words, lame puns and so on. There has to be a clever pun or wordplay for it to be considered a dad joke.
Again, to all the fellow dads, I apologise if I'm sounding too harsh. But I just needed to get it off my chest.
Do your worst!
They were cooked in Greece.
I'm surprised it hasn't decade.
For context I'm a Refuse Driver (Garbage man) & today I was on food waste. After I'd tipped I was checking the wagon for any defects when I spotted a lone pea balanced on the lifts.
I said "hey look, an escaPEA"
No one near me but it didn't half make me laugh for a good hour or so!
Edit: I can't believe how much this has blown up. Thank you everyone I've had a blast reading through the replies 😂
It really does, I swear!
Because she wanted to see the task manager.
Heard they've been doing some shady business.
but then I remembered it was ground this morning.
Edit: Thank you guys for the awards, they're much nicer than the cardboard sleeve I've been using and reassures me that my jokes aren't stale
Edit 2: I have already been made aware that Men In Black 3 has told a version of this joke before. If the joke is not new to you, please enjoy any of the single origin puns in the comments
They’re on standbi
