Podcasts about endotracheal

Most ACLS medications are given IV push. But, what happens if we can't get an IV? Why IO is better than ETT as an alternative route. The locations we should place an IO when running a code and a location we should avoid. The ACLS medications that can be given intraosseous. Where you can find more information about intraosseous access during resuscitation efforts. In the absence of an IV or IO, some medications may be given down the endotracheal tube.The disadvantages of medication administration via ETT.Review of the medications that can be given down the tube and how they should be given.Medications should not be given down the tube when anything other than an endotracheal tube is used as an advanced airway.Connect with me:Website: https://passacls.com@PassACLS on X (formally known as Twitter)@Pass-ACLS-Podcast on LinkedInGive back - buy Paul a bubble tea hereGood luck with your ACLS class!

Non-pharmacological interventions for the prevention of pain during endotracheal suctioning in ventilated neonates.Pirlotte S, Beeckman K, Ooms I, Cools F.Cochrane Database Syst Rev. 2024 Jan 18;1(1):CD013353. doi: 10.1002/14651858.CD013353.pub2.PMID: 38235838As always, feel free to send us questions, comments, or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through Instagram or Twitter, @nicupodcast. Or contact Ben and Daphna directly via their Twitter profiles: @drnicu and @doctordaphnamd. The papers discussed in today's episode are listed and timestamped on the webpage linked below. Enjoy!

Most ACLS medications are given IV push. But, what happens if we can't get an IV? Why IO is better than ETT as an alternative route. The locations we should place an IO when running a code and a location we should avoid. The ACLS medications that can be given intraosseous. Where you can find more information about intraosseous access during resuscitation efforts. In the absence of an IV or IO, some medications may be given down the endotracheal tube. The disadvantages of medication administration via ETT. Review of the medications that can be given down the tube and how they should be given. Medications should not be given down the tube when anything other than an endotracheal tube is used as an advanced airway.Connect with me:Website: https://passacls.com@PassACLS on X (formally known as Twitter)@Pass-ACLS-Podcast on LinkedInGive back via PayPal Good luck with your ACLS class!

I read from endotracheal to endurance.     The word of the episode is "end time".     Theme music from Jonah Kraut https://jonahkraut.bandcamp.com/     Merchandising! https://www.teepublic.com/user/spejampar     "The Dictionary - Letter A" on YouTube   "The Dictionary - Letter B" on YouTube   "The Dictionary - Letter C" on YouTube   "The Dictionary - Letter D" on YouTube   "The Dictionary - Letter E" on YouTube     Featured in a Top 10 Dictionary Podcasts list! https://blog.feedspot.com/dictionary_podcasts/     Backwards Talking on YouTube: https://www.youtube.com/playlist?list=PLmIujMwEDbgZUexyR90jaTEEVmAYcCzuq     https://linktr.ee/spejampar dictionarypod@gmail.com https://www.facebook.com/thedictionarypod/ https://www.threads.net/@dictionarypod https://twitter.com/dictionarypod https://www.instagram.com/dictionarypod/ https://www.patreon.com/spejampar https://www.tiktok.com/@spejampar 917-727-5757

Join Mawi, Shelly, and Ben (new Ben) for stories of ETT malfunctions, Aortas that can't be fixed, and the most insulin given in a case that we've EVER heard of. You'll laugh, you'll cry, and maybe hurl. Hopefully not the hurling part. 

Most ACLS medications are given IV push. But, what happens if we can't get an IV? When IV access isn't available, we should consider administering our IV medications via intraosseous (IO)or endotracheal tube (ETT) route. Why IO is better for than ETT as an alternative route. The locations we should place an IO when running a code and a location we should avoid.The ACLS medications that can be given intraosseous. Where you can find more information about intraosseous access during resuscitation efforts. In the absence of an IV or IO, some medications may be given down the endotracheal tube. The disadvantages of medication administration via ETT. Review of the medications that can be given down the tube and how they should be given. Medications should not be given down the tube when anything other than an endotracheal tube is used as an advanced airway.**American Cancer Society (ACS) Fundraiser This is the fifth year that I'm participating in Men Wear Pink to increase breast cancer awareness and raise money for the American Cancer Society's life-saving mission.I hope you'll consider contributing.Every donation makes a difference in the fight against breast cancer! Paul Taylor's ACS FundraiserTHANK YOU! Connect with me:Website: https://passacls.com@PassACLS on Twitter@Pass-ACLS-Podcast on LinkedInGive back & support the show:via PayPal Good luck with your ACLS class!

Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast is an exciting journey towards improved anesthesia patient safety.Join us for a Rapid Response to Questions from our Readers show. Our topics today include endotracheal tube cuff failure and changes in drug dilution for infusions in the operating room. Plus, we hear from the manufacturers in response to the cases. Are you performing a pre-induction check of the pilot balloon and ETT cuff? Are you checking the concentration of drugs diluted in the operating room prior to administration? Tune in as we address these questions and more?Additional sound effects from: Zapsplat.For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/169-endotracheal-tube-cuff-failure-and-medication-safety-associated-with-drug-dilution/© 2023, The Anesthesia Patient Safety Foundation

Most ACLS medications are given IV push. But, what happens if we can't get an IV? When IV access isn't available, we should consider administering our IV medications via intraosseous (IO)or endotracheal tube (ETT) route. Why IO is better for than ETT as an alternative route. The locations we should place an IO when running a code and a location we should avoid. The ACLS medications that can be given intraosseous. Where you can find more information about intraosseous access during resuscitation efforts. In the absence of an IV or IO, some medications may be given down the endotracheal tube. The disadvantages of medication administration via ETT. Review of the medications that can be given down the tube and how they should be given. Medications should not be given down the tube when anything other than an endotracheal tube is used as an advanced airway.Connect with me:Website: https://passacls.com@PassACLS on Twitter@Pass-ACLS-Podcast on LinkedInGive back & support the show:via PayPal Good luck with your ACLS class!

Teleflex's voluntary recall of its Rüsch endotracheal tubes highlights the possibility of oxygen desaturation, and in the event, any immediate or long-term health consequences depend on the degree and duration of desaturation. Fast Five hosts Sean Whooley and Danielle Kirsh share what issue caused the recall and how many complaints the company has received so far. The FDA's IDE approval of Metavention's renal denervation therapy represents an important milestone in the treatment of hypertension. Whooley details what the platform does, how it works and how optimistic executives are. Real-world data validating the efficacy and usability of Bigfoot Biomedical's diabetes management platform underscores its potential to revolutionize diabetes care. Kirsh and Whooley discuss some of the key data points from the study and the company's future plans. Insulet's ongoing efforts to integrate its Omnipod 5 system with Abbott's FreeStyle Libre 2 sensor marks a significant advancement in the company's diabetes management technology. Whooley talks about where the technology is currently integrated and plans for a clinical study in the future. The appointment of Lea Daniels Knight as CFO of Integra Lifesciences brings a seasoned financial leader to the company's executive team. Hear about her prior experience in finance and medtech and what the company's CEO has to say. Check out the show notes for links to the stories we discussed and more at MassDevice.com/podcast.

Most ACLS medications are given IV push. But, what happens if we can't get an IV? When IV access isn't available, we should consider administering our IV medications via intraosseous (IO)or endotracheal tube (ETT) route. The locations we should place an IO when running a code and a location we should avoid. The ACLS medications that can be given intraosseous. Where you can find more information about intraosseous access during resuscitation efforts.In the absence of an IV or IO, some medications may be given down the endotracheal tube.Why IO is better for than ETT as an alternative route. The disadvantages of medication administration via ETT. Review of the medications that can be given down the tube and how they should be given. Medications should not be given down the tube when anything other than an endotracheal tube is used as an advanced airway.Connect with me:Website: https://passacls.com@PassACLS on Twitter@Pass-ACLS-Podcast on LinkedInGive back & support the show:via PayPal Good luck with your ACLS class!

Dr. Nick Kumar and Dr. Andy Siemens from the Massachusetts General Hospital anesthesia residency join the show to discuss the literature comparing double lumen endotracheal tubes and bronchial blockers. Dr. Dan Saddawi-Konefka joins as our faculty expert - special thanks to Dan for supporting the ongoing Depth of Anesthesia podcast elective. Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and share our content with your colleagues. — Follow us on Instagram @DepthofAnesthesia and on Twitter @DepthAnesthesia for podcast and literature updates. Email us at depthofanesthesia@gmail.com with episode ideas or if you'd like to join our team. Music by Stephen Campbell, MD. — References Clayton-Smith A, Bennett K, Alston RP, Adams G, Brown G, Hawthorne T, Hu M, Sinclair A, Tan J. A Comparison of the Efficacy and Adverse Effects of Double-Lumen Endobronchial Tubes and Bronchial Blockers in Thoracic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth. 2015 Aug;29(4):955-66. doi: 10.1053/j.jvca.2014.11.017. Epub 2014 Dec 2. PMID: 25753765. Uwe Klein, Waheedullah Karzai, Frank Bloos, Mathias Wohlfarth, Reiner Gottschall, Harald Fritz, Michael Gugel, Albrecht Seifert; Role of Fiberoptic Bronchoscopy in Conjunction with the Use of Double-lumen Tubes for Thoracic Anesthesia : A Prospective Study. Anesthesiology 1998; 88:346–350 doi: https://doi.org/10.1097/00000542-199802000-00012 Risse J, Szeder K, Schubert AK, Wiesmann T, Dinges HC, Feldmann C, Wulf H, Meggiolaro KM. Comparison of left double lumen tube and y-shaped and double-ended bronchial blocker for one lung ventilation in thoracic surgery-a randomised controlled clinical trial. BMC Anesthesiol. 2022 Apr 2;22(1):92. doi: 10.1186/s12871-022-01637-1. PMID: 35366801; PMCID: PMC8976407. Morris BN, Fernando RJ, Garner CR, Johnson SD, Gardner JC, Marchant BE, Johnson KN, Harris HM, Russell GB, Wudel LJ Jr, Templeton TW. A Randomized Comparison of Positional Stability: The EZ-Blocker Versus Left-Sided Double-Lumen Endobronchial Tubes in Adult Patients Undergoing Thoracic Surgery. J Cardiothorac Vasc Anesth. 2021 Aug;35(8):2319-2325. doi: 10.1053/j.jvca.2020.11.056. Epub 2020 Nov 28. PMID: 33419686. Jo Mourisse, Jordi Liesveld, Ad Verhagen, Garance van Rooij, Stefan van der Heide, Olga Schuurbiers-Siebers, Erik Van der Heijden; Efficiency, Efficacy, and Safety of EZ-Blocker Compared with Left-sided Double-lumen Tube for One-lung Ventilation. Anesthesiology 2013; 118:550–561 doi: https://doi.org/10.1097/ALN.0b013e3182834f2d

Most ACLS medications are given IV push. But, what happens if we can't get an IV? When IV access isn't available, we should consider administering our IV medications via intraosseous (IO)or endotracheal tube (ETT) route. Why IO is better for than ETT as an alternative route. The locations we should place an IO when running a code and a location we should avoid. The ACLS medications that can be given intraosseous. Where you can find more information about intraosseous access during resuscitation efforts. In the absence of an IV or IO, some medications may be given down the endotracheal tube. The disadvantages of medication administration via ETT. Review of the medications that can be given down the tube and how they should be given. Medications should not be given down the tube when anything other than an endotracheal tube is used as an advanced airway. Connect with me:Website: https://passacls.com@PassACLS on Twitter@Pass-ACLS-Podcast on LinkedInGive back & support the show:via PayPal Good luck with your ACLS class!

Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast is an exciting journey towards improved anesthesia patient safety.What is your anesthetic plan for ERCP procedures? Tune in today for the conclusion of our special Pro-Con debate series. We are reviewing the final arguments in favor of general endotracheal anesthesia. Spoiler alert: Both sides can agree that keeping patients safe requires a qualified anesthesia professional.Additional sound effects from: Zapsplat.© 2023, The Anesthesia Patient Safety FoundationFor show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/137-the-debate-continues-general-endotracheal-anesthesia-for-ercp/

Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast is an exciting journey towards improved anesthesia patient safety.What is your anesthetic plan for ERCP procedures? The debate between monitored anesthesia care and general endotracheal anesthesia continues today. We are focusing on the Con-side of the debate in favor of GEA for ERCP with special guest, Luke Janik, who contributed audio clips to the show today.Additional sound effects from: Zapsplat.© 2023, The Anesthesia Patient Safety FoundationFor show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/136-the-debate-continues-general-endotracheal-anesthesia-for-ercp/

In this episode we welcome critical care nurse practitioner, Kali Dayton, DNP, AGACNP. Kali is a member of the Society of Critical Care Medicine and host of the ‘Walking Home From The ICU' podcast. Kali works closely with international ICU teams to help transform patient outcomes. They focus on early mobility and management of delirium in the ICU. She joins us to chat about her early days and experience in the ICU, sedation in patients and the effects of mobility of patients in the ICU, medications, how she helps with patient healing and more. Kali tells us about what inspired her to start her podcast and shares a story about her experience with an ICU survivor.SPONSORBETTERHELPBetterHelp is the largest online counseling platform worldwide. They change the way people get help with facing life's challenges by providing convenient, discreet, and affordable access to a licensed therapist. BetterHelp makes professional counseling available anytime, anywhere, through a computer, tablet or smartphone.Sign up today: http://betterhelp.com/solvinghealthcare and use discount code “solvinghealthcare"TRANSCRIPTKK: We are on the brink of a mental health crisis. This is why I am so appreciative of the folks over at BetterHelp everybody the largest online counseling platform worldwide to change the way people get help with facing life's challenges by providing convenient, discreet, and affordable access to licensed therapists. BetterHelp makes professional counseling available anytime, anywhere through a computer, tablet, or smartphone. Sign up today go to better health.com And use a promo code solving healthcare and get 10% off signup fees.SP: COVID has affected us all and with all the negativity surrounding it, it's often hard to find the positive. One of the blessings that has given us is the opportunity to build an avenue for creating change. Starting right here in our community discussing topics that affect us most such as racism and health care, maintaining a positive mindset, creating change the importance of advocacy, and the many lessons we have all learned from COVID. If you or your organization are interested in speaking engagements, send a message to kwadcast99@gmail.com or reach out on Facebook @kwadcast or online at drkwadwo.caKK: Welcome to ‘Solving Healthcare', I'm Kwadwo Kyeremanteng. I'm an ICU and palliative care physician here in Ottawa and the founder of resource optimization that one, we are on a mission to transform healthcare in Canada. We're going to talk with physicians, nurses, administrators, patients and their families because inefficiencies, overwork and overcrowding affects us all. I believe it's time for a better health care system that's more cost effective, dignified, and just for everyone involved. KK: Kwadcast nation super exciting episode I got flowing with you. We got Kali Dayton. She is a nurse practitioner that has taken ICU delirium, ICU mobility so seriously, she's got her own consulting firm. She also has her own podcast ‘Walking from the ICU'. Such a great phenomenon. So, we got her you'll hear this episode. It's a live cast that we did a couple of weeks ago. I'm just proud of her. Someone that's taken getting people healthier and out of the ICU and functional seriously, and we need more of that going on right now. We're only gonna see higher demands. So, without further ado, I'm gonna bring Kali on but first, check out our latest newsletter, kwadcast.substack.com It has everything Kwadcast, our episodes, or newsletter, guest blog appearances, guest vlog appearances, you're gonna love it. Kwadcast.substack.com Check it out. Without further ado, I want to introduce you to Kali Dayton. Welcome to the podcast.KD: Thank you so much for having me on. I've been following your podcast; I appreciate your mission. I see a lot of our objectives are in line.KK: Oh 100% 100%. So, Kali, can you walk us through your story? You're a nurse practitioner. That is, like I said, changing the outlook for critically ill patients. How did you get here?KD: Absolutely. I'm sure a lot of my listeners know my story very well. I started out as a brand-new nurse, many years ago, over a decade ago, in awake and walking ICU. That's just what I call it now. That's the term that I've coined to describe what they do there. In the interview in my naivete, I was just excited to be there. I had no idea what they were talking about when they asked, ‘Would you be willing to walk patients that are on ventilators?' and I was willing to do anything, right. I was just brand new graduate. I said yeah, of course absolutely teach me everything. I didn't understand the magnitude of that question until probably three to eight years later. Because when I started working there, no one made a big deal out of it, for decades and that ICU it's a medical surgical ICU, its high acuity, they've had a COVID ICU throughout the pandemic. They've maintained it this practice of allowing almost every patient to wake up, usually right after intubation, unless there's an actual indication for sedation. What's been intubated on mechanical ventilation is not an indication for sedation. So, unless they have an inability oxygen with movement, seizures and cranial hypertension, something like that, otherwise they are awake. They're reoriented and they're allowed to communicate, tell us what they need. We manage their pain according to what they tell us. They're usually mobilizing shortly after within hours after intubation, and throughout the day, and throughout their time on the ventilator. So that was completely normal. No one told me ‘Hey, Kali, this is the gold standard of care. This is the model for all early mobility protocols in the world' Everyone knows about this ICU. No one told me that. So, I spent a few years there thinking that that was normal critical care, medicine, knowing none the wiser. Then I became a travel nurse, and I went to other ICUs in the in the United States. My very first contract when I walked into the ICU, it just felt different. But I knew I expected things to feel different, right? It's a new environment. But everyone was in bed. Everyone looked like they were asleep. There were very few signs of life, and I got my patient assignment, and the patient was sedated and on the ventilator. I didn't know why they were sedated. I wanted to continue my routine, do a neuro exam, hopefully get the patient in the chair ready for physical therapy, because that was my routine, in the wake & walk ICU. A lot of times physical therapy comes out of that patient is in the chair waiting for the physical therapist, take them on a walk even on the ventilator. So, I asked my orientee nurse, ‘Hey, can I get this patient up and take him for a walk?' and she looked at me in horror and said, ‘No, they're on the ventilator. They're intubated' What didn't make sense to me, because I've cared for at least hundreds, maybe even 1000s of patients that were on the ventilator and were awake and walking. I had no idea what she was talking about. I said, ‘I know that they're intubated. But why are they sedated?' ‘Because they're intubated?' and I say, ‘Okay, but why are they sedated?' and we went in circles. That was the first time it ever crossed my mind that a patient would be automatically sedated, just because they were intubated. I quickly realized that that was the common perspective throughout the ICU, that I was the odd man out there. Here's the thing. Despite my years of experience, treating patients like that, I knew how to do it. I didn't know why we did it. No one had taught me what sedation actually does. No one taught me what it's actually like for patients, and how much it changes outcomes. So, in that environment, I didn't have the tools to support my approach and my practices and to advocate for my patients. I was still kind of a new nurse, and I was, you know, you just had to fit in in the ICU. There's so much peer pressure, there's the culture is such a huge part of it. I ended up just taking the ‘When in Rome' approach and I just went with what I was surrounded with, and I ended up following along sedating my patients. I didn't really obviously know the difference. I mean, I saw a difference in outcomes. I saw patients stay on the ventilator for far longer. I missed the human connection, I noticed that there were a lot of tracheostomies and nursing home and LTech discharges that I did not see the way can walk in ICU 93% of survivors from that high acuity medical surgical ICU that I came from, went straight home after the after the ICU.KK: That is nuts. That is nuts.KD: That's what I thought was normal. So, I was noticing things, but I couldn't really put my finger on it. I couldn't advocate and I just went with it. Right. I even laughed at some of the nursing jokes about yeah, I hope my patient sedated, and totally snowed today. Thinking that that was funny, and it wasn't till years later that I was in grad school. Of course, even in my acute care doctorate program, nothing was mentioned about sedation or mobility practices. It was just assumed even in our case studies, it was assumed that if a patient came in with pneumonia, they were going to be sedated if they were on a ventilator. I was on a plane ride, and I sat next to a survivor. When he heard that I was a nurse and ICU nurse, the color dropped from his face. He started telling me about his experience over four years before that moment when he was a patient. He told me what it was like to be on a ventilator. He just barely mentioned the ventilator. All he could fixate on was what it was like to be in the middle of a forest with his limbs nailed to the ground and trees were falling down on him and he couldn't run away. Demons were coming to the sky and lots of things that he still couldn't talk about, because he was so deeply traumatized. I was stranger on this plane and he's sobbing to me, telling me about what he experienced. Of course, I wanted to diagnose him and I said ‘it sounds like you had ICU delirium' but that meant nothing to him. I came to realize as I listened with real empathetic ears, that that wasn't just a nightmare. Those weren't hallucinations. Those were vivid and real. He was psychologically scarred as if he physically lived through those scenarios. I was really shaken. I really hoped that he was one in a million, because he was telling me that for year after discharge, it was really difficult to relearn how to sit, stand, walk, swallow, that was really hard. The hardest part was that for year after discharge, every time he closed his eyes, he would be lost back in that forest back in that scenario, and he could not sleep. So, the depression, anxiety, physical disability, I didn't ask about the cognitive function because I didn't enough know enough to know that he wouldn't be at high risk of having post ICU dementia. He said that he still had not returned to his career. His life was over. He said ‘I know I feel bad even telling you this, I should be grateful to the ICU to him for saving my life, but my life is over. The life I knew before the ICU is gone. I lost my life in the ICU. If I were ever to become sick, I would never cross a toe back into the ICU. He was a DNR/DNI in his 40s, with no other real comorbidities because he never wanted to live through that again. I think what he meant by that was ICU delirium. I had worked in the ICU about six years. We have never I never heard anyone talk about anything like that. So, I thought this must be a fluke, he must be one in a million. So, I went survivor groups. I thought I would have to post and ask survivors questions. No, the second I got into survivor group, I just scroll through and almost all their posts were about the trauma suffered under sedation and these medically induced comas, what it was like to not be able to balance their check book, read a book, read a clock, like they were barely able to text. These are people thinking ‘How long is this going to last? my brain is not the same'. So that is what got me into looking into the research. I was shocked to find decades of research, exposing the harm of our normal practices. Yet we continue to do those things and I was back in that awake and walk ICU. Seeing a completely different way and I've seen this contrast from what I experienced for years as a travel nurse. Then where I was currently at as a doctorate student, nurse, and then I started working as a nurse practitioner, in that same ICU. That's when I started this podcast ‘Walking home from the ICU' to show what they were doing in the ICU and now it's turned into ‘how do we revolutionize our normal practices in the ICU?'KK: I got so much here, first. I never even would have comprehended or would have thought that your initial experience, I didn't realize that your initial experience