Podcasts about positive pressure ventilation

DISCLAMER >>>>>>    The Ditch Lab Coat podcast serves solely for general informational purposes and does not serve as a substitute for professional medical services such as medicine or nursing. It does not establish a doctor/patient relationship, and the use of information from the podcast or linked materials is at the user's own risk. The content does not aim to replace professional medical advice, diagnosis, or treatment, and users should promptly seek guidance from healthcare professionals for any medical conditions.                                                  >>>>>> The expressed opinions belong solely to the hosts and guests, and they do not necessarily reflect the views or opinions of the Hospitals, Clinics, Universities, or any other organization associated with the host or guests.                                                                                  Disclosures: Ditch The Lab Coat podcast is produced by (Podkind.co) and is independent of Dr. Bonta's teaching and research roles at McMaster University, Temerty Faculty of Medicine and Queens University. On today's episode of "Ditch the Labcoat," our host Dr. Mark Bonta dives deep with renowned intensive care expert Dr. Niall Ferguson into the world of intensive care, ventilators, and the balance between technology and humanity in critical care medicine.In a compelling conversation, we unlock insights into the evolution of respiratory care, the ethical considerations surrounding life support, and how the COVID-19 pandemic reshaped our approach to patient care.Key takeaways from this episode:- The Overuse of ICU Resources: Dr. Ferguson discusses the careful balance required when utilizing ICU facilities, emphasizing the need for proportionate care to maximize patient dignity and humanity, even in unconscious states.- The Evolution of Ventilation Techniques: Delve into the history of ventilatory support, from the iron lung to modern positive pressure ventilation, and understand how these critical interventions have been both a lifeline and a learning curve during pandemics.- Patient-Centered Care: Drs. Bonta and Ferguson underscore the necessity of clear, honest communication between healthcare providers and patients, aligning treatment with patient health goals, especially when considering life-support interventions.Don't miss the heartfelt stories, professional insights, and the fusion of human touch with technology that Dr. Ferguson brings to this enlightening discussion on "Ditch the Labcoat".Dr. Niall Ferguson shares a compelling tale from medical history, asserting the dramatic impact of vaccines in eradicating polio. He recounts the 1952 polio conference in Copenhagen, which, ironically, preceded a polio outbreak later that year in the same city. This outbreak led to deaths from not just respiratory muscle weakness but from bulbar polio, affecting the victim's ability to swallow and clear secretions. The conventional iron lung was unable to aid patients in coughing or clearing these secretions, resulting in numerous fatalities.However, a pivotal moment in medical innovation emerged when an astute anesthetist named Bjorn Ibsen intervened. Recognizing patients were hypoventilating, Ibsen proposed a more effective method: invasive positive pressure ventilation, an invention that has since revolutionized medical care. This story, relayed by Dr. Ferguson, underscores the relentless pursuit of medical advances in the face of disease outbreaks and the critical role that vaccines play in preventing such health crises.00:00 Ventilator's origin, critical care medicine, teamwork in healthcare.05:24 Vaccines ended polio, led to ventilation innovation.14:45 COVID patients may have low oxygen levels.20:50 Setting up province wide COVID response; challenges.25:20 Mechanical ventilation can cause respiratory damage.28:15 Balancing life support on ventilator, ECMO concerns.37:43 Patients' readiness and family's understanding affect decisions.40:40 Importance of end-of-life conversations for clarity.48:27 Some private hospitals have overly luxurious ICUs.52:18 Doctor prioritizes in-person patient interaction during rounds.54:47 Impactful conversation about ventilator history and medicine.01:00:30 Gratitude and encouragement for future engagement.© 2024 ditchthelabcoat.com - All Rights Reserved 

Overcoming Fear in Neonatal Resuscitation: A Step-by-Step Guide Blog post: Neonatal Resuscitation Introduction: Welcome to another episode of EMScast, where high-level education meets real-world emergency medical scenarios. Today, we have Dr. Avery MacKenzie, an ER physician from Southwest Colorado, joining us to discuss a topic that often induces stress – neonatal resuscitation. Dr. MacKenzie shares her experiences and insights into handling neonatal emergencies in rural settings. Summary: Dr. MacKenzie opens the episode by acknowledging the inherent fear associated with neonatal resuscitation, especially in rural emergency departments where one might be the sole provider. She emphasizes that despite the fear, the process is not hard, and providers already possess the necessary skills. Key Takeaways: 1. **Facing the Fear:**    - Dr. MacKenzie encourages listeners to remember that while neonatal resuscitation may seem intimidating, the skills required are well within their expertise. 2. **Algorithm Overview:**    - The neonatal resuscitation algorithm is simplified into manageable steps, beginning with stimulating, warming, and drying the baby for the first 30 seconds.    - The next 30 seconds involve providing positive pressure ventilation to initiate breathing.    - Monitoring the heart rate is crucial, and if it remains below 100, providers should focus on correcting ventilation strategies. 3. **Initial Assessment:**    - Dr. MacKenzie introduces a simple three-question assessment for determining the need for resuscitation: term gestation, good muscle tone, and respiratory effort. 4. **Positive Pressure Ventilation:**    - The trigger for initiating positive pressure ventilation is if the heart rate is less than 100 or the baby is apneic or gasping.    - The emphasis is on adequate ventilation, and adjustments, such as using the MR. SOPA mnemonic, can be made to improve ventilation. 5. **Advanced Airway Considerations:**    - While advanced airways, such as intubation, are possible, Dr. MacKenzie highlights that pre-hospital protocols may favor supraglottic airways due to the challenging nature of neonatal intubation and the need to limit pauses in oxygenation and respiratory support. 6. **Continued Support:**    - The algorithm emphasizes a continuous loop of assessment, correction, and reassessment, with the goal of maintaining the baby's heart rate above 100. Conclusion: Dr. MacKenzie wraps up the episode by reassuring providers that familiarity with the neonatal resuscitation algorithm and periodic mental reviews can alleviate the fear associated with these critical situations. The key is to focus on what providers already know and apply those skills with confidence.

About one in ten live births around the world are preterm and many of these babies will develop respiratory distress and require help with their breathing. Various strategies are available for this and an updated Cochrane review from July 2023 provides the latest evidence on the comparison of nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure when a baby's breathing tube is removed. We asked one of the authors, Marc-Olivier Deguise from the Children's Hospital of Eastern Ontario in Canada to tell us about the findings, and he used ElevenLabs to make this recording.

About one in ten live births around the world are preterm and many very preterm babies will develop respiratory distress soon after birth and require help with their breathing. Various strategies are available for this and an updated Cochrane review from July 2023 provides the latest evidence on the early use of nasal intermittent positive pressure ventilation compared with nasal continuous positive airway pressure. We asked one of the authors, Marc-Olivier Deguise from the Children's Hospital of Eastern Ontario in Canada to tell us about the findings, and he used ElevenLabs to make this recording.

