Resus Blog

Cutting the Neck- A final word!

admin — Sun, 25 Jul 2010 01:19:40 +0000

The one area of greatest concern, amongst delegates when I'm giving an airway workshop, is when and how, to do a surgical airway. Why do we fear this so much? It's very simple. There are three main reasons: 1. We keep asking ourselves, "When should I really do the surgical airway?" So we aren't sure of the indications. 2. We keep asking ourselves, "What if I screw it up?" 3. We don't do this procedure often, in fact very rarely, so we are not as skilled as we would like to be. Let me go over some of the main points associated with surgical airway, that will clarify all of these issues. The surgical airway is a last avenue, it is usually the final pathway in the management of the emergency airway. The indication for the surgical airway is simply cannot ventilate and cannot oxygenate. It is not cannot intubate. Although our initial aim is to secure the airway, by putting a cuff in the trachea and inflating it, our plans must change, once we cannot obtain access to the trachea, via the cords. You say, but I can't intubate and I don't have a secure airway. I must do the surgical airway. No! Stop for a moment and think. The third reason [...]

Electrical Injury - who needs to be monitored?

admin — Mon, 05 Jul 2010 13:59:47 +0000

Electrical injury, although not a common occurence can present with significant injury. Often the extent of the injury can be under-estimated as it mostly occurs below the skin, with little more than an entry and exit wound to see. The very fact that patients with these injuries don't present often, can result in management challenges. These can range from resuscitation approaches, to decision making as to who needs to be monitored. The obvious high voltage exposure, with significant burn and injury, is not really a challenge in terms of monitor/non-monitor decision making. The challenge is from that group of patients that are well, with minimal injuries. Who, if any, of these patients do we monitor? Electrical burns have a trimodal distribution: 1. The first peak is in children. This is primarily due to behaviors such as cord biting. 2. The second peak is in adolescents who engage in risky behaviour and the third group is: 3. Those whose work involves electricity and potential exposure. Childhood injuries are usually biting injuries, where the child will chew through an electric cord. The result will be a burn to the lips or mouth. These burns are usually bloodless and painless as the vessels have been cauterised and the nerves damaged. One of the main issues in dealing with this kind of elelctrical injury is [...]

ventricular tachycardia and methadone

admin — Sun, 20 Jun 2010 00:23:09 +0000

Here's an interesting cardiac case we had the other day. A 42 year old male with a past history of IVDU and alcohol abuse and brain injury, presents with what looks like withdrawal. Current medications included methadone and earlier on the same day, he was commenced on naltraxone. Initially he is found to be becoming progressively more agitated and having brief episodes of depressed conscious state, with improvement between. He is 'jittery' with myoclonic movements in the bed. On vitals, he is found to be afebrile with a fluctuating Glascow Coma Score, bradycardic, and to have a systolic blood pressure of 80mmHg, and so he is taken to a resuscitation cubicle. Is he in withdrawal? Is he seizing? As I enter the resus cubicle to find out why the patient is there, I notice a wide complex tachycardia at a rate of about 230bpm. He is still moving. It is self limited after a few seconds. Then a further episode. In between episodes we do this ECG:[...]

Could this be a Pulmonary Embolism?

admin — Tue, 08 Jun 2010 07:52:12 +0000

In a previous blog we looked at the following patient who presented to the emergency department: 62 year old male presents to the Emergency Department with what he calls a flare-up of his congestive cardiac failure. He states he is short of breath. He is a frequent presenter to the department with this complaint. He has not taken his frusemide for the past 48hours. He states that he feels very tired. He is a well looking man with normal vitals Heart sounds dual, no murmur. normal JVP, bilateral pitting oedema to mid calves. Chest clear Abdomen soft His ECG and CXR are normal Bloods including a troponin are normal. I'm unsure of the diagnosis, but given he hasn't taken his frusemide, I treat him with that. I am going to discharge him, however it is late at night and he lives alone, so we decide to keep him in the department overnight. In the morning, he looks well and feels better, but still lethargic, ECG is unchanged, but for some reason someone does a follow-up troponin and it is 4. He is diagnosed with a NSTEMI and sent to cardiology. I now ask the question could it have been a pulmonary embolism and not a NSTEMI? Certainly if we look at this case we see that the patient had dyspnoea with a normal chest on auscultation and on chest X-ray. Hmmm... What are the risk factors for pulmonary embolism? Well we know of the classic ones of anything affecting Virchow's triad. There are the hereditary factors of Protein C and S deficiency as well as others and the acquired factors such as immobility, recent surgery, cancer and others. This patient had congestive cardiac failure(CCF). Is that a risk factor? As it turns out it is. In a population based study by Helt et al (Arch Intern med. 2002;162:1245-1248), the attributable risk associated with venous thromboembolism was 9.5%. So there is an increased risk in CCF. What about symptoms and signs? Surely they would help. Stein et al (Chest 1991;100:598-603), looked at patients with a suspected pulmonary embolism(PE) and with no previous evidence of cardiac or respiratory disease. He then looked at the symptoms in patients [...]

