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Surgical Airway Summary

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Our online walkabout on the emergency surgical airway is coming to an end. I hope you’ve found this helpful, I know I enjoyed doing it. The emergent cricothyroidotomy presents many educational challenges. It is a high stakes, low-frequency procedure performed in the stressful failed airway situation, where time is not on your side.

Preparing yourself for this scenario requires several key technical and non-technical skills outlined in summary here:

  • A working knowledge of airway anatomy and the confidence to quickly identify important anatomical landmarks.
  • Familiarity with the necessary procedural skills – ideally practiced and reviewed in cadaver as well as sim labs so that the muscle memory is there when you need it.
  • Situational awareness: a term that encompasses the logistical, emotional and psychological skills necessary to take appropriate and effective action. In this case it is defined by how effectively you can identify the failed airway and move through the failed airway algorithm in order to put scalpel to skin. It includes the recognition of normalcy bias and focus lock and the danger of repetitive attempts at laryngoscopy to the hypoxic patient,

This exercise is not a substitute for good clinical training, rather it is designed to highlight key concepts by drawing together disparate online resources into a coherent and educational narrative. As the name EMBER Project (EM Bundles & Education Research) suggests, our goal is to provide bundles of educational material and to discover innovative ways to bring it to you. This time. the entire bundle of resources presented over the last couple of weeks, along with commentary and opinions from other physicians and experts will be up on the EMBER Project’s Facebook page and on Storify today for review – and for future reference. Please join the conversation and add your insight. Until then, may the airway be ever in your favor!

 

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May the Airway be Ever in Your Favor!

May the Airway be Ever In Your Favor

May the Airway be Ever In Your Favor

Presentation for the 2014 Airway Course @NYP

This year I’m giving the lecture on emergency cricothyrotomy at our annual airway course. This is a relatively simple procedure, but it’s mastery presents several training challenges. Beyond knowledge of relevant anatomy, and familiarity with a rarely performed procedure, this low frequency event almost always occurs in the high stress/high stakes environment of the failed airway.

Success in this environment requires more than knowledge of anatomy, or familiarity with the steps of a procedure: it demands leadership and teamwork, situational awareness, logistical preparedness, and insight into how the mind works in moments of stress. Unless you can move quickly through the failed airway algorithm and arrive at the point where scalpel meets skin then your technical knowledge is useless.

Over the next two weeks the EMBER Project’s daily posts will highlight these technical and non-technical skills related to the surgical airway, and the environment in which it is performed. We will curate some great online resources, and guide you through a multiplicity of concepts to create a clearly demarcated roadmap to master the material. After the course “The EMBER” (a bundle of online resources) will be posted on Storify in a concise format that will offer a permanent reference and future resource for review.

If you’re attending the course, this will be an essential addition to your learning, and will prep your knowledge base for the upcoming sim and cadaver lab work. For others who want a good review, this is a free and open access resource. Before getting started, I want to thank all the great educators and airway experts out there out there, who have taken the time to make their experience and knowledge available to all of us.

The adventure will get started in earnest tomorrow, so get ready for some cricothyrotomy madness by following here, AND on Facebook or Twitter to get the full program. See you at the head of the bed, and may the airway be ever in your favor!

 

 

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C-Spine Clearance (Hawaiian Style)

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After two wonderful years in Hawaii, I’m returning to New York to take up new clinical and educational challenges.  Before I do, I thought it was appropriate to send one last “postcard from the ED”. This one comes from a case that reminded me that when it comes to decision rules, “there are more things in heaven and earth…than are dreamt of in your philosophy.” Here it is:

A 38 year old surfer comes into the ED by private vehicle. He was driven by a friend to get some pain medication for “spraining my neck”. After being hit by a large wave and tossed around he felt a pop and began to notice severe pain in his neck. At first he tried to paddle back out, but the pain forced him to come to the beach.  After about an hour the pain had not improved and he decided he needed some stronger pain medication.

He had no other injuries, no focal neurologic deficits, and had not been drinking. On examination he had no change in his level of consciousness, he had a normal neurologic exam.  The location of his pain was para-spinal located in the upper cervical muscles by the occiput, and he said “his throat hurt”. He was unable and unwilling to rotate his neck in any direction.