About one in ten live births around the world are preterm and many of these babies will develop respiratory distress and require help with their breathing. Various strategies are available for this and an updated Cochrane review from July 2023 provides the latest evidence on the comparison of nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure when a baby's breathing tube is removed. We asked one of the authors, Marc-Olivier Deguise from the Children's Hospital of Eastern Ontario in Canada to tell us about the findings, and he used ElevenLabs to make this recording.

About one in ten live births around the world are preterm and many very preterm babies will develop respiratory distress soon after birth and require help with their breathing. Various strategies are available for this and an updated Cochrane review from July 2023 provides the latest evidence on the early use of nasal intermittent positive pressure ventilation compared with nasal continuous positive airway pressure. We asked one of the authors, Marc-Olivier Deguise from the Children's Hospital of Eastern Ontario in Canada to tell us about the findings, and he used ElevenLabs to make this recording.

A practical case-based approach to the management of bronchopleural fistulas while patients are on positive pressure ventilation.  

Non-invasive positive pressure ventilation or NIPPV is ventilatory assistance without an invasive artificial airway like an endotracheal tube. The oxygen is delivered to a spontaneously breathing patient through a tight-fitting mask or in this case a helmet. Helmet based ventilation is a modern solution to an outdated method. The most popular choice in providing NIPPV is the cpap, a tightly fitted mask over the nose and mouth. The biggest problem with cpap is comfort and inconsistency associated with interruption for patient care. The helmet based approach provides a more efficient and effective way to deliver pressure and oxygen. In this episode, we welcome our guest, Aurika Savickaite. She is a registered nurse and patient care manager at the University of Chicago Medical Center's Medical Intensive Care Unit and was part of the successful testing of the helmet ventilator in the ICU at the University of Chicago during a three-year trial study. Catch more of Aurika as we learn more about helmet ventilation and empowering nurses in this exciting episode of Cup of Nurses.

GuestBhakti Patel MDUniversity of Chicago, Chicago ILPulmonary and Critical Care Medicine HostMatt Stutz MDCook County Health and Hospital System, Chicago ILPulmonary and Critical Care Medicine

The modern CICU has evolved to include patients with complex pulmonary mechanics requiring more non-invasive and mechanical ventilation. Series co-chairs Dr. Eunice Dugan and Dr. Karan Desai along with CardioNerds Co-founder Dr. Amit Goyal were joined by FIT lead, Dr. Sam Brusca, who has completed his NIH Critical Care and UCSF Cardiology fellow and currently faculty at USCF. We were fortunate enough to have two expert discussants: Dr. Burton Lee, Head of Medical Education and Global Critical Care within the National Institutes of Health Critical Care Medicine Department and master clinician educator with the ATS Scholar's Critical Care for Non-Intensivists program, and Dr. Chris Barnett, ACC Critical Care Cardiology council member and Section Chair of Critical Care Cardiology at UCSF.  In this episode, these experts discuss the basics of mechanical ventilation, including the physiology/pathophysiology of negative and positive pressure breathing, a review of ventilator modes, and a framework for outlining the goals of mechanical ventilation. They proceed to apply these principles to patients in the CICU, specifically focusing on patients with RV predominant failure due to pulmonary hypertension and patients with LV predominant failure. Audio editing by CardioNerds Academy Intern, student doctor, Shivani Reddy. The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif. Pearls • Notes • References • Production Team CardioNerds Cardiac Critical Care PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes - Positive Pressure Ventilation in the CICU Respiratory distress, during spontaneous negative pressure breathing can lead to high transpulmonary pressures and potentially large tidal volumes. This will increase both RV afterload (by increasing pulmonary vascular resistance) and LV afterload (by increasing LV wall stress). An analogy for the impact of negative pleural pressure during spontaneous respiration on LV function is that of a person jumping over a hurdle. The height of the hurdle does not increase, but the ground starts to sink, so it is still harder to jump over. Intubation in patients with right ventricular failure is a tenuous situation, especially in patients with chronic RV failure and remodeling (increased RV thickness, perfusion predominantly during diastole, RV pressure near or higher than systemic pressure). The key tenant to safe intubation is avoiding hypotension, utilizing induction agents such as ketamine or etomidate, infusing pressors, and potentially even performing awake intubations. Non-invasive positive pressure ventilation in HFrEF has hemodynamic effects similar to a cocktail of IV inotropes, dilators, and diuretics. CPAP decreases pulmonary capillary wedge pressure (LV preload), decreases systemic vascular resistance (afterload), and increases cardiac output. Airway pressure during mechanical ventilation is based on the “equation of motion”: Pressure = Volume/Compliance + Flow*Resistance + PEEP. Our goals of oxygenation on mechanical ventilation include achieving acceptable PaO2/Sat with the lowest FiO2 possible (avoiding oxygen toxicity) and optimal PEEP (which increases oxygenation but can have detrimental impact on cardiac output) Our goals of ventilation on mechanical ventilation include achieving acceptable pH and PaCO2 while preventing ventilator induced lung injury and avoiding auto-PEEP. We prevent lung injury by reducing tidal volume (ideally

In the medical industry, innovation is an integral part of the process to enhance systems and boost efficiency and productivity inside the facility while also improving patient outcomes.Helmet-based ventilation isn't something new in the medical field yet through creative applications it can provide practical solutions even with the pandemic we are experiencing today.In Episode 39, we are learning more about NIV or Non-Invasive Ventilation as I've invited Aurika Savickaite, a registered nurse who is part of the team led by Dr. Bakhti Battelle who produced a training program for professionals highlighting the use of Helmet-based ventilation in acute respiratory distress syndrome. Aurika shares with us the parts, benefits, and importance of this helmet in the medical community, as well as its role to prevent intubation among patients and reduce their mortality rate. Don't miss Episode 39 to learn more about how this old technology can be brought to modern medical care and improve the workload in your facility!Memorable Quotes:Every innovation leads to a new thing, but not every new thing is innovation. - Dr. Jette GabiolaIn a helmet, the aspiration chance is close to zero because the air is not pushing your stomach content into your lungs. - Aurika SavickaiteOther Resources Mentioned:Comparison of Helmet NIV, Face Mask and Invasive Mechanical VentilationOnline Training CourseEffect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress SyndromeAbout the Guest:Aurika Savickaite is a registered nurse, Master of Science in Nursing – Acute Care Nurse Practitioner degree at Rush University College of Nursing, and was actively involved in a three-year project and testing of helmet-based ventilation in the ICU at the University of Chicago.Led by Dr. Bakhti Battelle, Aurica and her team produced a training program for professionals highlighting the use of Helmet-based ventilation in acute respiratory distress syndrome. Her goal is to create and provide the medical community with the training necessary for the use of helmet-based ventilation.Follow Aurika on:WebsiteYouTubeLinkedInAbout the Host:Dr. Jette Gabiola is a Clinical Professor of Medicine at Stanford University and the President & CEO of ABCs for Global Health. Click here for her full profile or read her full interview here. See acast.com/privacy for privacy and opt-out information.