How good are we at predicting ischaemic chest pain?

admin — Mon, 24 May 2010 00:05:57 +0000

Here's a case I had recently: 62 year old male presents to the Emergency Department with what he calls a flare-up of his congestive cardiac failure. He states he is short of breath. He is a frequent presenter to the department with this complaint. He has not taken his frusemide for the past 48hours. He states that he feels very tired. His examination is as follows: He is a well looking man with normal vitals Heart sounds dual, no murmur. normal JVP, bilateral pitting oedema to mid calves. Chest clear Abdomen soft His ECG and CXR are normal Bloods including a troponin are normal. I'm unsure of the diagnosis, but given he hasn't taken his frusemide, I treat him with that. I am going to discharge him, however it is late at night and he lives alone, so we decide to keep him in the department overnight. In the morning, he looks well and feels better, but still lethargic, ECG is unchanged, but for some reason someone does a follow-up troponin and it is 4. He is diagnosed with a NSTEMI and sent to cardiology. So the question I posed was, "How good are we at diagnosing cardiac chest pain?" and "Are there some signs or symptoms such as shortness of breath that are more important than we may initially think they are?" Pope et al(NEJM 2000;343:1167-1170) looked at the rate of missed diagnoses of cardiac ischaemia in the emergency department. This was a study of some 10689 patients and the conclusion was that there was a subgroup of patients more likely not to be admitted, who had ischaemia or infarction. Those more likely to not be admitted were: [...]

I’ve changed the way I do surgical airway

admin — Sat, 24 Apr 2010 04:01:10 +0000

I think there's a better way. This comes after talking to people who've done ton's of surgical airway. When you work in Australia and don't get the volume of patients that have the trauma and other conditions that will lead more often to the surgical airway, you define your technique to suit what you do and this is what we've done in the past. But now we ask, is there even a better way? What better way to learn than to ask Emergency Physicians in the country where surgical airways are more common than corn chips - OK maybe that's not quite true, but you know I'm talking about the US of A. Many of you have attended my airway workshop. Given that its one of the only workshops of its kind in Australasia, where do I go if I want to see if I can get challenged? Yes sir, "I saddled up the truck and moved to Beverly"(most of you younger guys won't know this quote, but the older and more arthritically challenged amongst you, like me, will know that line is from an old series,'The Beverley Hillbillies'. Anyway, I was taking an airway workshop and talking to the guys from USC and we had great discussion on airway and especially surgical airway. I showed them my horizontal technique and discussed the issues related to it. Now let me put this in context for you, and a little bit of a rant will follow! This rant is about the way anaesthetics or ICU or anyone else reacts when the ED does a surgical airway. A few years ago I was working at a trauma centre down [...]

Basic Life Support and Resuscitation

admin — Wed, 31 Mar 2010 03:25:58 +0000

Basic Life Support from resustv.com on Vimeo.

Basic Life Support from resustv.com on Vimeo. This is a little video we did a while ago for the medical students and gives them a practical approach to an arrest scenario. Bad acting aside, it does the job.(As many should notice, the only thing we don't do first is give the initial 2 breaths). The video takes a few seconds to start. Basic Life Support is a key skill for all of us. I mean for ALL of us. In Emergency medicine we resuscitate often and so we almost take it for granted that we know this material. If you are a General Practitioner, a healthcare practitioner of any sort, be it surgeon or physician, you need to know this. If you are a nurse, you need to know this. Those of you who are not medical practitioners, but may be dental practitioners or even that subgroup that undertakes sedation of patients, you need to know this! In medicine, whether you see oncology patients every day, take out gallbladders, or provide family medicine, it is expected of all of us and we must expect it of ourselves, that we know this stuff backwards. We must know the basics of resuscitation. Just when you were getting it, ILCOR will bring out something new this year. Odds are that the number of compressions to breaths will again increase, highlighting the importance of chest compression and maintenance of coronary perfusion pressure. In fact, I'll stick my neck out and say that airway will take [...]

Designing the Perfect Emergency Department

admin — Sat, 20 Mar 2010 22:25:31 +0000

Designing Emergency Departments is challenging. This is purely because emergency medicine is a young specialty and still in a state of flux. We are trying new things all the time to improve performance and efficiency. We add paediatric waiting rooms and short stay units and 'fast track' areas and streaming. When all is said and done, is there such a thing as the perfect emergency department? Probably not, but we can get very close. I've had the privilege of designing emergency departments now for some 15 years and in more than one country. You can't keep doing something for that long and not notice what works. There are patterns. As they say 'success leaves clues'. I've noticed that there are some essential aspects[...]

The LEMON Approach for predicting the difficult airway.

admin — Sat, 20 Mar 2010 12:19:03 +0000

The 3:3:2 Rule for predicting The Difficult Airway from resustv.com on Vimeo. www.resustv.com is coming in late APRIL 2010- videos of lectures on all of acute medicine The L.E.M.O.N. approach is just that, an approach to predicting the potentially difficult airway. It is a way of adding some measurable parameters to what should become a 'gestault' approach, where you know, or have a 'vibe', a feeling, call it what you will, about the relative ease or difficulty of any airway. This gestault is usually gained following years of experience. BUT it can be taught. The LEMON rule allows us to remember to look externally and to look at those parameters that will make the intubation simple or difficult. LEMON stands for:[...]

The BURP, the Sellick and the bimanual- which is better?

admin — Mon, 15 Mar 2010 10:40:32 +0000

Which is better? BURP or Bimanual. Is Cricoid Pressure of any use? Sellick described cricoid pressure in 1961. How useful is it? Well its purpose is to minimise the passive movement of gastric contents into the oropharynx and the potential aspiration of those contents, during rapid sequence intubation. How good is it? I was recently asked this at an Airway Workshop and I had to say for what we have, it's pretty good. BUT the evidence is not that great! In fact some of the newer evidence now says, it may be detrimental a [...]