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Apnoeic Oxygenation in Resuscitation: Is it time?

We are finally seeing the years of airway in resuscitation dogma being challenged. The original approach to airway which mandated intubation and probably led to significant delays in CPR and an increase in mortality, are now gone. Bag-valve-mask vs supraglottic vs intubation The literature that compares intubation, laryngeal mask(LMA) and bag valve mask(BVM) has given…

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VAPOX and Ventilation During the Apnoeic Period

In Rapid Sequence Intubation(RSI), there is that period of apnoea that occurs following delivery of paralytics and prior to attempting laryngoscopy and intubation. It’s a period of 40 to 50 seconds, before we attempt to do anything. “Don’t bag!” we often scold. “It’ll fill the stomach and cause regurgitation and aspiration”…… In the background the patient’s saturations…

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Should we intubate in the ramped position?

I’ve spoken on awake intubationat the EMCORE Conferences, especially at the last Masterclass. I also spoke about the potential benefits of intubating patients in the ramped positionie., head of the bed up at 25-30 degrees. Mostly this is based Off studies, using operating theatre patients that have already been intubated, then disconnected from oxygen sources and observed to see how long…

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How Dangerous is Pulmonary Embolism?

How Dangerous is Pulmonary Embolism? The diagnosis and management of pulmonary embolism(PE), like most things in emergency medicine; it’s about risk stratification. In chest pain, the low risk patient is approached very differently to the high risk, ST elevation chest pain patient. It is exactly the same in PE. There is that group of patients…

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5 Things To Help You Get The Airway

1. Know When To Intubate The Advanced Airway is not just about doing, but also about thinking. It may sound strange, but we should have an approach that allows us to quickly ascertain the appropriateness of intubation. My choice is when there is failure of ( whether this is now or imminent) of oxygenation and…

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More Non-Invasive Ventilation

Following the video on how to use non-invasive ventilation, I was asked to briefly again explain in graphical form how I see non-invasive ventilation as working. This is a very basic view. In terms of Non Invasive Ventilation, we can first start by thinking about CPAP (Continuous Positive Air Pressure) Ventilation. We can set this…

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Non-Invasive Ventilation

Introduction If find myself reaching more and more for the non-invasive ventilation, in the COPD patient. I’ve always loved it for acute pulmonary oedema. However, there is something about assisting the patient’s work of breathing, that allows me to ‘titrate’ what I give. A Case The ambulance bring a patient in on a rebreather. She…

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Effectiveness of Apnoeic Oxygenation Questioned

Everyone knows I’m a huge fan of apnoeic oxygenation. I use it for sedation, for intubation, heck I sprinkle some on my cereal in the morning. But here is a study published this week, whose conclusions do not support the use apnoeic oxygenation during endotracheal intubation of critically ill adults.Semler et al of the Fellow investigators…

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Difficult Airway Cases: What would you do?

Airway management is frightening, especially if you don’t do it often. Having a plan when we approach an airway is important. My plan involves: Maximising oxygenation with apnoea oxygenation Using the right drugs Performing epiglottoscopy, rather than looking for the cords Having a fallback plan. For me this means thinking about the 3 elements that…

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Roc Rocks, I’ll miss you Sux

Rocuronium vs Suxamethonium(Succinylcholine) I remember teaching the Advanced Airway Workshop and having one slide with “SUX is KING”. Times have changed!Which is the better paralytic agent to use in the Emergency Department; Suxamethonium(Succinylcholine for our US colleagues) or Rocuronium? This argument has been ongoing for some time, with debates, podcasts and written reviews by proponents…

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Stylet or Bougie for Intubation

As many of you will know, I’ve been teaching airway workshops now for many years, and have put over 3500 doctors through the Advance Airways Workshop.     I teach equipment in the following way:Your weapon of choice is the size 3 curved blade.Everyone gets a 7.5 tube in the emergency situationAlways use a stylet…

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My Rules for Getting the Airway

There are all these fancy terms out there in respect to airway. There’s apnoeic oxygenation, delayed sequence intubation, the vortex etc….. Let me tell you something, you already know. This stuff has been around in one form or another for a while, but we have discovered its application to emergency medicine only recently. After giving…

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