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat and I'm Rahul Damania. We are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine. Welcome to our Episode a 15 mo F with respiratory distress and runny nose. Here's the case: A 15 mo F presents to the ED with cough, runny nose, and increased work of breathing. Her mother states that the patient has had these symptoms for the past three days, however, the work of breathing progressed. The patient has had 2 fevers during this course, with the highest 101F. She says that her 3 yo cousin who she visited for the holidays had similar symptoms. Mother notes decreased PO and wet diapers. The patient presented to the ED with the following vital signs: T 38.5C, HR 155, BP 70/48 (MAP 50), RR 48, 92% on RA. The patient on the exam was noted to be tachypneic with abdominal retractions, grunting, and nasal flaring. The patient was nasally suctioned and initiated on 12 L 40% of HFNC. The patient was then transferred to the PICU for further management. To summarize key elements from this case, this patient has: Increased work of breathing indicates respiratory distress. She has a prodrome of symptoms that worsened prior to presentation And a sick contact. All of which brings up a concern for acute respiratory failure requiring non-invasive positive pressure ventilation in the form of HFNC. Let's transition into some history and physical exam components of this case? What are key history features in this child who presents with respiratory distress & URI sx? Usually, children under the age of two with bronchiolitis will present with cough, respiratory distress, and crackles on lung exam. The crackles indicate atelectatic alveoli that are filled with fluid which occurs due to inflammatory processes in the lung triggered by respiratory viruses. Respiratory distress, increased work of breathing, respiratory rate, and oxygenation all can change rapidly with crying, coughing, and agitation. Are there some red-flag symptoms or physical exam components in a child with acute respiratory distress which you could highlight? That is a great question. We really want to highlight the distinction between respiratory distress and respiratory failure. Children with respiratory failure in our case may have issues with oxygenation or ventilation as well as increased work of breathing that necessitates higher levels of respiratory support like HFNC. In a 2003 Journal of Pediatrics study, infants who were most severely affected with bronchiolitis were born prematurely,

Dr. Seth Assar joins us to discuss the SMOG Respiratory Distress guideline. This is a wide-ranging discussion that covers many of the differential diagnoses for a patient who is having difficulty breathing. Listen closely for a use of Ketamine that you may be less familiar with.Dr. Assar points out the inherent risks of intubation and mentions a study identifying a real risk of mortality with the procedure: Schwartz, D. E., Matthay, M. A., & Cohen, N. H. (1995). Death and other complications of emergency airway management in critically ill adults: a prospective investigation of 297 tracheal intubations. The Journal of the American Society of Anesthesiologists, 82(2), 367-376. The risk is further increased in patients in hemorrhagic shock and an article in the last JSOM makes this clear. See:Thompson, P., Hudson, A. J., Convertino, V. A., Bjerkvig, C., Eliassen, H. S., Eastridge, B. J., ... & Rappold, J. F. (2020). Risk of Harm Associated With Using Rapid Sequence Induction Intubation and Positive Pressure Ventilation in Patients With Hemorrhagic Shock. Journal of Special Operations Medicine: a Peer Reviewed Journal for SOF Medical Professionals, 20(3), 97-102. Finally, be on the lookout for Dr. Assar's forthcoming article in the JSOM on mechanical ventilation.This episode relates to TC 8-800, Table II and IV.

In this episode of the Journal Committee we discuss the different machines available to assist patients when they struggle with breathing as well as what happens when the air we breathe is polluted with wildfire smoke. Our guests include a respiratory therapist and a wildland firefighter. Citations are posted below:Bruells, C. S., Smuder, A. J., Reiss, L. K., Hudson, M. B., Nelson, W. B., Wiggs, M. P., . . . Powers, S. K. (2013). Negative Pressure Ventilation and Positive Pressure Ventilation Promote Comparable Levels of Ventilator-induced Diaphragmatic Dysfunction in Rats. Anesthesiology, 119(3), 652-662. doi:10.1097/aln.0b013e31829b3692Corrado, A., & Gorini, M. (2002). Negative-pressure ventilation: Is there still a role? European Respiratory Journal, 20(1), 187-197. doi:10.1183/09031936.02.00302602Energy, J. (2020, April 07). Modern iron lung designed to address ventilator shortage. Retrieved October 14, 2020, from https://newatlas.com/medical/british-engineers-modern-iron-lung-covid-19-ventilator-alternative/Grasso, F., Engelberts, D., Helm, E., Frndova, H., Jarvis, S., Talakoub, O., . . . Kavanagh, B. P. (2008). Negative-Pressure Ventilation. American Journal of Respiratory and Critical Care Medicine, 177(4), 412-418. doi:10.1164/rccm.200707-1004ocKurt. O. K., Zhang, J., & Pinkerton, K. E. (2016). Pulmonary health effects of air pollution. Current Opinion in Pulmonary Medicine, 22(2), 138-143. doi:10.1097/mcp.0000000000000248Lee, B., Kim, B., & Lee, K. (2014). Air Pollution Exposure and Cardiovascular Disease. Toxicological Research, 30(2), 71-75. doi:10.5487/tr.2014.30.2.071Liu J. C., Pereira, G., Uhl, S. A., Bravo, M. A., & Bell, M. L. (2015). A systematic review of the physical health impacts from non-occupational exposure to wildfire smoke. Environmental Research, 136, 120-132. doi:10.1016/j.envres.2014.10.015Liu, J. C., Wilson, A., Mickley, L. J., Dominici, F., Ebisu, K., Wang, Y., . . . Bell, M. L. (2017). Wildfire-specific Fine Particulate Matter and Risk of Hospital Admissions in Urban and Rural Counties. Epidemiology, 28(1), 77-85. doi:10.1097/ede.0000000000000556Peters, A., Annette Peters From the Department of Environmental Health (A.P., Dockery, D., Douglas W. Dockery From the Department of Environmental Health (A.P., Muller, J., James E. Muller From the Department of Environmental Health (A.P., . . . Peters, C. (2001, June 12). Increased Particulate Air Pollution and the Triggering of Myocardial Infarction. Retrieved October 14, 2020, from https://www.ahajournals.org/doi/10.1161/01.CIR.103.23.2810Raymondos, K., Ahrens, J., & Molitoris, U. (2015). Combined Negative- and Positive-Pressure Ventilation for the Treatment of ARDS. Case Reports in Critical Care, 2015, 1-5. doi:10.1155/2015/714902Rep. No. EPA-452/R-19-901 (2019).Staff, K., Boxman, K., Rolfe, F., Wu, L., DeMars, G., & Auld, A. (2020). Hays company bringing back 'iron lungs' to help rural hospitals in need of ventilators. Retrieved October 14, 2020, from https://www.kwch.com/content/news/Hays-company-bringing-back-iron-lungs-to-help-rural-hospitals-in-need-of-ventilators-569640331.html

In our COVID-19 Critical Care series we are hitting you with the fundamentals of critical care that you may need when caring for COVID-19 patients. In this episode we cover non-invasive positive pressure ventilation and continuous positive airway pressure ventilation. ReferencesKeenan, S. et.al. (2011). Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. Canadian Medical Association Journal. PMID: 21324867Nee, P. et.al. (2010). Critical care in the emergency department: acute respiratory failure. Emergency Medicine Journal. PMID: 21112972 Caples SM, Gay PC. Noninvasive positive pressure ventilation in the intensive care unit: a concise review. Crit Care Med. 2005;33(11):2651–2658.