was people were able to ambulate and get out of bed and reduce the amount of sedation. KD: People are gonna say ‘Oh, well, that must have been, you know, long term mentors or not that high acuity' They were the first ICU to publish the study back in 2007, showing that it was safe and feasible to walk patients on ventilators and in that study, they had PF ratios less than 100.KK: What that means in nonmedical folk is that your lungs were extremely damaged and require a lot of supplemental oxygen to make sure your saturations are high enough that your oxygen levels are high enough. So, this is the sickest of the sick. From a breathing perspective, getting up and hustling and movement answered. So that is amazing. From a personal side, it must have been an absolute mind F that you couldn't, that you went from one extreme to the other. I'm doing tell you from my I've worked in several ICUs in my country, and the latter is the norm, people aren't getting up on a ventilator, you know, they're not getting, they're barely getting up into a chair on a ventilator. KD: They aren't even getting sedation vacations, they're snowed. KK: One of my main jobs in the ICU when I walk in is minimize the sedation and even often I've seen in practice, they're getting Dilaudid or opioid infusions for no real reason to be honest with you. They're not post op. They have no pain syndrome and we're given pain medication in infusion, which accumulates and what you're describing to amongst patients, my other job is in palliative care when they get toxic or delirium. Delirium from medication. Yeah, that can be traumatic, these memories, these images. That must have been an absolute frustrating experience to go from one version to the other.KD: I was just really confused. I mean, I was still I feel like I'm still new in my career and impressionable. No one taught me the why that's the unfortunate thing about a lot of our medical education is we're taught how we're taught task lists, but we're not taught the why that allow us to critically think and see a bigger picture. I feel like looking back I was really victim to that. I but I would still ask every ICU ‘So, shouldn't this patient get up? Can I get them up?' because it I knew that was beneficial. I wanted that and a lot of it for me was, I wanted to see my patients get better. When you're walking a patient moments later, you know that they're progressing, you get to connect with them, you get to know who your patients are, I had no idea who my patients were, they were just bodies in the bed. That's not why I got into medicine. So even just selfishly, I wanted them to be off sedation, had I known that by taking off sedation, we could decrease their seven-day mortality by 68%. Oh, I would have been all over that, but I didn't know. I did work in one ICU, where they had some level of ABCDEF bundle, which is a protocol to help guide teams to minimize sedation and get patients up. There's such a spectrum of compliance and different approaches to it. So, I was taught to do an awakening trial, which means you turned on sedation. The purpose really should be to get them off sedation, it should be sedation cessation, but I was taught. So, you know, at five o'clock in the morning, we must turn down sedation, it's super annoying, I know but just turn it down. Wait to see them thrash - that's how you know, when you see all their limbs move that they haven't had a stroke. When you can tell they can't tolerate the ventilator, then you turn the sedation back on and call it a failed trial, just chart it. I was confused. I didn't know what the objective was, I didn't know what we were doing. I didn't know why they were agitated. For her to say it's because I can't tolerate the ventilator. That was confusing to me because I'd seen so many patients tolerate the ventilator. I didn't understand delirium, and I hated awake new trials. They were laborious, they were stressful, they felt unsafe. It's hard to see patients between delirium, it's hard to see them be so uncomfortable, and you can see the terror in their eyes. But again, when in Rome, I just did what I was told, unfortunately. So, this is my journey now is almost my penance for the harm that I caused my patients during those years. KK: Well, Let's be honest, Kali, you can't be looking at it that way, man. We all remember sedation is the norm. What we're doing now is trying to advocate for change. I can't emphasize enough the change can be dramatic for people like it really comes down to function. If you in the ICU and you're paralyzed into intubated on sedation and analgesia, you're not moving, like you're not using your muscle. Then when you're trying to go back to what you want it to where you want it to be. I think a lot about our COVID patients. They were in the 40s/50s/60s, that are trying to get back to working, trying to get back to doing the activities that they love to do. When you think about this not only are you impacting their ability, like they're not getting to their functional level, but what's it doing for their family. Now you got a loved one that's got to take care of them, that might have to take off time off work too. It just is an absolute amplifier when people can't be functional.KD: For those that maybe don't work in the medical field, or even especially those that do, here's what we're not talking about the bedside, here's what we're not telling patients and families. When we go into surgery, they give us informed consent, they tell us here are the remote risk that things that could happen, right. What we don't do before intubation for patients and our families is tell them the actual risks of sedation. We don't understand ourselves that sedation is not sleep, it disrupts the brain activity so severely that they don't get real REM cycle. So, my perspective is that it's a form of torture, really, I mean, that's what we do, and war in the military, we deprive people of sleep, and that's what we're doing to our patients when we give medications that make it so they cannot get restorative sleep. Many of our study, sedatives are myotoxic, meaning that they're toxic to the muscles, so it causes more muscle breakdown. Then on top of that, if there's absolute disuse when you're stopped sleeping deeply sedated, you're not even contracting a muscle usually. So that disuse makes it so that our muscles break down more. That disruption of sleep often caught is one of the mechanisms that causes delirium, which is acute brain failure. It's an organ dysfunction. That can turn into long term post ICU, dementia, cognitive impairments. So, they cannot return to their normal lives can't take care of their families can't go back to their jobs because they can't. Cognitively their brains can't function the same way anymore. They have this post ICU PTSD because of those vivid scenarios that they live. I'm not going to call them hallucinations, because that's, that's not accurate. Those were real to them. We just don't see that big picture of sedation, and we just don't even question and I do that a lot in my life too. They're things that I'm just taught that I don't question, but we don't question whether or not sedation is necessary. Sometimes it is. When we understand how risky it is, then we can do a true risk versus benefit analysis for each patient to say, ‘they're intubated for this reason, does that necessitate sedation?' If not, let's get it off and see what they need. Let them communicate. Let's prevent delirium. Your platform is all about preventative medicine. In the ICU you come in with one acute critical illness and we sign them up for chronic conditions?KK: Absolutely, as you said, like it really is about what can we do to prevent this from becoming a chronic condition. Honestly, it's a culture change, from what I could see. What's sad about medicine, is that we have data to support how bad things are or how good things are. The amount of time we invest in create that change is limited. If you look at the data for sedation vacation, so that same principle of, turn off someone's sedation, periodically, that we know that has positive outcomes, like we know that, but you could go through an ICU, throughout any country in North America and the odds are that they're not getting it routinely. Why doesn't that happen? That's why I'm proud of Kali. Number one, being a champion of this, ICU care sucks, but a lot of us that will end up in there. So, we want to be able to optimize care, but also like just doing some about it. It's one thing to want to bring attention to it but also, being an activist. I think it helps. So, you've got the podcast, Kali, you've done some other work, how else have you been able to increase awareness? You could even get into like, what the podcast also has done for you or in the people around you?KD: So with a podcast, I started that right before COVID hit. I don't know if your god person but I, God told me to start a podcast in December 2019. I barely even listened to podcast didn't know how to start one, but I couldn't. I couldn't rest. I knew exactly that I had to start, I had to put out 32 somewhat episodes by the beginning of March of 2020. I didn't know why it had to be so fast and so furious, and survivors came out of nowhere. I interviewed my colleagues, researchers, it was just this miraculous setup that just came together, put out all these episodes, and then COVID hit. I thought ‘well now it's all gonna be all about COVID, and no one's gonna care about this'. God back handed me and said, ‘This is for COVID They're gonna be millions of people on ventilators, how is this not relevant to COVID'. So, I continue to throw out COVID Even though I recognize that the ICU community was not really in a place to revolutionize. The hard thing is that this could have been so beneficial to COVID we created more work for ourselves with the sedation practices, you talked about awakening and breathing trials. Once I just looked at only wake & breathing trial started sedation, turn it off once a day and then turn it back on. Decrease ventilator days, by 2.4 days, days in the ICU decreased by three days in that hospital decreased by 6.3 days, when we're in a staffing crisis, we need to have a process of care that's efficient actually gets patients out of the ICU. Instead, we created this bottleneck where patients are now stuck on the ventilator because they're too weak to breathe on their own. Even if their lungs are better. Now they need tracheostomies. They're stuck in a ventilator. We can't at least in the States, we couldn't get them to LTACH because LTACH's were too full of all the other COVID long term patients. So, then the ICU wasn't rehabilitating these patients, and so then they develop more hospital complications, and then they ended up needing more care. It's just we created so much more work for ourselves. It just was a hard time to really take on a new endeavor and totally change your practices. But during COVID, everyone ran back to the 90s. Not everyone but a lot of people ran back to the 90s. As far as using benzodiazepines, higher doses of sedation, deeper sedation longer times, there was so much fear. We did a lot of fear-based medicine. So, I just kept chugging along with my podcast, knowing that the community was going to need healing after all of this. We were going to need a lot of rehabilitation within our own clinicians, but also within our practices. So now, teams are coming to me saying what we're doing now. We're still doing COVID care even these are not COVID patients, we're still we're back to deeply sedated patients. Where are we lost so many seasoned clinicians, new clinicians came in during COVID. They've been trained to deep deep, deeply sedate, they don't know how to move patients they're scared to. But one team said I look on my ICU It's not an ICU, these aren't ICU patients. These are LTACH patients. These are rehab patients that we're not rehabilitating. We're bottlenecked. We can't get these patient outpatients out, we can't get new patients, we're stuck. We're creating that kind of scenario. So now, I work as a consultant and I do training with the teams, I teach them the why the reality of delirium, giving them a picture of an awake & walking ICU using real case studies, pictures, videos, so that we have a vision of what could be I feel like the ABCDEF bundle when it was rolled out in the mid 2000's good change happened, a lot of things moved forward. I do feel like we didn't explain fully the why behind it. Until every ICU clinician hears the voice of survivors, they won't be afraid of sedation, they'll still be inclined. We started, we continued this start sedation automatically, then at some subjective point down the road, start to take it off, when they come out, agitated, turn it back on, we just didn't, we didn't give them this perspective of ‘Hey, most patients should be awakened walking. Here's how to treat delirium and here's how the team works together' we put a lot of it on nurses, which is not fair, feasible or sustainable. So, as I work with teams, I tried to really give them a foundation of why, and then how, how to treat patients without automatically sedating them. When the sedation necessary. How do we navigate appropriate and safe sedation practices? When do we use it? How do we mobilize patients, I go on site with teams and I do simulation training, we do real case studies and practice and the whole team practices together. Because it's a skill set, we think about pronation, when we started printing patients, everyone was terrified. And it took so many people and it took so long, you know watching every little line and now teams flip them like pancakes, right? It becomes a skill set. So, I tried to get them opportunity to practice that on a pretend patient. So, they can think through critically think through the scenario, think through delirium, thanks for ICU acquired weakness, then practice mobilizing patients with different levels of mobility.KK: My brain is going like, the whole time, it's like you need to come