Based on NEXUS this patient could have potentially been cleared clinically.  However, having lived in Hawaii for some time, I have learned to respect the power of the ocean. For me any surf related injury is a high risk mechanism until proven otherwise. If you were not to treat this as a high-risk mechanism and were using the Canadian c-spine rule, you would have gotten to the “able to rotate neck” part before slapping that cervical collar back in place, which is what I did.  Below you can see the reformatted image of a C1 fracture. The patient was accepted for transfer to the trauma center, where he was treated and released with no neurologic deficits.

In hindsight I believe the absence of midline tenderness was due to the extreme amount of soft tissue pain he was in, and the muscular splinting of his unstable C1 fracture. To me it could have counted as a distracting injury however I’m not sure I’ve ever considered para-spinal strain as a distracting injury. Maybe it is a flaw in the language, since the word distracting means “taking your attention elsewhere”. This implies that the pain should be somewhere other than the neck.

Other than mechanism, the real red flag for me was his unwillingness to move his neck. In my experience the alert patient with an unstable c-spine fracture DOES NOT want to move!!!  I’ve also come to realize, working in rural community hospitals here in Hawaii, you paradoxically see more of the isolated serious walk in traumas than you do in a major trauma center. Often the rules of tertiary care practice do not translate. Here are some of the key take away points for me in this case.

North Shore Surfing Accident

Postcards from the Emergency Department (Hawaii)

  1. A patient with a mechanism that is unfamiliar to the physician may be overlooked as high risk due to lack of experience with that type of injury.
  2. For obvious reasons clinical decision rules in trauma are designed using a patient pool which is skewed towards common injury patterns. Unusual mechanisms or patterns of injury unique to your clinical environment (in this case surfing) should be treated as potentially outside the scope of these rules.

There has been some recent trauma literature suggesting that these rules don’t apply to trauma activation criteria patients, This was a reminder that they do not always apply to non-trauma activation patients either. We teach these clinical decision rules, but it is imperative that we also teach the inclusion and exclusion criteria used in the studies, the potential flaws in the human application of these rules, and the limitations of all studies to be generalizable to all patients, so that we can better decide if they apply to the patient in our ED at any given moment.

Finally, if you do use the rules I would consider the combination of NEXUS and Canadian algorithm.  Dr Scott Weingart has a compelling argument and a nice diagram showing how the two can work in synergy.  In this case my patient would have also failed to be cleared clinically based on the combined rule.

The EMBER is a small bundle of free open access resources to deepen your knowledge. Thanks to all the educators out there putting time and energy into teaching others.

http://emcrit.org/podcasts/cervical-spine-injuries-i/

http://www.mdcalc.com/nexus-criteria-for-c-spine-imaging/

http://hsc.unm.edu/emermed/resident_readings/EDArticles_PDF/Trauma/NEJM_03-%20CAN%20C-Spine%20v%20Nexus.pdf

http://www.ncbi.nlm.nih.gov/pubmed/21610391


Who are the stewards of healthcare?

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I met a father yesterday in our ED who didn’t want antibiotics for his child’s otitis media.  He had read that a wait and see approach with appropriate analgesia might be a better option, and I was reminded that better stewardship of our healthcare is everyone’s concern.  It made me so happy to see a parent making such an informed choice, rather than thinking to myself (as I sometimes do) about how bad my Press Gainey score was going to be for being “the idiot doctor who didn’t want to give my child antibiotics for an ear infection”.

Our healthcare system is like recycling, carbon emissions or government spending: everyone agrees we should do more with less and be better stewards in theory, but when it comes to practice it’s always someone else’s problem. Is it because the system is so large we don’t feel that our actions matter, or do we feel entitled to use the resources we have, even if they offer no clear benefit to our patients? I don’t know the answer to this, but I do know that I still do unnecessary tests everyday in the emergency department.  Some are because of my concerns over missing disease in low risk patients, some are because I’m following “standard of care” or “best practice” based on poor evidence, some are because specialists want them or won’t admit or see the patient without them, sometimes its the end of my shift and it’s the path of least resistance.

The list of why unnecessary testing occurs is long and the vigilance required to stay on course and do what I think is right for each individual patient and the healthcare system as a whole is enormous.  In fact I would say a large percentage of my education time and practice is devoted to this one task.  The difficulty is in finding the support and resources to continue the process of informed and judicious use of medical resources against the onslaught of demands made by an avaricious, RVU/procedure driven, and risk averse healthcare industry.