Timeless Todd joins us for a chat about his latest RIT course and we go over our training sessions this week. RIT, Positive Pressure Ventilation, Hydrolive Ventilation and Transitional attack. Hey Fire Family, please Check out and support Matt's cause at www.2ndAlarm.org and don't forget to Share, Like, Subscribe and visit us on our Facebook Page at www.facebook.com/VFFPodcastDTFF/ to do the same! If you have a subject that you would like us to discuss, a question that you would like to ask or if you would like to be ON the next Episode, then you can message us on our Facebook Page at www.facebook.com/VFFPodcastDTFF/. Thanks to everyone for all your support, stay safe Fire Family and Stay DTFF! To check out the rankings click here https://blog.feedspot.com/volunteer_podcasts/ #DTFFpodcast #DownToFightFire #Firefighting #Volunteer #Firefighter #FireFamily #Firefighters #EMS #Rescue #Fire #Emergency #FireDepartment #FirstResponders #Firedept #FireDepartment #FireHouse #FireRescue #ThinRedLine #FireService #BrotherHood #SisterHood #FireFighterLife #Fireman #VolunteerFirefighter #VolunteerFirefighters #StopTheBleed #StayDTFF

Listen as Dr. Brian McAlvin defines non-invasive positive pressure ventilation, discusses its physiology, and reviews the effects of BiPAP on the lungs. Initial publication: March 20, 2019. Please visit: http://www.openpediatrics.org OPENPediatrics™ is an interactive digital learning platform for healthcare clinicians sponsored by Boston Children’s Hospital and in collaboration with the World Federation of Pediatric Intensive and Critical Care Societies. It is designed to promote the exchange of knowledge between healthcare providers around the world caring for critically ill children in all resource settings. The content includes internationally recognized experts teaching the full range of topics on the care of critically ill children. All content is peer-reviewed and open access-and thus at no expense to the user. For further information on how to enroll, please email: openpediatrics@childrens.harvard.edu

Commentary by Dr. Valentin Fuster

Dr. Bilal Jalil presents "Positive Pressure Ventilation" through the following questions: 1. Why is my patient intubated? 2. What MV modes do I need to know about? 3. How do I set the initial ventilator settings? 4. Am I harming my patient with a ventilator? 5. The ventilator is alarming!!! What do I do? 6. Can I extubate my patient?   Some items in this lecture may have come from the lecturer’s personal academic files or have been cited in-line or at the end of the lecture. For more information, see our citation page. Disclaimers©2016 LouisvilleLectures.org

https://ampa.org/   Happy Friday of #EMSWeek2017! https://emcrit.org/wp-content/uploads/push-dose-pressors.pdf    Resuscitation - beginning from initial patient contact to the emergency department to the intensive care unit is a continuun of care - though the first few minutes of patient contact with a critically ill patient can have tremendous repercussions on the patient's ultimate outcome.  Whether in critical care transport or in 911 emergency response, patient's may require a medication in small aliquots immediately that would be either unfeasible or cumbersome to administer via infusion on a dedicated pump.  While circumstances in which a patient needs a push dose medication may be uncommon, the administration of these drugs can be potentially lifesaving.  There are two prehospital scenarios in which the paramedic carries the necessary medication in their armamentariam and with appropriate instruction and training can safely reconstitute into an appropriate dose for use in out-of-hospital resuscitation for the critically ill patient.  Push dose pressors are often employed in profoundly hypotensive patients that will require endotracheal intubation.  Rapid Sequence Intubation and Positive Pressure Ventilation are both associated with hypotension, thus in the patient that requires advanced airway and is hypotensive upon EMS arrival, push dose pressors may be employed to effectively "resuscitate before you intubate".  Typically Epinephrine is diluted to an appropriate dose and adminstered in small aliquots (10mcg/ml) for inotropoic support to optimize hemodynamics prior to RSI or intubation.  There is also anaesthesia literature supporting the use of neosynephrine as well as phenylephrine for this purpose, though these medications are less readily available prehospitally.  Even brief episodes of relative hypotension can cause effects seen days later; in critically hypotensive patients these may be even more pronounced.  By using push dose pressors, a field provider can safely and effectively resuscitate their patient in order to mitigate the risks associated with endotracheal intubation prior to securing an advance airway. Conversely, a separate and distinct class of patients who suffer from decompensated heart failure may present with respiratory distress due to volume overload with pathophysiology associated with marked systemic hypertension. While CPAP is the mainstay of therapy for these patients prehospitally and has significantly reduced intubation of the CHF patient over the past several years, IV Lasix and topical Nitroglycerin play little role in the EMS management of the decompensated heart failure patient.  Nevertheless, these patients often require preload and afterload reduction to manage their symptomatology; it is common to initiate nitroglycerin infusions in critical care transport as well as in the emergency department for management of this hypertension.  Nitroglycerin lowers preload via venous vasodilation at low doses and lowers after load via arterial vasodilation at higher doses, making the patient's vascular container larger lowering the systemic pressure. Aggressive, high dose NTG paired with the recruitment of the alveoli using CPAP & PEEP make up the mainstay of pre-hospital treatment of APE and decompensated heart failure. Bolus doses as high as 2 mg (2000 mcg) of nitroglycerin have been given safely and effectively in previous studies.  In emergent resuscitations we need to focus on bolus dose medications in the acute phase versus starting and titrating critical care infusions while a patient is in extremis. The goal is to achieve clinical end points of treatment faster with bolus dosing at the bedside and then begin maintenance infusions once resuscitation goals are met and the hemodynamics are stable.  Similar to push dose pressors in the acutely hypotensive EMS patient requiring resuscitation, patients with decompensated heart failure may benefit acutely with push dose nitroglycerin, a potent vasodilator.   @AmpaDocs #CCTMC17 Mark your calendars for #CCTMC18 April 9-11th 2018 Wyndham Riverwalk - San Antonio Texas     Query us on Twitter: www.twitter.com/EMS_Nation Like us on Facebook: www.facebook.com/prehospitalnation   Wishing Everyone a safe tour! ~Faizan H. Arshad, MD @emscritcare www.emsnation.org

Producers looking for ways to reduce porcine reproductive and respiratory syndrome (PRRS) find positive-pressure ventilation with some modifications works, especially in older building, according to Aaron Lower, DVM, Carthage Veterinary Clinic, Carthage, Iowa. The post Positive-pressure ventilation makes a comeback to reduce PRRS transmissions appeared first on Pig Health Today.