see our group.KD: Let's do it. I'll hope on a plane tomorrow – I can't actually. I'm going to Kentucky tomorrow, but let me know I'll be there!KK: We would absolutely love to have you. Just knowing where a lot of clinicians lack is hearing the voice of the people that have gone through it. Clearly, that's been a motivator for you in terms of why we need to pivot and provide less sedation to our patients and mobilize our patients and avoid them from having all these secondary complications as a result of being immobile. The means are there. KD: The data is strong; the data is really powerful. I mean, decreased mortality by 68%. Who doesn't want to do that, right? So, but almost even more powerful are the voices survivors, when you hear their voices in your head when you're sitting in a patient. It's haunting COVID, there were times when patients could not oxygenate the movement. I had to sedate them. I hated it. I just felt sick because I, I just didn't know what they were experiencing. I didn't know if they were in pain. I didn't know what was going on underneath that they were going to live with us the rest of our lives, it's because of the survivors that have interviewed on my podcast, they are the educators.KK: Yeah, I have so many ideas going through my head. I would love after when we jump off, links to the some of the episodes from the survivors that we can pass along to our group, to our show in general, but our group to give a sense of what it really is like to go through this. Yeah, our patients don't come I mean, every once in a while we get a patient come back and say how they're doing but they don't give us the they don't give us the negative side, they really focus on showing some gratitude. KD: Which is good, but if they came back, it's probably because they weren't too traumatized to come back. The ones that don't come back. I mean, why would you go back to the place that you are sexually assaulted?KK: Yeah, no, yeahKD: It's like to trigger and some people can't even go the same street as that hospital. On my website under the resources tab, the clinician podcast, at the bottom, the page is organized by topics. One of those topics is survivors of sedation and mobility, as well as survivors of an awake & walk ICU. So, you can hear their different perspectives and testimonies, it's organized by different topics. KK: You're an organized cat, I'm looking at it right now. I can tell you, you're very structured and organized just by the way your website is set up. It's on point.KD: It's curriculum. This is education, this is not just a hobby. I mean, this is we've got to make sure we get the right information to the right people.KK: You're so boss. You're gonna be running an organization one day, and ICU, I don't know. I see big things for you.KD: We'll see. I mean, I have a lot of optimism for the future of critical care, going to conferences, meeting with people at the bedside podcast listeners reaching out. It's not just me that cares about this. That's why I continue is that there are so many people that I call revolutionists, sometimes as the lone voice in their ICUs. But they're bringing big changes, they're making waves there so my motivation with podcasts is to provide the ammo, the quiver the arrows in their quiver, so that they can share that with their colleagues get more buy in, so that they don't have to reinvent the wheel. It's a lot to change a perspective and change a culture. It's hard.KK: Yeah, and maybe just seeking some advice, we had Dr. Wes Ely on the show and how to create some culture change around this issue. I want to hear your perspective. Kali, how do you think you do create that culture change? Because you bring this up to many staff, and they'll be like, ‘Oh, they're gonna extubate themselves? Oh, we're short staffed. This is not gonna be able to work.' What are your thoughts?KD: Yeah, this has been a lot of my journey is figuring out what are the barriers? and how do we address them? I think we're over the checklists. I think it is important to systemize and protocolized our practices. When we implement these kinds of changes, we this can't just be “Hey, Nurse, take off the sedation' that is not going to work. They have some valid fears at all I had ever seen. With a patient coming off sedation. After days, two weeks of sedation, I would have a lot of inhibitions. When I'm busy. I don't have time to wrangle that patient. I don't have time to make sure they don't self extubate. I have a Thank you for reading Solving Healthcare Media with Dr. Kwadwo Kyeremanteng. This post is public so feel free to share it.whole episode on unplanned extubations, but delirium increases the chances of unplanned extubations by 11 times. So, it's just changing the perspective understanding what is delirium? why should we be panicked about it? What causes it? We are practices are some of the biggest risk factors and culprits of delirium in the ICU, and to learn doubles that are in hours required for care. So, when we're short staffed, why would we create a delirium factory? When it doubles our workload? It doesn't make sense, but when that's all we know, we don't understand that there's a better way to do it. So, my approach when I go to help a team have culture change is to, again explain the ‘why' give a perspective of what could be, here's what patients can be like, when we don't sedate them. If they when they wake up after intubation, it's like coming out of a colonoscopy. Endotracheal tubes not comfortable. Here are some tools to help make it more comfortable. Here's how we can talk to them. Give them a pen and paper, I would get agitated and panicked. I couldn't communicate. Here's how you involve the family, here's the toolbox to help you succeed and have that patient be calm & compliant. And they will protect their tubes. I've had patients write ‘please be careful my tube' That's what I need to experience. So, when you find a couple of case that isn't so easy hits, easy wins. Allow your team to see a patient awake, communicative, calm in even more while on the ventilator, the perspective starts to shift. Then they start to ask, okay, that was easy. That was fun. That changed outcomes. They walked up the ICU. Who else can we do this on and it starts to have a domino effect. So suddenly, we expect him to just shut up and do it. That's, that's not going to cut it. I don't think that I think that's partially why the ABCDEF bundle rollout, years ago was not has kind of gone away, because we didn't provide the why. We also, again, I think starting sedation, and then taking off later, is a lot of work. We should only do that if it's absolutely necessary. Otherwise, I mean, I have an episode with a hospital in Denmark, they do the same thing and that allow patients to wake up right after intubation. They are so much easier, more compliant, because they don't have delirium, we have to understand that that agitation is usually rooted in delirium, we have to come to really be terrified of delirium.KK: I'm really enjoying this, I'm really liking this because it's even at that added perspective of saying, ‘Hey, your workload is going to be worse if people are delirious, so let's avoid going delirious in the first place' Let's just get a grip on this bad boy, out of the gate.KD: You're all about preventative and it's like, Let's prevent one of the biggest culprits of mortality. Delirium doubles the risk of dying in the hospital. So, people say we don't have time to mess with all sedation practices, like let's just sedate them and like, save their lives and figure it out later. No. By doing that, by increasing the risk of delirium, we could double their chances of dying. So, if we care about mortality, then we will care about our sedation practices. We also know that ICU acquired weakness is really laborious. When people imagine mobilizing patients on ventilators. What they're imagining is taking off sedation days to weeks later when they're delirious. They can barely lift a finger and now we're trying to mobilize these, you know, 200 plus pound adults to the side of the bed. That's dangerous, laborious, it takes so many people. If a patient walks into the ICU or into the hospital, hypoxic hypotensive, whatever. We have moments later, we haven't stabilized. Why can't they walk? Did we cut their legs off? Right? So, once we have oxygenated, perfused, what's the harm in sitting outside of the bed and seeing how they do when they're not delirious, they can tell us how they're feeling. We can provide more support on the ventilator; they can probably walk better than they did come in and hypoxic. Once they're stabilized hours later, or even 24 hours later. So that is so much easier when they maintain their ability to walk. So, in the COVID ICU, many patients were standby assists to the chair with a nurse while they were on a ventilator, because they're alone in the room, right? Physical therapy could go in and work with a patient, just scoot the ventilator wall to wall as they're stuck in their rooms, help them stand or sit, step on steps, they were alone in that room with these patients, because they were strong enough to do it, because we didn't allow them to be under myotoxic sedation and I would say rot in the bed. So, all of that plays into an ease of workload. Then obviously the get off the ventilator sooner, get out of the ICU sooner. It makes the workload easier. So, it's a little bit of an exchange and efforts in some ways. Yes, you must talk to a patient. Yes, you must assess them a little bit more. But also, could during COVID, I was hearing about swapping out propofol bottles every hour, picking up to go in and out to titrate vasopressors that we were getting just because of the sedative and hypotensive effects. All of that is effort but wasn't necessary and wasn't beneficial.KK: I'm telling you, you are changing the boogie. Yeah, changing the conversation and perspective. This is something that can dramatically impact patient care. If we could get the buy in, in the culture. Wow.KD: You know, people will say ‘Well, we don't have we're trying to save $25 million this year. We can't afford to pay our payer clinician some extra time for education or whatnot' The ABCDEF bundle, even in their spectrum of compliance, decreased healthcare costs by 24 to 30%. KK: Oh, yeah. KD: ICU acquired weakness increases healthcare costs by I want to say 30-40%. Delirium increases healthcare costs by 40%. ICU acquired weakness increases healthcare costs by 30.5%. So, by having a process of care that prevent those complications with decreased healthcare costs. So why wouldn't we, right? KK: 100%. We even we had a paper out last year showing the financial impacts of ICU delirium. We always think to have the opportunity cost, that money could be diverted into more staffing, more resources for physio, optimizing nutrition, all these things can be enhanced. If we, if we make it a priority. KD: I think it's one of our one of our strongest cards to play for staff, safe staffing ratios. To say staff is better, we'll get better care in this using this protocol. We will save you so much money so it's investing thousands to save millions or billions.KK: I love it. You're speaking my language. We are definitely going to have you back in some capacity. I don't know that for some reason. It's not just gonna be the show. I really want to get you talking to our group. Maybe regional rounds, or something. I don't know what it's gonna be. It's something that we need to hear more of talked about the patient experience, your own experience and the drive like what's pushing this. Knowing my people a lot of intensivists and an ICU nurses and allied health professionals, we want to achieve this, get our patients to a point where they are better. Really better, not just alive, but thriving. This starts here. I really do believe it starts here. So I just want to give number one, Kali some mad love on what you're doing and continue to hustle, it's paying off. Second. How do people get to know you a little bit more? and about the show and the consulting and so forth?KD: So, have a website www.daytonicuconsulting.com. There's more information about consulting services available, the podcast is on there, the podcast has transcriptions and citations organized by topics. KK: So organized folks. KD: 116 episodes, and I really didn't even know how much of a what's called a rabbit hole that this would become. There's so much to learn about the science behind what we're doing as well as the patient and clinician perspective. So, check that out, find the topics. If nothing else start at the beginning. I think the beginning lays a foundation, I was very intentional about how I organized it at the beginning to lay a foundation of ‘why' and ‘how' comes later. I'm on Instagram @daytonicuconsulting, Twitter, Tik Tok. Go ahead and set up a consultation with me send me an email and we can chat about your team, your barriers, even your family members what's going on? I'm obviously obsessed. So, I'm here for you! let me know.KK: So good. So good. Thank you so much for joining us. Those on the chat group or that are watching live. You want a piece of this episode just tap NL into the chatbox will give you a copy the video and the end the podcast when it's released. Awesome work. Congratulations.KD: Thanks for caring about this.KK: 100% KK: Kwadcast nation that's exactly what I'm talking about changing the boogie right here in ICU care. Follow us on Instagram, YouTube Tiktok Facebook @Kwadcast Leave any comments at kwadcast99@gmail.com, subscribe to our newsletter. Essentially, it's like a membership you want to know more about Kwadcast nation. Go to Kwadcast.substack.com Check it out. Leave that five-star rating and continue to allow us to change boogie in unison. Take care, peace. We love you.Solving Healthcare Media with Dr. Kwadwo Kyeremanteng is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber. Get full access to Solving Healthcare Media with Dr. Kwadwo Kyeremanteng at kwadcast.substack.com/subscribe