The New York Times posted on a great resource for both patients and doctors that I believe is worth mentioning.  It is a list of the most commonly overused tests in seventeen different medical specialities.  Emergency Medicine is not one of the specialties listed (although it should be), however there are many emergency department relevant tests listed among the various specialty lists. I find this resource particularly helpful in stemming the tide of what other specialists ask of me in my Emergency Department (like PPI for GI bleed or pre-op echoes in cardiac patients) and in making decisions for why I’m admitting a patient.  If my major reason is an expedited workup with one of these unnecessary tests then perhaps I will think twice.

For example here are the top five recommended DON’Ts from the American College of Radiology:

1. Don’t do imaging for uncomplicated headache.

Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well-being.

2. Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.

While deep vein thrombosis (DVT) and PE are relatively common clinically, they are rare in the absence of elevated blood d-Dimer levels and certain specific risk factors. Imaging, particularly computed tomography (CT) pulmonary angiography, is a rapid, accurate and widely available test, but has limited value in patients who are very unlikely, based on serum and clinical criteria, to have significant value. Imaging is helpful to confirm or exclude PE only for such patients, not for patients with low pre-test probability of PE.

3. Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.

Performing routine admission or preoperative chest x-rays is not recommended for ambulatory patients without specific reasons suggested by the history and/or physical examination findings. Only 2 percent of such images lead to a change in management. Obtaining a chest radiograph is reasonable if acute cardiopulmonary disease is suspected or there is a history of chronic stable cardiopulmonary disease in a patient older than age 70 who has not had chest radiography within six months.

4. Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.

Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is nearly as good in experienced hands. Since ultrasound will reduce radiation exposure, ultrasound is the preferred initial consideration for imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is cost-effective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity of 94 percent.

5. Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.

Simple cysts and hemorrhagic cysts in women of reproductive age are almost always physiologic. Small simple cysts in postmenopausal women are common, and clinically inconsequential. Ovarian cancer, while typically cystic, does not arise from these benign-appearing cysts. After a good quality ultrasound in women of reproductive age, don’t recommend follow-up for a classic corpus luteum or simple cyst <5 cm in greatest diameter. Use 1 cm as a threshold for simple cysts in postmenopausal women.

The other seventeen lists are just as good and have a great deal of information relevant to our daily practice.  Of course no list trumps clinical judgement.  The environment we work in, the prevalence of a certain disease in our community, the quality of our tests, and our testing threshold should ultimately determine what we order and what we don’t, but having the support of other specialty societies to NOT do tests is a welcome resource. Along with sites like The NNT and EMLITofNOTE it is another tool to continue improving our daily practice.

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Case Reports from the ED

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Note the subtle venous congestion and edema of the right hand and wrist in this patient with an upper extremity deep venous thrombosis (Paget-Schroetter Disease),

Here is a slightly different twist on Virchow’s triad, and one that I had not seen before until yesterday:  a spontaneous upper extremity DVT (Paget Schroetter Disease) in an otherwise healthy person with no risk factors.  It’s uncommon, but not a complete zebra.  The pathophysiology and subsequent management also differs from your traditional DVT, so I thought it was worthwhile to highlight some of the features that make it unique.

The EMBER Project.003

The EMBER: as always, a collection of interesting information about this topic from around the web.

Paget–Schroetter disease – Wikipedia

First rib resection for Paget-Schroetter Syndrome – YouTube

Spontaneous upper extremity venous thrombosis (Paget-Schroetter syndrome) – Up To Date

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Postcards from the ED

Upper Extremity Hematoma

I was going to use this post to talk about potential spaces in the body until I made the mistake of mentioning it to a surgical friend of mine (yes, I have them) who got all upset that I was really talking about a compartment and not a potential space (apparently I’ve been inappropriately mixing anatomical spaces my entire career). While the definition of a compartment versus a potential space is still debated hotly among anatomy nerds (yes I called you a nerd), for an EP there’s nothing like a dramatic case to remind you that not all potential spaces (or compartments or whatever, hey will you relax please?) are created equal.The elderly and morbidly obese often have a lot more “potential” to extravasate into these spaces.

In the case pictured here, a minor fall in a small woman with abundant loose adipose tissue in her arms led to substantial blood loss before spontaneously rupturing through the skin. She arrived to the ED in class III hemorrhagic shock.

So I guess if you want to be clear about it, old people on Coumadin have a lot of “potential” to bleed copiously into what seem like rather small compartments.  Okay there, does that make you happy?  I know it does.

If you would like to review the difference between a compartment and a potential space here is a mind-numbing review for you. Anatomical spaces: a review. Newell RL. Anatomy Unit, School of Biosciences, Cardiff University, UK. Newell@cardiff.ac.uk

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