Children the world over are fascinated with what can possibly “fit” in their orifices.  Diagnosis is often delayed.  Anxiety abounds before and during evaluation and management.     Most common objects:1,2 Food Coins Toys Insects Balls, marbles Balloons Magnets Crayon Hair accessories, bows Beads Pebbles Erasers Pen/marker caps Button batteries Plastic bags, packaging Non-pharmacologic techniques Set the scene and control the environment.  Limit the number of people in the room, the noise level, and minimize “cross-talk”.  The focus should be on engaging, calming, and distracting the child. Quiet room; calm parent; “burrito wrap”; guided imagery; have a willing parent restrain the child in his or her lap – an assistant can further restrain the head. Procedural Sedation Most foreign bodies in the ear, nose, and throat in children can be managed with non-pharmacologic techniques, topical aids, gentle patient protective restraint, and a quick hand.  Consider sedation in children with special health care needs who may not be able to cooperate and technically delicate extractions.  Ketamine is an excellent agent, as airway reflexes are maintained.3  Remember to plan, think ahead: where could the foreign body may be displaced if something goes wrong?  You may have taken away his protective gag reflex with sedation.  Position the child accordingly to prevent precipitous foreign body aspiration or occlusion. L’OREILLE – DAS OHR – вухо – THE EAR – LA OREJA – 耳 – L'ORECCHIO Essential anatomy: The external auditory canal. Foreign bodies may become lodged in the narrowing at the bony cartilaginous junction.4  The lateral 1/3 of the canal is flexible, while the medial 2/3 is fixed in the temporal bone – here is where many foreign bodies are lodged and/or where the clinician may find evidence of trauma.  Pearls: Ask yourself: is it graspable or non-graspable?5 Graspable: 64% success rate, 14% complication rate Non-graspable: 45% success rate, 70% complication rate5 If there is an insect in the external auditory canal, kill it first. They will fight for their lives if you try to dismember or take them out.  “In the heat of battle, the patient can become terrorized by the noise and pain and the instrument that you are using is likely to damage the ear canal.”5,6  Use lidocaine jelly (preferred), viscous lidocaine (2%), lidocaine solution (2 or 4%), isopropyl alcohol, or mineral oil. Vegetable matter? Don’t irrigate it – the organic material will swell against the fixed structure, and cause more pain, make it much harder to extract, and may increase the risk of infection. Pifalls: Failure to inspect after removal – is there something else in there? Failure to assess for abrasions, trauma, infection – if any break in skin, give prophylactic antibiotic ear drops Law of diminishing returns: probability of successful removal of ear foreign bodies declines dramatically after the first attempt   LE NEZ – DIE NASE – ніс – THE NOSE – LA NARIZ – 鼻 – IL NASO Essential anatomy: Nasopharyngeal and tracheal anatomy. Highlighted areas indicate points at which nasal foreign bodies may become lodged.4 Pearls: Consider using topical analgesics and vasoconstrictors to reduce pain and swelling – and improve tolerance of/cooperation with the procedure. Use 0.5% oxymetolazone (Afrin) spray and a few drops of 2 or 4%   Pros: as above.  Cons: possible posterior displacement of the foreign body.7 Be ready for the precipitous development of an airway foreign body Pitfalls: Beware of unilateral nasal discharge in a child – strongly consider retained foreign body.8 Do not push a foreign body down the back of a patient's throat, where it may be aspirated into the trachea. Be sure to inspect the palate for “vacuum effect”: small or flexible objects may be found on the roof of the mouth, just waiting to be aspirated.   LA GORGE – DER HALS – горло – THE THROAT – LA GARGANTA – 喉 – LA GOLA Before we go further – Remember that a foreign body in the mouth or throat can precipitously become a foreign body in the airway.  Foreign body inhalation is the most common cause of accidental death in children less than one year of age.9,10 Go to BLS maneuvers if the child decompensates. Infants under 1 year of age – back blows: head-down, 5 back-blows (between scapulae), 5 chest-thrusts (sternum).  Reassess, repeat as needed. Children 1 year and up, conscious – Heimlich maneuver: stand behind patient with arms positioned under the patient’s axilla and encircling the chest. The thumb side of one fist should be placed on the abdomen below the xiphoid process. The other hand should be placed over the fist, and 5 upward-inward thrusts should be performed. This maneuver should be repeated if the airway remains obstructed.  Alternatively, if patient is supine, open the airway, and if the object is readily visible, remove it.  Abdominal thrusts: place the heel of one hand below the xiphoid, interlace fingers, and use sharp, forceful thrusts to dislodge.  Be ready to perform CPR. Children 1 year and up, unconscious – CPR: start CPR with chest compressions (do not perform a pulse check). After 30 chest compressions, open the airway. If you see a foreign body, remove it but do not perform blind finger sweeps because they may push obstructing objects further into the pharynx and may damage the oropharynx.  Attempt to give 2 breaths and continue with cycles of chest compressions and ventilations until the object is expelled. Chest films are limited: 80% of airway foreign bodies are radiolucent.11  Look for unilateral hyperinflation on expiratory films: air trapping.  Essential anatomy: Most esophageal foreign bodies in children occur at the level of the thoracic inlet / cricopharyngeus muscle (upper esophageal sphincter).  Other anatomically narrow sites include the level of the aortic arch and the lower esophageal sphincter. Coin en face – in the esophagus – lodged at the thoracic inlet.12  The pliable esophagus accommodates the flat coin against the flat aspect of the vertebra.11 Beware the “double-ring” sign: this is a button battery13 This is an emergency: the electrolyte-rich mucosa conducts a focal current from the narrow negative terminal of the battery, rapidly causing burn, necrosis, and possibly perforation.  Emergent removal is required. Button batteries that have passed into the stomach do not require emergent intervention – they can be followed closely. Not a button battery, not a sharp object, not a long object? If there is no obstruction, consider revaluation the next day – may wait up to 24 hours for passage.14  Sharieff et al.15 found that coins found in the mid to distal esophagus within 24 hours all passed successfully. What conditions prompt urgent removal? Size Infants: objects smaller than 2 cm wide and 3 cm long will likely pass the pylorus and ileocecal valve10 Children and adults: objects smaller than 2 cm wide and 5 cm long will likely pass the pylorus and ileocecal valve9 Character Sharp objects have a high rate of perforation (35%)1 Pearls: History is essential. Believe the parents and assume there is an aspirated/ingested foreign body until proven otherwise. History of choking, has persistent symptoms and/or abnormal xray? Broncoscopy! Cohen et al.16 found that of 142 patients evaluated at a single site university hospital, 61 had a foreign body. Of the 61 patients, 42 had abnormal physical exams and radiographs and 17 had either abnormal physical exams or radiographs, and 2 had normal physical exams and radiographs, but both had a history of persistent cough.  