Most ACLS medications are given IV push. But, what happens if wecan't get an IV?When IV access isn't available, we should consider administering our IV medications via intraosseous (IO)or endotracheal tube (ETT) route. Why IO is better for than ETT as an alternative route.The locations we should place an IO when running a code and a location we should avoid.The ACLS medications that can be given intraosseous. Where you can find more information about intraosseous access during resuscitation efforts.In the absence of an IV or IO, some medications may be given down the endotracheal tube.The disadvantages of medication administration via ETT.Review of the medications that can be given down the tube and how they should be given.Medications should not be given down the tube when anything other than an endotracheal tube is used as an advanced airway. Connect with me:Website: https://passacls.com@PassACLS on Twitter@Pass-ACLS-Podcast on LinkedInGive back & support the show:via PayPal Good luck with your ACLS class!

Most ACLS medications are given IV push. But, what happens if we can't get an IV?When IV access isn't available, we should consider administering our IV medications via intraosseous (IO)or endotracheal tube (ETT) route.Why IO is better for than ETT as an alternative route.The locations we should place an IO when running a code and a location we should avoid.The ACLS medications that can be given intraosseous.Where you can find more information about intraosseous access during resuscitation efforts.In the absence of an IV or IO, some medications may be given down the endotracheal tube.The disadvantages of medication administration via ETT.Review of the medications that can be given down the tube and how they should be given. Medications should not be given down the tube when anything other than an endotracheal tube is used as an advanced airway.Connect with me:Website: https://passacls.com@PassACLS on Twitter@Pass-ACLS-Podcast on LinkedInGood luck with your ACLS class!

Most ACLS medications are given IV push. But, what happens if we can't get an IV? When IV access isn't available, we should consider administering our IV medications via intraosseous (IO)or endotracheal tube (ETT) route. Why IO is better for than ETT as an alternative route. The locations we should place an IO when running a code and a location we should avoid. The ACLS medications that can be given intraosseous. Where you can find more information about intraosseous access during resuscitation efforts. In the absence of an IV or IO, some medications may be given down the endotracheal tube. The disadvantages of medication administration via ETT. Review of the medications that can be given down the tube and how they should be given. Medications should not be given down the tube when anything other than an endotracheal tube is used as an advanced airway. Not ACLS but something I'm just as passionate about is the battle against cancer. This is the fourth year that I'm participating in Real Men Wear Pink and have pledged to wear pink every day in October to: raise awareness of breast cancer; connect with breast cancer patients & survivors; and raise money for the American Cancer Society's life-saving mission. Chances are that you know someone that has fought breast cancer or have lost a loved one to this insidious disease. Please consider making a donation to my American Cancer Society fundraiser and make a difference in the fight against breast cancer. Donations go directly to the American Cancer Society and can be made anonymously to protect your privacy. http://main.acsevents.org/goto/paultaylor (Paul Taylor's Real Men Wear Pink ACS Fundraiser) THANK YOU! Connect with me: Website:  https://passacls.com (https://passacls.com) https://twitter.com/PassACLS (@PassACLS) on Twitter https://www.linkedin.com/company/pass-acls-podcast/ (@Pass-ACLS-Podcast) on LinkedIn Good luck with your ACLS class!

Interview with Alexander Gelbard, MD, author of Endotracheal Tube Size in Critically Ill Patients. Hosted by Paul C. Bryson, MD, MBA.

Interview with Alexander Gelbard, MD, author of Endotracheal Tube Size in Critically Ill Patients. Hosted by Paul C. Bryson, MD, MBA.

In this episode of the podcast, we will discuss tracheal intubation-associated hypotension. Endotracheal intubation is a common procedure in the clinical care of critically ill patients. Tracheal intubation in the ICU is often associated with cardiovascular complications that can include hypotension, cardiac arrest, or death. A recently published clinical trial evaluating the impact of a 500ml- bolus of crystalloid solution intravenously on cardiovascular complications post-intubation is the catalyst for our discussion. Additional Resources Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically Ill Patients Undergoing Tracheal Intubation. A Randomized Clinical Trial. The PREPARE II Investigators. https://jamanetwork.com/journals/jama/fullarticle/2793545 Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing tracheal intubation (PREPARE) a randomized controlled trial. The PREPARE Investigators. https://pubmed.ncbi.nlm.nih.gov/31585796/ Previous episodes of Critical Matters discussing other Intravenous Fluid topics. Critical Matters_Fluid Responsiveness: https://bit.ly/3bBTOg7 Critical Matters_Fluid BaSICS: https://bit.ly/3y99S0j Link to REBELEM post on Post Intubation Hypotension: The AH SHITE mnemonic. https://rebelem.com/post-intubation-hypotension-the-ah-shite-mnemonic/ Link to PulmCrit Blog on PREPARE clinical trial. https://emcrit.org/pulmcrit/prepare/ Books mentioned in this episode: Leonardo Da Vinci. By Walter Isaacson. https://amzn.to/3Nw0PfG Benjamin Franklin. By Walter Isaacson. https://amzn.to/3OM3N0C

In this episode I bid farewell to my passing out residents and discuss some trauma myths like Manual in line stabilization and the use of steroids in acute spinal cord injuries. You all can go through the following articles to learn more - 1. Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Ann Emerg Med. 2007 Dec;50(6):653-65. doi: 10.1016/j.annemergmed.2007.05.006. Epub 2007 Aug 3. PMID: 17681642. 2.Manoach S, Paladino L. Manual in-line stabilization for acute airway management of suspected cervical spine injury: historical review and current questions. Ann Emerg Med. 2007 Sep;50(3):236-45. doi: 10.1016/j.annemergmed.2007.01.009. Epub 2007 Mar 6. PMID: 17337093. 3. Thiboutot F, Nicole PC, Trépanier CA, Turgeon AF, Lessard MR. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can J Anaesth. 2009 Jun;56(6):412-8. doi: 10.1007/s12630-009-9089-7. Epub 2009 Apr 24. PMID: 19396507. 4. Kapp JP. Endotracheal intubation in patients with fractures of the cervical spine [technical note]. J Neurosurg. 1975;42:731-732. 5. Hachen HJ. Idealized care of the acutely injured spinal cord in Switzerland. J Trauma. 1977;17:931-936 6. Bohlman HH. Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature. J Bone Joint Surg Am. 1979;61:1119-1142. 7. Podolsky S, Baraff LJ, Simon RR, et al. Efficacy of cervical spine immobilization methods. J Trauma. 1983;23:461-465. 8. Hugenholtz H, Cass DE, Dvorak MF, Fewer DH, Fox RJ, Izukawa DM, Lexchin J, Tuli S, Bharatwal N, Short C. High-dose methylprednisolone for acute closed spinal cord injury--only a treatment option. Can J Neurol Sci. 2002 Aug;29(3):227-35. doi: 10.1017/s0317167100001992. PMID: 12195611. 9. Suberviola B, González-Castro A, Llorca J, Ortiz-Melón F, Miñambres E. Early complications of high-dose methylprednisolone in acute spinal cord injury patients. Injury. 2008 Jul;39(7):748-52. doi: 10.1016/j.injury.2007.12.005. Epub 2008 Jun 9. PMID: 18541241. 10. Bracken MB, Shepard MJ, Collins WF, Holford TR, Young W, Baskin DS, Eisenberg HM, Flamm E, Leo-Summers L, Maroon J, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med. 1990 May 17;322(20):1405-11. doi: 10.1056/NEJM199005173222001. PMID: 2278545. 11. Bracken MB, Collins WF, Freeman DF, Shepard MJ, Wagner FW, Silten RM, Hellenbrand KG, Ransohoff J, Hunt WE, Perot PL Jr, et al. Efficacy of methylprednisolone in acute spinal cord injury. JAMA. 1984 Jan 6;251(1):45-52. PMID: 6361287. 12. Evaniew N, Noonan VK, Fallah N, Kwon BK, Rivers CS, Ahn H, Bailey CS, Christie SD, Fourney DR, Hurlbert RJ, Linassi AG, Fehlings MG, Dvorak MF; RHSCIR Network. Methylprednisolone for the Treatment of Patients with Acute Spinal Cord Injuries: A Propensity Score-Matched Cohort Study from a Canadian Multi-Center Spinal Cord Injury Registry. J Neurotrauma. 2015 Nov 1;32(21):1674-83. doi: 10.1089/neu.2015.3963. Epub 2015 Jul 17. PMID: 26065706; PMCID: PMC4638202.

