For M&M’s, I will focus on a few of the take home learning points.
Kelly: The decision-making when dealing head with injured patients who are combative is very tricky. Elective intubation is always risky but sometimes you have to do it to protect the patient and move on to safely image and workup the patient.
Harwood: Every combative, head-injured patient deserves an initial attempt at sedation to calm them before attempting intubation. Also check the glucose in every combative patient. Hypoglycemia is a common cause of altered behavior.
Elise: Chemical restraint should either precede or be given at the same time as physical restraint.
Elise and Andrea: Ketamine and/or Precedex would both be great options in this situation. Ketamine is now considered neuro-protective instead of previous thinking that it was dangerous in head injured patients.
EAST Guidelines state that intubation is indicated in combative patients that are not responsive to attempts at sedation.
Elise: It is so crucial to perform an airway assessment prior to performing an intubation. If despite your best efforts, the airway attempt is going south, your bridge to cricothyrotomy is LMA.
Girzadas: If the airway is at all expected to be difficult, strongly consider performing intubation with ketamine and topical anesthesia and no paralytic. Also the McGrath Video laryngoscope has an angulated optic device to allow you to see a very anterior airway.
Be sure you have suction, oxygen, back up devices (bougie, LMA, Cric tray) prior to starting intubation.
*EMCrit Intubation Checklist. You can download or print out checklists for intubation at emcrit.org.
Elise and Kari: When using the glidescope, only use the glidescope stylet. Using another more malleable stylet has much potential for failure in securing the airway.
Kelly: If the intubation looks to be difficult and it is not immediately emergent, you should consider calling anesthesia as back up. It is not a sign of weakness to call anesthesia, it is called proper preparation for a difficult airway.
Barounis Tips concerning Glidescopes and Extubation: Links to a few articles on glidescopes and traumatic intubations:
1. Glidescopes can be dangerous see above
1. The stylet is basically a harpoon. when you can't see the tube on the screen be very careful when inserting it into the oropharynx and mindful of the location. (can cause perforation and trauma to tonsillar pillar as you often have the stylet pointed towards the cheek to avoid blocking your point of view).
2. Point head and neck in neutral position for glide (unlike sniffing with MAC).
3. Do not insert ett too posterior in the pharynx, otherwise the ett is trying to go into trachea but bumps into the arytenoids and it is hard to disengage.
4. When engaging the arytenoids, have a friend pull out the stylet (which I know most people do), but another advantage is to ROTATE the ett clockwise as you enter through the cords and the friend or assistant is pulling out the stylet. this prevents the ett hanging up on the right posterior arytenoid.
5. LUBE the ett, it will go in smoother over a VERY DRY mucosa and arytenoid.
6. LUBE the stylet it makes pulling it out much easier
3. Extubating patients with laryngeal edema
One major problem with edema that is above the cuff is that a cuff leak is meaningless. A cuff leak is the stand-alone idiot test to tell someone if there is edema. Problem is the cuff is below the cords and if deflated there might be air movement around the deflated cuff, but above the ett is still a splint around swollen vocal cords or an edematous soft palate.
if one suspects trauma or edema best to perform laryngoscopy and fiberoptic evaluation prior to extubation.
If one anticipates a difficult extubation, for any reason can place cook airway exchange catheter in place.
I do this.
1. Patient is sedated with precedex
2. Patient gets lidocaine down ett to numb cords
3. Patient gets topical 4% lido in mouth
4. Patients get lidocaine atomizer around cords and posterior pharynx
5. I meausre how deep to insert cook exchange catheter
6. I remove ett over cook exchange catheter
7. I sit patient up with catheter in place and monitor
8. I have all aiway equipment and personel available if they crash (happens usually immediately)
9. I have an RT bring a racemic epi neb to bedside BEFORE extubation, i do not wait until an emergency arises and someone needs to find and start a racemic epi neb. when you need it, you need it NOW
Schmitz Financial Issues for Residents
You should plan your finances to prepare for a life expectancy of 90 years old.
Most financial experts state that you will need about 88% of your pre-retirement income to maintain your lifestyle in retirement. You may be able to get by with less but shooting for the 88% mark will give you the best chance of not having to severely change your lifestyle.
Starting the habit of regular saving early in your career is the key to a lifetime habit of saving. A lifetime of saving is the best way to hit that 88% mark. Saving also teaches you to have a lifestyle that doesn’t use 100% of your income. Thus when you retire, you actually can get by on less than 88% of your pre-retirement income.
*Compound interest is the most effective way to grow your savings to meet your retirement needs. To take advantage of compound interest, you need to start saving as early as possible.
You absolutely need to save enough of your yearly income to get the full employer match in your retirement account. The match amounts to a 3% raise. Basically, it’s free money if you have the discipline to get it.
*The power of starting early coupled with compound interest. Blue line is saving started early and continued during working years. Green line is starting somewhat late in working years. Dashed line is starting early but then not continuing beyond age 35. You can see how the dashed line falls off the trajectory of the solid blue line when saving stops.
Excellent websites for financial guidance:
*Third degree heart block. Compare 3rd degree heart block with the two types of second degree heart block pictured below. 3rd degree heart block has regular R-R intervals and regular P-P intervals and the P-P and R-R intervals are asynchronous with eachother. Both types of 2nd degree heart block have grouped beats with intermittent pauses in the R-R intervals.
*Second degree heart block Type 2
*Second degree heart block Type 1 Wenckebach
Muelleman Rural Injuries
The most common fatal injury mechanism in rural areas is motor vehicle crashes.
47 million Americans live more than 1 hour from a trauma center
6 million Americans live more than 1 hour from an ED
There are 5,000ED’s in the US
Firearm associated homicide is less common in rural areas
Firearm associated suicide and unintentional injury is more common in rural areas.
MVC death rates drop as population density goes up. Many factors that could explain this relationship. Research has shown that age of patient and crash characteristics predict 50% of the added mortality. High speed crashes account for increased mortality. No seatbelt also increases mortality. ETOH use increases mortality. Distance of the crash from a board certified EP increases your mortality. Most rural trauma deaths occur in the ED. These deaths mostly are due to hemorrhage, lack of airway, or pneumothorax.
The ATLS course was actually developed by an emergency physician. ACEP turned down sponsorship of ATLS. So the emergency physician took the course to the American College of Surgeons and they made it the world-wide course it is today.
Muelleman Your Path to ABEM Certification
The ABEM mission is to ensure the highest quality of Emergency Medicine care.
Board certification allows you to be recognized as the specialist you have trained to become.
The In-training exam is designed to predict your probability of passing the ABEM Qualifying exam. The In-Training exam will be moving to an electronic format probably 2018.
ABEM Certification requirements:
Successful completion of an accredited EM Residency training program
Valid and current Medical License
Pass the written and oral tests within 5 years of completion of residency training
Total cost for initial certification is right around $2500.
Delay taking the exam for any reason, makes you less likely to pass the exam.
Passing score is 76 for the Qualifying exam. Pass rate is around 90% nation-wide
Oral exam pass rate is around 98% nation-wide
There are about 34,000 ABEM diplomats.