Bottom line: history of choking PLUS abnormal exam, abnormal films, or persistent symptoms, evaluate with bronchoscopy. For patients with some residual suspicion of an aspirated foreign body (mild initial or improving symptoms; possibly abnormal chest x-ray; low but finite risk), consider chest CT with virtual bronchoscopy as a rule-out strategy.17,18 Outpatients who have passed a small and non-concerning object into the stomach or beyond: serial exams and observing stools – polyethylene glycol 3350 (MiraLAX) may be given for delayed passage19 Pifalls: A single household magnet will likely pass through the GI tract, with the aforementioned dimensional caveats. Two or more magnets, however, run the risk of attraction and trans-bowel wall pressure necrosis. Not all magnets are created equal. Neodymium magnet toys (“buckyballs”) were recalled in 2014 (but are still out there!) due to their highly attractive nature.  These magnets must be removed to avoid bowel wall ischemia. 19–21 Patients should avoid wearing belt buckles or metallic buttons in case of single magnet ingestion while waiting for the single magnet to pass DES OUTILS DU MÉTIER – DIE HANDWERKSZEUG – Знаряддя праці – TOOLS OF THE TRADE – LAS HERRAMIENTAS DEL OFICIO – GLI ATTREZZI DEL MESTIERE –  仕事のツール It’s best to keep your armamentarium as large as you can.   Curette A small foreign body in the lateral 1/3 of the auditory canal may be amenable to a simple curettage.  Hair beads (if the central hole is accessible) may be manipulated out with the angled tip of a rigid curette.  Steady the operating hand by placing your hypothenar eminence on the child’s zygoma or temporal scalp, to avoid jutting the instrument into the ear canal with sudden movement.  There is a large selection of disposable simple and lighted curettes on the market. Right-angle Hook Various eponymous hooks are available for this purpose; one in popular use is the Day hook, which may be passed behind the foreign body.22  An inexpensive and convenient alternative to the commercially available right-hooks is a home-made version: make your own by straightening out a paperclip and bending it to a right angle23 at 2-3 mm from the end (be sure not to use the type that have a friable shiny metallic finish, as the residue may be left behind in the ear canal).  If it is completely lodged, use of a right-angle hook will likely only cause trauma to the canal. Alligator forceps Alligator forceps are best for grasping soft objects like cotton or paper.  Smooth, round or oval objects are not amenable to extraction with alligator forceps.  When using them, be sure to get a firm, central grip on the object, to avoid tearing it into smaller, less manageable pieces.  Pro tip: Look before you grip! Be careful to visualize the area you are gripping, to avoid pulling on (and subsequently avulsing) soft tissue in the ear canal. Cyanoacrylate (Dermabond®, SurgiSeal®) Apply cyanoacrylate to either side of a long wooden cotton swab (the lecturer prefers the cotton tip side, for improved grip/molding around object).  Immediately apply the treated side to the object in the ear canal in a restrained patient.  Steady the hypothenar eminence on the child’s face to avoid dislodgement of the cotton swab with sudden movement.  Apply the treated swab to the foreign body for 30-60 seconds, to allow bonding.  Slowly pull out the foreign body.  Re-visualize the ear canal for other retained foreign bodies and abrasion or ear canal trauma. Did the cyanoacrylate drip?  Did the swab stick to the ear canal? No problem – use 3% hydrogen peroxide or acetone.24  Pour in a sufficient amount, allow to work for 10 minutes.  Both agents help to dissolve ear wax, the compound, or both.  Repeat if needed to debond the cyanoacrylate from the ear canal.24,25 Irrigation Irrigation is the default for non-organic foreign bodies that are not amenable to other extraction techniques.  Sometimes the object is encased in cerumen, and the only “instrument” that will fit behind the foreign body is the slowly growing trickle of water that builds enough pressure to expulse it.  Do not use if there is any organic material involved: the object will swell, causing much more pain, difficulty in extraction, and possibly setting up conditions for infection. Position the child either prone or supine, gently restrain (as above).  Let gravity work for you: don’t irrigate in decubitus position with the affected ear up.  It may be more accessible to you, but you may never get the foreign body out. To use a butterfly needle: use a small gage (22 or 24 g) butterfly set up, cut off the needle, connect the tubing to a 30 mL syringe filled with warm or room-temperature water. Insert the free end of the tubing gently, and “secure” the tubing with your pinched fingers while irrigating (think of holding an ETT in place just after intubation and before taping/securing the tube).  Gently and slowly increase the pressure you exert as you irrigate. To use an IV or angiocatheter: use a moderate size (18 or 20 g) IV, remove the needle and attach the plastic catheter to a 20 mL syringe, and irrigate as above. Acetone Acetone has been used successfully to remove chewing gum, Styrofoam, and superglue from the ear canal24,26,27  Use in cases where there is no suspicion of perforation of the tympanic membrane. Docusate Sodium (Colace®) Cerumen is composed of sebaceous ad ceruminous secretions and desquamated skin.  Genetic, environmental, and anatomical factors combine to trap a foreign body in the external canal.  Use of a ceruminolytic such as docusate sodium may help to loosen and liberate the foreign body.28  Caveat medicus: Adding docusate sodium will make the object more slippery – this may or may not be an issue given the nature of the foreign body. In the case where loosening the ear wax may aid extraction (and will not cause a slippery mess), consider filling the ear canal will docusate sodium (Colace), having the child lie with the affected side up, waiting 15 minutes, and proceeding.  This is especially helpful when planning for irrigation. Magnets Rare earth magnets (a misnomer, as their components are actually abundant) such as neodymium can be useful in retrieving metallic foreign bodies (e.g. button batteries in the nose or ears).29,30  Magnetic “pick-up tools” – used by mechanics, engineers, and do-it-yourselfers – are inexpensive and readily available in various sizes, shapes, and styles such as a telescoping extender.  Look for a small tip diameter (to fit in the ear canal as well as the nose) and a strong “hold” (at least a 3-lb hold). Alternatively, you may purchase a strong neodymium bar magnet (30- to 50-lb hold) to attach to an instrument such as an alligator forceps, pick-up forceps, or small hemostat (a pacemaker magnet may also work).  The magnetic bar, placed in your palm at the base of the instrument, will conduct the charge (depending on the instrument) and allow you to retrieve many metallic objects.31  Although stainless steel is often said to be “non-magnetic”, it depends on the alloy used, and some may actually respond to the strong rare earth magnet.  