This is how I make sure the abdomen is not surgical, what helps me with the disposition of children with bronchiolitis and how do I decide what ET tube size I need. 

In this VETgirl online veterinary continuing education podcast,we will discuss transtracheal washes (TTW) and endotracheal washes (ETW) in dogs. Both types of tracheal washes (TW) offer clinicians an opportunity to sample the airways that avoids the required cost, equipment, or expertise of bronchoscopy. Cytology and bacterial culture of airway samples can provide essential diagnostic information, yet it is not always clear which type of TW should be recommended. Does one method provide superior results? Do patient variables or clinical suspicions influence which method to choose? Does ETW increase the risk of oral bacterial contamination? These are the types of questions that are commonly heard when discussing TW methods, and a better understanding of the advantages and disadvantages of each method also help when interpreting results. For this reason, Graham et al wanted to evaluate this in a study entitled "Factors associated with clinical interpretation of tracheal wash fluid from dogs with respiratory disease: 281 cases (2012-2017)." In this study, the authors compared the cytology and culture results of ETW and TTW. They wanted to determine if diagnostic results were comparable between methods, and how often discrepancies were observed.

We have now reached the 14 day point since the ETS was published in the Federal Register (June 21st) where most the OSHA requirements should be in place. Here is the language from OSHA about implementation: Employers must comply with most provisions within 14 days, and with provisions involving physical barriers, ventilation, and training within 30 days. OSHA will use its enforcement discretion for employers who are making a good faith effort to comply with the ETS. Here are some resources for implementation: OSHA ETS Checklist SPICE Training Session OSHA ETS Fact Sheet Is your workplace covered by the ETS? There have been a lot of questions about aerosol generating procedures. Listed below is the definition according to OSHA. It's slightly different from CDC. AGPs are defined as medical procedures that generate aerosols that can be infectious and are of respirable size. Under the ETS, only the following procedures are considered AGPs: Open suctioning of airways; Sputum induction; Cardiopulmonary resuscitation; Endotracheal intubation and extubation; Non-invasive ventilation (e.g., BiPAP, CPAP); Bronchoscopy; Manual ventilation; Medical/surgical/postmortem procedures using oscillating bone saws; and Dental procedures involving: Ultrasonic scalers, High-speed dental hand pieces, Air/water syringes, Air polishing, and Air abrasion. Want more information like this? Join me here: Facebook Page or here: IP Mentor Podcast or here: LinkedIn. If you like my pages, you will get notifications when I post and go live so you can ask me questions. If you subscribe to my podcast, you will get notifications for new episodes when they are released. I would enjoy hearing from you if there are some topics that you would like for me to cover in the future. You can always email me at missytravis@ipandcconsulting.com. Interested in more learning opportunities or a personal consultation? Check out my website: www.ipandcconsulting.com. You can book a personal consultation with me there. You can also download some free resources!

Intubation Essentials-- Part 1 Preparation and ChecklistsAbout our guests:Dr. Alyssa Stoner is an Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine and practicing pediatric intensivist at Children's Mercy Kansas City.Dr. Gina Patel is a fellow in pediatric critical care at Children's Mercy Kansas City.How to support PedsCrit?Please share, like, rate and review on Apple Podcasts or Spotify!Donations appreciated @PedsCrit on Venmo --100% of all funds will go to supporting the show to keep this project going.ObjectivesThe participant will be able to compile a complete list of equipment necessary to perform a pediatric intubation, with acknowledgment of mnemonic.The participant will be able to determine the appropriate size and depth of insertion of endotracheal tube based on patient's age utilizing a common estimation formulas.The participant will be able to describe the appropriate patient set up; including positioning for a successful intubation. When a checklist is elusive a simple mnemonic can be helpful to recall the necessary equipment:Mnemonic: SOAP MESuction Device: Ensure suction is turned on and at appropriate levelYaunker or large bore suction tube 14 FrenchConsider second suction set up especially if concerned about pulmonary hemorrhage or pulmonary edemaOxygen Delivery system: ensure oxygen sources is connected and functioning appropriatelyNasal Cannula vs. High Flow/ Non-RebreatherConsider non-Invasive if poor oxygenationConsider need for apneic oxygenation depending on clinical situation Self-inflating anesthesia bag with appropriately sized mask Airway Equipment:Direct Laryngoscope: Blade type and size considerations Video Laryngoscope: CMAC or Glidescope dependent upon access and comfort Endotracheal tube: Correct size + size downBack up airway IE: Laryngeal Mask Airway (LMA)Patient Position: Most of procedural success is based upon the appropriate patient positioningConsider age of patient and position accordingly to achieve appropriate sniffing position, consider utilizing small shoulder roll (in patients

Inhttps://rdcu.be/clEb4 ( this randomized clinical trial) that included 999 patients, the use of a stylet for tracheal intubation in critically ill adult patients resulted in significantly higher first‑attempt intubation success than the use of tracheal tube alone. The incidence of serious adverse events evaluated by the rate of traumatic injuries related to tracheal intubation was similar in the two groups. Speakers: Prof Sheila MYATRA. Consultant Critical Care Specialist, Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai (IN). Secretary, Indian College of Critical Care Medicine of the Indian Society of Critical Care Medicine (ISCCM). Prof Samir JABER. Head of the Critical Care and Anesthesia Department of Saint-Eloi University Hospital, Montpellier (FR). Full "exceptional class" (highest degree) professor in Anesthesiology and Critical Care, Faculty of Medicine of Montpellier. Senior Deputy Editor of the ICM Journal.

In this episode, we explore the evidence on whether smaller endotracheal tubes are... 1. Less likely to maintain a secure patent airway 2. Less reliable in facilitating positive pressure ventilation 3. Less able to seal the trachea and protect the lungs from aspiration We also discuss the potential harms associated with larger endotracheal tubes.  Our guests are Dr. Shamir Karmali and Dr. Peter Rose from the Department of Anesthesiology at Vancouver General Hospital. Thanks for listening! If you enjoy our content, consider supporting our mission at https://bit.ly/3n0sklh. — Follow us on Instagram @DepthofAnesthesia and on Twitter @DepthAnesthesia. Email us at depthofanesthesia@gmail.com. Music by Stephen Campbell, MD. — References Coordes A, Rademacher G, Knopke S, Todt I, Ernst A, Estel B, Seidl RO. Selection and placement of oral ventilation tubes based on tracheal morphometry. Laryngoscope. 2011 Jun;121(6):1225-30. doi: 10.1002/lary.21752. Epub 2011 May 6. PMID: 21557233. Dominelli PB, Ripoll JG, Cross TJ, Baker SE, Wiggins CC, Welch BT, Joyner MJ. Sex differences in large conducting airway anatomy. J Appl Physiol (1985). 2018 Sep 1;125(3):960-965. doi: 10.1152/japplphysiol.00440.2018. Epub 2018 Jul 19. PMID: 30024341; PMCID: PMC6335094. El-Boghdadly K, Bailey CR, Wiles MD. Postoperative sore throat: a systematic review. Anaesthesia. 2016 Jun;71(6):706-17. doi: 10.1111/anae.13438. Epub 2016 Mar 28. PMID: 27158989. Ellis SF, Pollak AC, Hanson DG, Jiang JJ. Videolaryngoscopic evaluation of laryngeal intubation injury: incidence and predictive factors. Otolaryngol Head Neck Surg. 1996 Jun;114(6):729-31. doi: 10.1016/s0194-5998(96)70093-1. PMID: 8643294. Fiastro JF, Habib MP, Quan SF. Pressure support compensation for inspiratory work due to endotracheal tubes and demand continuous positive airway pressure. Chest. 1988 Mar;93(3):499-505. doi: 10.1378/chest.93.3.499. PMID: 3277803. Futagawa K, Takasugi Y, Kobayashi T, Morishita S, Okuda T. Role of tube size and intranasal compression of the nasotracheal tube in respiratory pressure loss during nasotracheal intubation: a laboratory study. BMC Anesthesiol. 2017 Oct 17;17(1):141. doi: 10.1186/s12871-017-0432-1. PMID: 29041911; PMCID: PMC5645985. Hu B, Bao R, Wang X, Liu S, Tao T, Xie Q, Yu X, Li J, Bo L, Deng X. The size of endotracheal tube and sore throat after surgery: a systematic review and meta-analysis. PLoS One. 2013 Oct 4;8(10):e74467. doi: 10.1371/journal.pone.0074467. PMID: 24124452; PMCID: PMC3790787. Hwang JY, Park SH, Han SH, Park SJ, Park SK, Kim JH. The effect of tracheal tube size on air leak around the cuffs. Korean J Anesthesiol. 2011 Jul;61(1):24-9. doi: 10.4097/kjae.2011.61.1.24. Epub 2011 Jul 21. PMID: 21860747; PMCID: PMC3155132. Karmali S, Rose P. Tracheal tube size in adults undergoing elective surgery - a narrative review. Anaesthesia. 2020 Nov;75(11):1529-1539. doi: 10.1111/anae.15041. Epub 2020 May 16. PMID: 32415788. Koh KF, Hare JD, Calder I. Small tubes revisited. Anaesthesia. 1998 Jan;53(1):46-50. doi: 10.1111/j.1365-2044.1998.00290.x. PMID: 9505742. Pavlin EG, VanNimwegan D, Hornbein TF. Failure of a high-compliance low-pressure cuff to prevent aspiration. Anesthesiology. 1975 Feb;42(2):216-9. doi: 10.1097/00000542-197502000-00019. PMID: 1115375. Randestad A, Lindholm CE, Fabian P. Dimensions of the cricoid cartilage and the trachea. Laryngoscope. 2000 Nov;110(11):1957-61. doi: 10.1097/00005537-200011000-00036. PMID: 11081618. Shah C, Kollef MH. Endotracheal tube intraluminal volume loss among mechanically ventilated patients. Crit Care Med. 2004 Jan;32(1):120-5. doi: 10.1097/01.CCM.0000104205.96219.D6. PMID: 14707569. Stenqvist O, Sonander H, Nilsson K. Small endotracheal tubes: ventilator and intratracheal pressures during controlled ventilation. Br J Anaesth. 1979 Apr;51(4):375-81. doi: 10.1093/bja/51.4.375. PMID: 465261. Tanaka A, Isono S, Ishikawa T, Sato J, Nishino T. Laryngeal resistance before and after minor surgery: endotracheal tube versus Laryngeal Mask Airway. Anesthesiology. 2003 Aug;99(2):252-8. doi: 10.1097/00000542-200308000-00005. PMID: 12883396. Tonnesen AS, Vereen L, Arens JF. Endotracheal tube cuff residual volume and lateral wall pressure in a model trachea. Anesthesiology. 1981 Dec;55(6):680-3. doi: 10.1097/00000542-198155060-00013. PMID: 7305056. Walker EMK, Bell M, Cook TM, Grocott MPW, Moonesinghe SR; Central SNAP-1 Organisation; National Study Groups. Patient reported outcome of adult perioperative anaesthesia in the United Kingdom: a cross-sectional observational study. Br J Anaesth. 2016 Jun 12;117(6):758-766. doi: 10.1093/bja/aew381. Erratum in: Br J Anaesth. 2017 Sep 1;119(3):552. PMID: 27956674. Wilson AM, Gray DM, Thomas JG. Increases in endotracheal tube resistance are unpredictable relative to duration of intubation. Chest. 2009 Oct;136(4):1006-1013. doi: 10.1378/chest.08-1938. Epub 2009 May 1. PMID: 19411293. Young PJ, Rollinson M, Downward G, Henderson S. Leakage of fluid past the tracheal tube cuff in a benchtop model. Br J Anaesth. 1997 May;78(5):557-62. doi: 10.1093/bja/78.5.557. PMID: 9175972. __ By listening to this podcast, you agree not to use information as medical advice to treat any medical condition in either yourself or others, including but not limited to patients that you are treating. Opinions expressed are solely those of the host and guests and do not express the views or opinions of Massachusetts General Hospital.