Most stainless steel has a minimum of 10.5% chromium, which gives the steel its 'stainless' properties (essentially corrosion resistance).  A basic stainless steel has a “ferritic” structure and is magnetic.  Higher-end stainless steel such as in kitchen cutlery have an “austenitic” structure, with more chromium added, and so less magnetic quality.  (Ironically, the more “economical” instruments in the typical ED suture kit have less chromium, and so are more magnetic – use these with your neodymium bar magnet to conduct the magnetic charge and extract the metallic foreign body.) Bottom line: if it’s metal, it’s worth a try to use a magnet.  Even if the metal is very weakly magnetic, the strong neodymium magnet may still be able to exert a pull on it and aid in extraction. Snare Technique A relatively new method, described by Fundakowski et al.32 consists of using a small length of 24-gauge (or similar) wire (available inexpensively online, and kept in your personal “toolkit”; see Appendix B below) to make a loop that is secured by a hemostat (the 24-gauge wire is easily cut into strips with standard trauma scissors).  After treatment with oxymetolazone (0.05%) and lidocaine (1 or 2%) topically, the loop is passed behind the foreign body (in the case report, a button battery).  Pull the loop toward you until you feel that it is sitting up against the button battery.  Now, turn the hemostat 90° to improve your purchase on the foreign body.  Pull gently out.  This technique is especially useful when the foreign body has created marked edema, either creating a vacuum effect or making it difficult for other instruments to pass. Balloon Catheters (Katz extractor®, Fogarty embolectomy catheter) Small-caliber devices (5, 6, or 8 F) originally designed for use with intravascular or bladder catheterization may be used to extract foreign bodies from the ear or nose.7,33  A catheter designed specifically for foreign body use is the Katz extractor.  Inspect the ear or nose for potential trauma and to anticipate bleeding after manipulation (especially the nose).  Deflate the catheter and apply surgical lubricant or 2% lidocaine jelly. Insert the deflated catheter and gently pass the device past the foreign body.  Inflate the balloon and slowly pull the balloon and foreign body out.  Re-inspect after extraction. NB, from the manufacturer of the Katz extractor, InHealth: “the Katz Extractor oto-rhino foreign body remover is intended principally for extraction of impacted foreign bodies in the nasal passages. This device may also be used in the external ear canal, based upon clinical judgment.” Mother’s kiss The mother’s kiss was first described in 1965 by Vladimir Ctibor, a general practitioner from New Jersey.34 “The mother, or other trusted adult, places her mouth over the child’s open mouth, forming a firm seal as if about to perform mouth-to-mouth resuscitation. While occluding the unaffected nostril with a finger, the adult then blows until feeling resistance caused by closure of the child’s glottis, at which point the adult gives a sharp exhalation to deliver a short puff of air into the child’s mouth. This puff of air passes through the nasopharynx, out through the non-occluded nostril and, if successful, results in the expulsion of the foreign body. The procedure is fully explained to the adult before starting, and the child is told that the parent will give him or her a “big kiss” so that minimal distress is caused to the child. The procedure can be repeated a number of times if not initially successful.”34 Positive Pressure Ventilation with Bag Valve Mask This technique is an approximation of the above mother’s kiss technique – useful for unwilling parents or unsuccessful tries.10,25  The author prefers to position the child sitting up.  A self-inflating bag-mask device is fitted with a very small mask: use an abnormally small mask (otherwise inappropriately small for usual resuscitative bag-mask ventilation) to fit over the mouth only.  Choose an infant mask that will cover the child’s mouth only.  Occlude the opposite nostril with your finger while you form a tight seal with the mask around the mouth. Deliver short, abrupt bursts of ventilation through the mouth – be sure to maintain good seals with the mask and with your finger to the child’s nostril – until the foreign body is expulsed through the affected nostril. Beamsley Blaster (Continuous Positive Pressure) Technique For the very uncooperative child with a nasal foreign body amenable to positive pressure ventilation who fails the mother’s kiss and bag-mask technique, a continuous positive pressure method may be used. Connect one end of suction tubing to the male adaptor (“Christmas tree”) of an air or oxygen source.  Connect the other end of the suction tubing to a male-to-male adaptor (commonly used for chest tube connections or connecting / extending suction tubes).  Insert the end of the device into the child’s unaffected nostril.  The air flow will deliver positive pressure ventilation continuously. With this technique there is a theoretical risk of barotrauma to the lungs or tympanic membranes.  However, there is only one case reported in the literature of periorbital subcutaneous emphysema. To minimize this risk, some authors recommend limiting to a maximum of four attempts using any positive pressure method.10 Nasal speculum Optimize your visualization with a nasal speculum.  The nostrils, luckily, will accommodate a fair amount of distention without damage.  Hold the speculum vertically to avoid pressure on and damage to the vessel-and-nerve-rich nasal septum.  Hold the handle of the speculum in the palm of your hand comfortably and while placing your index finger on the patient’s ala.  This will help to control the speculum and your angle of sight. Your other hand is then free to use a hook or other tool for extraction. Lighting is especially important when using the nasal speculum: a focused procedure light or head lamp is very helpful.  The author keeps a common camping LED headlamp in his bag for easy access. Suction tips / catheters Various commercial and non-commercial suction devices are on the market for removal of foreign bodies.  All connect to wall suction, and vary by style, caliber of suction, and tip end interface.  A commonly available suction catheter is the Frazier suction tip (right), a single-use device used in the operating room. A modification to suction can be made with the Schuknecht foreign body remover (left; not to be confused with the suction catheter of the same name): a plastic cone-shaped tip placed on the end of the suction catheter to increase vacuum surface area and seal.  Laryngoscope and Magill Forceps If a child aspirates and occludes his airway, return to BLS maneuvers (as above).  If the child becomes obtunded, use direct laryngoscopy to visualize the foreign body and remove with the Magill forceps.  Hold the laryngoscope in your left hand as per usual.  Hold the Magill forceps in your right hand – palm side down – to grasp and remove the foreign body.  