Each year, approximately 790,000 patients in the United States develop acute respiratory failure that requires intubation and mechanical ventilation.

Each year, approximately 790,000 patients in the United States develop acute respiratory failure that requires intubation and mechanical ventilation.

Simon Carley, Associate Editor of EMJ, talks through his highlights of the July 2020 edition of the Emergency Medicine Journal. Read the primary survey here - https://emj.bmj.com/content/37/7/395 Details of the papers mentioned in this podcast can be found below: Updated framework on quality and safety in emergency medicine - https://emj.bmj.com/content/37/7/437 Evaluating the sustained effectiveness of a multimodal intervention aimed at influencing PIVC insertion practices in the emergency department - https://emj.bmj.com/content/37/7/444 Endotracheal intubation with barrier protection - https://emj.bmj.com/content/37/7/398 Aerosol containment box to the rescue: extra protection for the front line - https://emj.bmj.com/content/37/7/400 Accuracy of PE rule-out strategies in pregnancy: secondary analysis of the DiPEP study prospective cohort - https://emj.bmj.com/content/37/7/423 Oral nitroglycerin solution for oesophageal food impaction: a prospective single-arm pilot study - https://emj.bmj.com/content/37/7/434 Use of prehospital emergency medical services according to income of residential area - https://emj.bmj.com/content/37/7/429 Using emergency physicians’ abilities to predict patient admission to decrease admission delay time - https://emj.bmj.com/content/37/7/417 Read the full July issue here - https://emj.bmj.com/content/37/7.

Your daily COVID-19 LST Report: — climate: After lockdown was initiated, air pollution over northern India reached a 20-year low with New Delhi seeing 50% reduction in air pollution leading investigators to suggest that the COVID-19 pandemic is a good opportunity to learn and understand how lockdown activities can help minimize air pollution in the long term. — Epidemiology: A critically ill 69 year old male COVID-19 patient was found to have both classic COVID-19 CT findings as well as atypical reversed halo sign, suggestive of fungal infection. Endotracheal aspiration culture grew aspergillosis and despite voriconazole treatment the patient ultimately died, emphasizing the importance of considering complicating infections in COVID-19 patients. — Pathology: One study found that men and adults, who have each been noted as higher risk for severe COVID-19, had higher soluble angiotensin-converting enzyme-2 than women and children, respectively. Further research is warranted to explore if soluble high angiotensin-converting enzyme-2 level is a risk factor for COVID-19 severity. —Tramission and Prevention: False negative RT-PCR results are becoming an increasing problem. A case report of a 46 year old female describes how she initially tested positive on nasopharyngeal RT-PCR but was sent home one week later after results for 4 nasopharyngeal swabs and one anal swab were negative. The following week, however, she tested positive again on nasopharyngeal and anal swab RT-PCR and was readmitted to the hospital. Investigators summarize the numerous cases of various PPE-induced dermatoses — R&D: A human monoclonal antibody was identified to cross-neutralize SARS-CoV and SARS-CoV-2 in cell culture, targeting a common epitope through an unknown mechanism independent of receptor-binding interference. Further study could prove it useful in diagnostic testing, prevention, or treatment of COVID-19. — Mental Health: An online survey distributed randomly throughout China to over 5,000 adults without pre-existing psychiatric disorders found that prevalence of anxiety and depression has jumped to over 20%, up from the 2019 reported rate of 4%. — Visit COVID19LST.org for our full report with links to the articles. — Reach out to us at: contact@covid19lst.org --- Support this podcast: https://anchor.fm/covid19lst/support

In this episode we speak with Chris Hicks, Canadian emergency physician and trauma team leader who is a master of teaching the cognitive skills of resuscitation.  Chris shares several protocols from his hospital regarding code blue and intubation in the era of COVID-19 including: the pre-brief process, communication during a code in PPE, preparing for a code (when you have time), what to do when there’s a surprise arrest and the team isn’t in PPE, how to effectively use an airway checklist, and how to find your anchor when you’re stressed.    Many of us “pregame” and have psychological skills that prepare us for whatever stressors we may encounter during a shift.  Similarly, we have scripts for most of the things we do in EM. Our script for the process of resuscitating patients does not work in the COVID-19 era.  COVID keeps us in system 2 thinking, which is time-consuming, labor intensive, and not efficient when you have to make quick decisions. Everything around preparation, PPE, role designation, and process is now strange. Since it’s an unfamiliar situation, we have to understand process and structure in a scenario with no script.   When resuscitating COVID-19 patients who are code blue, an organized structure and consistency are essential. Here are some recommendations: Have a team based pre-brief. This is a deliberate discussion before you enter the room which stresses the importance of cross-monitoring and establishes the rules. The team gathers around a code blue protected airway cart which contains airway equipment and PPE. Above the cart is a poster-sized infographic which details the pre-brief process. One physician is assigned the team leader.  Roles are assigned. Inside the room are 2 MDs, 1 RN, and 1 RT. Outside the room are 2 RNs. 1 safety officer (MD or RN) Donning and doffing buddies are assigned. Team members check each other’s PPE. A safety officer observes the process and makes sure there are no lapses in the PPE protocol. Decisions are made in advance regarding what will be brought into the room (drugs, drips, other supplies). This whole process can take less than a minute. Communication during a code in full PPE must be deliberate, succinct, and directive. Use closed-loop communication techniques. Baby monitors can be an effective means of communicating to team members outside the resuscitation room.   What happens in the scenario where there’s an unanticipated arrest and you feel there’s no time to prepare? While it’s admirable and brave to want to rush into the room to care for the patient unprotected, that cannot be the case in this era. We must put staff safety ahead of patient care. Hick’s institution has developed a process for protected code blue which has 5 key messages. Ensure airborne PPE for all providers before initiating BLS/ACLS. If nobody is in PPE, then nobody responds. Consensus opinion is that if you don't have appropriate PPE, you cannot be providing high risk procedures. If 1 person is in PPE, they can enter the room, put a mask on the patient and start compression-only CPR while others don PPE. Apply a NRB mask with filter when starting CPR. No BVM ventilation prior to intubation. If BVM is necessary, it should be a two person, four handed technique. Prioritize intubation using a protected airway process. Airway is prioritized earlier in the process vs. a standard cardiac arrest. Endotracheal intubation is preferred over a supraglottic airway. Pause chest compressions during intubation.   We are cautioned against using the BVM as it is considered highly aerosolized. Where does that happen in the circuit? With BVM ventilation, you run the risk of the patient’s airway secretions getting out of the BVM unless you have an interposing mechanical filter. Their BVMs also have a side port where a PEEP valve is meant to fit. They routinely attach a PEEP valve to prevent any passive flow of secretions from escaping.   Another cognitive offloading tool is a detailed protected airway checklist. The airway checklist is run by the 2nd physician, not the airway operator. It’s a call and response process, double checking that all necessary supplies are available and a reminder of things that will NOT be done (“We will not be inserting an airway. We will not be topicalizing medications. etc”.)  For the intubator, it is reassuring to have somebody else supporting you to make sure the process is safe. See also Protected Airway Equipment Checklist   During one of Chris' first intubations, he found himself unusually stressed while he was waiting for the paralytic to take effect.  He handled this by visualizing every step of the procedure and quietly reminding himself to be “steady”. This mental rehearsal helped center himself. He went from feeling like he might pass out to feeling ready to go. This situation accentuated the importance of having psychological tools when you feel afraid and stressed. And of the need to have a sense of humility when confronted with new situations. It was a nice reminder that pregaming actually works. Link to a pre-departure checklist for critically ill patients being transferred to the ICU,

Author: Michael Hunt, MD Educational Pearls: Bedside transtracheal ultrasound to confirm proper endotracheal intubation is simple and effective Review of 17 studies showed transtracheal ultrasound was was 98.7% sensitive and 97.1% specific Curvilinear probe may be preferable as it provides a larger field of view Editor’s Note: rather than explain what you’re looking for… just go here References: Gottlieb M, Holladay D, Peksa GD. Ultrasonography for the Confirmation of Endotracheal Tube Intubation: A Systematic Review and Meta-Analysis. Ann Emerg Med. 2018 Dec;72(6):627-636. doi: 10.1016/j.annemergmed.2018.06.024. Epub 2018 Aug 14. PubMed PMID: 30119943. Summarized and edited by Erik Verzemnieks, MD

Calvin Brown III, MD presents four nominees for "2018 Airway Article of the Year."  The nominated articles were chosen from among those featured in the 2018 Quarterly Airway Research Updates.  Dr. Brown discusses the content and merits of each article and the audience votes for the "Airway Article of the Year."

In the past two decades, airway management has been revolutionized by the development of video laryngoscopy, hyperangulated blade geometry, optical stylets, laryngeal masks, and a host of advances in airway pharmacology and technique. The core skill of airway management, however, remains laryngoscopy, whether or not the operator uses a blade with a camera at the end. In this presentation, we break down laryngoscopy into its discrete components and describe best practice technique at each step. We will start by describing common mistakes made in patient positioning; proposing a set of parameters the provider can use to guide positioning that is optimal for laryngoscopy, including the configuration of the patient in the bed, the bed height and head elevation, as well as provider stance. We then move into the effect of laryngoscope grip on operator catecholamine management and describe the optimal laryngoscope grip for emergency airway management. We next confront one of the core principles of RSI, the delay between medication administration and commencement of laryngoscopy, and propose an alternative approach that emphasizes early laryngoscopy with deliberate slowness. We turn our attention to the value of the jaw thrust–as performed by an assistant–during airway management, and then move into a step by step analysis of laryngoscopy as the blade moves into the mouth, down the tongue and ultimately to the glottis. We espouse suction as an underutilized device by emergency providers, and describe the two most important intra-laryngoscopy optimization maneuvers: optimization of the position of the head, and optimization of the position of the larynx. We discuss the value of using the gum elastic bougie for both difficult and routine intubations and describe pitfalls encountered when using the bougie (and how to manage them). We conclude by describing the 3-finger tracheal palpation method of endotracheal tube depth confirmation.

When you give only after you're asked, you've waited too long. – John Mason First, learn to bag Place a towel roll under the scapulae to align oral, pharyngeal, and tracheal axes: Karsli C. Can J Anesth. 2015. Use airway adjuncts such as the oropharyngeal airway or a nasal trumpet. Use the two-hand ventilation technique whenever possible:   (See Adventures in RSI for more)     Supraglottic Airways: for difficult bag-valve-mask ventilation or a difficult airway (details in audio) LMA Classic Pros: Best studied; sizes for all ages Cons: Cannot intubate through aperture   LMA Supreme Pros: Better ergonomics with updated design; bite bloc; port for decompression Cons: Cannot pass appropriate-sized ETT through tube   King Laryngeal Tube Pros: Little training needed; high success rate; single inflation port Cons: Flexion of tube can impede ventilation or cause leaks; only sized down to 12 kg (not for infants and most toddlers)   Air-Q Pros: Easy to place; can intubate through aperture Cons: Not for neonates less than 4 kg   iGel Pros: Molds more accurately to supraglottis; no need to inflate; good seal pressures Cons: Cannot intubate through (without fiberoscopy)   Summary • If you can bag the patient, you're winning. • If you have difficulty bagging, or anticipate or encounter a difficult airway, then don't forget your friend the supraglottic airway (SGA). • Ego is the enemy of safety: SGAs are simple, fast, and reliable. • Just do it.   References Ahn EJ et al. Comparative Efficacy of the Air-Q Intubating Laryngeal Airway during General Anesthesia in Pediatric Patients: A Systematic Review and Meta-Analysis. Biomed Res Int. 2016;2016:6406391. Black AE, Flynn PE, Smith HL, Thomas ML, Wilkinson KA; Association of Pediatric Anaesthetists of Great Britain and Ireland. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth. 2015 Apr;25(4):346-62. Byars DV et al. Comparison of direct laryngoscopy to Pediatric King LT-D in simulated airways. Pediatr Emerg Care. 2012 Aug;28(8):750-2.  Carlson JN, Mayrose J, Wang HE. How much force is required to dislodge an alternate airway? Prehosp Emerg Care. 2010 Jan-Mar;14(1):31-5. Diggs LA, Yusuf JE, De Leo G. An update on out-of-hospital airway management practices in the United States. Resuscitation. 2014 Jul;85(7):885-92. Ehrlich PF et al. Endotracheal intubations in rural pediatric trauma patients. J Pediatr Surg. 2004 Sep;39(9):1376-80. Hernandez MR, Klock PA Jr, Ovassapian A. Evolution of the extraglottic airway: a review of its history, applications, and practical tips for success. Anesth Analg. 2012 Feb;114(2):349-68.  Huang AS, Hajduk J, Jagannathan N. Advances in supraglottic airway devices for the management of difficult airways in children. Expert Rev Med Devices. 2016;13(2):157-69. Jagannathan N, Wong DT. Successful tracheal intubation through an intubating laryngeal airway in pediatric patients with airway hemorrhage. J Emerg Med. 2011 Oct;41(4):369-73.  Jagannathan N et al. Elective use of supraglottic airway devices for primary airway management in children with difficult airways. Br J Anaesth. 2014 Apr;112(4):742-8. Jagannathan N, Ramsey MA, White MC, Sohn L. An update on newer pediatric supraglottic airways with recommendations for clinical use. Paediatr Anaesth. 2015 Apr;25(4):334-45. Karsli C. Managing the challenging pediatric airway: Continuing Professional Development. Can J Anaesth. 2015 Sep;62(9):1000-16. Luce V et al. Supraglottic Airway Devices vs Tracheal Intubation in Children: A Quantitative Meta-Analysis of Respiratory Complications. Paediatr Anaesth 24 (10), 1088-1098. Nicholson A et al. Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients. Cochrane Database Syst Rev. 2013 Sep 9;(9):CD010105. Ostermayer DG, Gausche-Hill M. Supraglottic airways: the history and current state of prehospital airway adjuncts. Prehosp Emerg Care. 2014 Jan-Mar;18(1):106-15.  Rosenberg MB, Phero JC, Becker DE. Essentials of airway management, oxygenation, and ventilation: part 2: advanced airway devices: supraglottic airways. Anesth Prog. 2014 Fall;61(3):113-8.  Schmölzer GM, Agarwal M, Kamlin CO, Davis PG. Supraglottic airway devices during neonatal resuscitation: an historical perspective, systematic review and meta-analysis of available clinical trials. Resuscitation. 2013 Jun;84(6):722-30. Sinha R, Chandralekha, Ray BR. Evaluation of air-Q™ intubating laryngeal airway as a conduit for tracheal intubation in infants--a pilot study. Paediatr Anaesth. 2012 Feb;22(2):156-60. Timmermann A. Supraglottic airways in difficult airway management: successes, failures, use and misuse. Anaesthesia. 2011 Dec;66 Suppl 2:45-56. Timmermann A, Bergner UA, Russo SG. Laryngeal mask airway indications: new frontiers for second-generation supraglottic airways. Curr Opin Anaesthesiol. 2015 Dec;28(6):717-26.   Supraglottic Airway on WikEM   This post and podcast are dedicated to Tim Leeuwenburg, MBBS FRACGP FACRRM DRANZCOG DipANAES and Rich Levitan, MD, FACEP for keeping our minds and our patients' airways -- open.  You make us better doctors.  Thank you. Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP Pediatric; Emergency Medicine; Pediatric Emergency Medicine; Podcast; Pediatric Podcast; Emergency Medicine Podcast; Horeczko; Harbor-UCLA; Presentation Skills; #FOAMed #FOAMped #MedEd

Turkish Manning, M Endotracheal Tube Suctioning (Turkish) Podcast 090616 by OPENPediatrics

Istanbul Pedreira, M Endotracheal Suctioning In 2013 What Do We Really Know? Podcast 030615 by OPENPediatrics

Nursing Manning, M Endotracheal Tube Suctioning Podcast 082613 by OPENPediatrics

Over the last few years cuffed endotracheal tubes are being used more frequently in critically ill children. This episode looks at the potential advantages of this practise and reviews the evidence of whether this trend is safe.   

It seems simple, but not treating this situation with respect can lead to disaster.

Interview with Patrick Sheahan, MB, MD, FRCSI (ORL-HNS), author of Effect of Endotracheal Tube Size on Vocal Outcomes After Thyroidectomy: A Randomized Clinical Trial

A brief description on what to consider when confronted with a patient with an air leak from the ET tube or a patient that self-extubates.

Christopher L. Carroll, MD, FCCM, lead author of an article published in the May 2010 issue of Pediatric Critical Care Medicine.

Background: Initiated by a clinical case of critical endotracheal tube (ETT) obstruction, we aimed to determine factors that potentially contribute to the development of endotracheal tube obstruction by its inflated cuff. Prehospital climate and storage conditions were simulated. Methods: Five different disposable ETTs (6.0, 7.0, and 8.0 mm inner diameter) were exposed to ambient outside temperature for 13 months. In addition, every second of these tubes was mechanically stressed by clamping its cuffed end between the covers of a metal emergency case for 10 min. Then, all tubes were heated up to normal body temperature, placed within the cock of a syringe, followed by stepwise inflation of their cuffs to pressures of 3 kPa and >= 12 kPa, respectively. The inner lumen of the ETT was checked with the naked eye for any obstruction caused by the external cuff pressure. Results: Neither in tubes that were exposed to ambient temperature (range: -12 degrees C to +44 degrees C) nor in those that were also clamped, visible obstruction by inflated cuffs was detected at any of the two cuff pressure levels. Conclusions: We could not demonstrate a critical obstruction of an ETT by its inflated cuff, neither when the cuff was over-inflated to a pressure of 12 kPa or higher, nor in ETTs that had been exposed to unfavorable storage conditions and significant mechanical stress.

James D. Fortenberry, MD, FCCM, discusses his editorial published in the September 2008 issue of Pediatric Critical Care Medicine, titled "8-Tracks, Betamax... Is the endotracheal tube next to go?" Fortenberry is a pediatric intensivist at Children's Healthcare of Atlanta in Georgia, where he also is the medical director of the system's clinical research. Dr. Fortenberry also is director, division of critical care medicine in the department of pediatrics at Emory University School of Medicine. The editorial was in response to an article published in the same issue by Leticia J. Yanez et al., "A prospective, randomized, controlled trial of non-invasive ventilation in pediatric acute respiratory insufficiency." (Pediatr Crit Care Med. 2008;9[5]:536) Released: 11/19/08

James D. Fortenberry, MD, FCCM, discusses his editorial published in the September 2008 issue of Pediatric Critical Care Medicine, titled "8-Tracks, Betamax... Is the endotracheal tube next to go?" Fortenberry is a pediatric intensivist at Children's Healthcare of Atlanta in Georgia, where he also is the medical director of the system's clinical research. Dr. Fortenberry also is director, division of critical care medicine in the department of pediatrics at Emory University School of Medicine. The editorial was in response to an article published in the same issue by Leticia J. Yanez et al., "A prospective, randomized, controlled trial of non-invasive ventilation in pediatric acute respiratory insufficiency." (Pediatr Crit Care Med. 2008;9[5]:536) Released: 11/19/08

Jeanine Wiener-Kronish, MD, discusses an article published in the September 2008 issue of Critical Care Medicine, titled "Increased mortality of ventilated patients with endotracheal Pseudomonas aeruginosa without clinical signs of infection." Dr. Wiener-Kronish is a professor of research and teaching in anaesthetics and anaesthesia at Harvard Medical School, and Chief of Anesthesia, Massachusetts General Hospital in Boston, (Crit Car Med 2008.36(9): 2495)