Take-home Points  Beware the “vacuum palate”: a flat (especially clear plastic) foreign body hiding on the palate Take seriously the complaint of foreign body without obvious evidence on initial inspection – believe that something is in there until proven otherwise Control the environment, address analgesia and anxiolysis, have a back-up plan Motto Like a difficult airway: plan through the steps MERCI – DANKE – Дякую – THANK YOU – GRACIAS –  ありがとう— GRAZIE Appendix A: Prevention At the end of the visit, after some rapport has been established, counsel the caregivers about age-appropriate foods and “child-proofing” the home.  This is a teachable moment – and only you can have this golden opportunity! Age-appropriate foods 0-6 months: breastmilk or formula 6-9 months: introduce solid puree-consistency foods 9-12 months: small minced solids that require no chewing (well cooked, soft, chopped foods) Although molars (required for chewing) erupt around 18 months, toddlers need to develop coordination, awareness to eat hard foods that require considerable chewing. Not until 4 years of age (anything that requires chewing to swallow):             Hot dogs             Nuts and seeds             Chunks of meat or cheese             Whole grapes             Hard or sticky candy             Popcorn             Chunks of peanut butter             Chunks of raw vegetables             Chewing gum Child-proofing the home Refer parents to the helpful multi-lingual site from the American Academy of Pediatrics: http://www.healthychildren.org/English/safety-prevention/at-home/Pages/Childproofing-Your-Home.aspx An abbreviated list: use age-appropriate toys and “test” them out before giving them to your child to verify that there are no small, missing, or loose parts.  Secure medications, lock up cabinets (especially with chemicals), do not store chemicals in food containers, secure the toilet bowl, and unplug appliances. Parents should understand that “watching” their child alone cannot prevent foreign body aspiration: a recent review found that in 84.2% of cases, incidents resulting in an airway foreign body occurred in the presence of an adult.35 Best overall tip: get down on all fours and inspect your living area from the child’s perspective.  It is amazing what you will find when you are least expecting it. Appendix B: The Playbook's ENT Foreign Body Toolkit Although your institution should supply you with what you need to deal with routine problems, we all struggle with having just what we need when we need it.  High-volume disposable items such as cyanoacrylate (Dermabond), curettes, supplies for irrigation, alligator forceps, and the like certainly should be supplied by the institution.  However, some things come in very handy as our back-up tools. NB: we should be cognizant of the fact that tools that must be sterilized or autoclaved are not good candidates for our personal re-usable toolkits. These items can all be found inexpensively – shop around online, or in home improvement stores: Head lamp, LED camping style: $5-15 Neodymium magnet “pick-up tool”: $5-15 Neodymium bar magnet: $6-20 Wire, 24-gauge, spool of 25 yards (for snare technique): $6 Day hook: $15-20 References Chapin MM, Rochette LM, Annest JL, Haileyesus T, Conner KA, Smith GA. Nonfatal Choking on Food Among Children 14 Years or Younger in the United States, 2001–2009. Pediatrics. 2013;132(2):275-281. doi:10.1542/peds.2013-0260. Committee on Injury V. Policy Statement—Prevention of Choking Among Children. Pediatrics. 2010:peds.2009-2862. doi:10.1542/peds.2009-2862. Brown L, Denmark TK, Wittlake WA, Vargas EJ, Watson T, Crabb JW. Procedural sedation use in the ED: management of pediatric ear and nose foreign bodies. Am J Emerg Med. 2004;22(4):310-314. Heim SW, Maughan KL. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007;76(8):1185-1189. DiMuzio J, Deschler DG. Emergency department management of foreign bodies of the external ear canal in children. Otol Neurotol Off Publ Am Otol Soc Am Neurotol Soc Eur Acad Otol Neurotol. 2002;23(4):473-475. Leffler S, Cheney P, Tandberg D. Chemical immobilization and killing of intra-aural roaches: an in vitro comparative study. Ann Emerg Med. 1993;22(12):1795-1798. Kiger JR, Brenkert TE, Losek JD. Nasal foreign body removal in children. Pediatr Emerg Care. 2008;24(11):785-792; quiz 790-792. doi:10.1097/PEC.0b013e31818c2cb9. Kadish HA, Corneli HM. Removal of nasal foreign bodies in the pediatric population. Am J Emerg Med. 1997;15(1):54-56. Tahir N, Ramsden WH, Stringer MD. Tracheobronchial anatomy and the distribution of inhaled foreign bodies in children. Eur J Pediatr. 2009;168(3):289-295. doi:10.1007/s00431-008-0751-9. Rempe B, Iskyan K, Aloi M. An Evidence-Based Review of Pediatric Retained Foreign Bodies. Pediatr Emerg Med Pract. 6(12). Digoy GP. Diagnosis and management of upper aerodigestive tract foreign bodies. Otolaryngol Clin North Am. 2008;41(3):485-496, vii - viii. doi:10.1016/j.otc.2008.01.013. Loren Yamamoto, Inaba A, DiMauro R. Radiologic Cases in Pediatric Emergency Medicine; University of Hawaii. Radiol Cases Emerg Med. http://www.hawaii.edu/medicine/pediatrics/pemxray/zindex.html. Accessed February 20, 2015. Painter K. Energizer makes button battery packages safer for kids. USA Today. ASGE Standards of Practice Committee, Ikenberry SO, Jue TL, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091. doi:10.1016/j.gie.2010.11.010. Sharieff GQ, Brousseau TJ, Bradshaw JA, Shad JA. Acute esophageal coin ingestions: is immediate removal necessary? Pediatr Radiol. 2003;33(12):859-863. doi:10.1007/s00247-003-1032-4. Cohen S, Avital A, Godfrey S, Gross M, Kerem E, Springer C. Suspected Foreign Body Inhalation in Children: What Are the Indications for Bronchoscopy? J Pediatr. 2009;155(2):276-280. doi:10.1016/j.jpeds.2009.02.040. Haliloglu M, Ciftci AO, Oto A, et al. CT virtual bronchoscopy in the evaluation of children with suspected foreign body aspiration. Eur J Radiol. 2003;48(2):188-192. doi:10.1016/S0720-048X(02)00295-4. Jung SY, Pae SY, Chung SM, Kim HS. Three-dimensional CT with virtual bronchoscopy: a useful modality for bronchial foreign bodies in pediatric patients. Eur Arch Otorhinolaryngol. 2011;269(1):223-228. doi:10.1007/s00405-011-1567-1. Hussain SZ, Bousvaros A, Gilger M, et al. Management of ingested magnets in children. J Pediatr Gastroenterol Nutr. 2012;55(3):239-242. doi:10.1097/MPG.0b013e3182687be0. Brown JC, Otjen JP, Drugas GT. Too attractive: the growing problem of magnet ingestions in children. Pediatr Emerg Care. 2013;29(11):1170-1174. doi:10.1097/PEC.0b013e3182a9e7aa. Brown JC, Otjen JP, Drugas GT. Pediatric magnet ingestions: the dark side of the force. Am J Surg. 2014;207(5):754-759; discussion 759. doi:10.1016/j.amjsurg.2013.12.028. Menner AL. Pocket Guide to the Ear: A Concise Clinical Text on the Ear and Its Disorders. Thieme; 2011. Colina D, Dudek S, Lin M. Tricks of the Trade: ENT Dilemmas - How Do I Get That Out of There? ACEP News. http://www.acep.org/Clinical---Practice-Management/Tricks-of-the-Trade--ENT-Dilemmas---How-Do-I-Get-That-Out-of-There-/?__taxonomyid=118010. Published July 2009. Accessed February 5, 2015. Abadir WF, Nakhla V, Chong P. Removal of superglue from the external ear using acetone: case report and literature review. J Laryngol Otol. 1995;109(12):1219-1221. Kadish H. Ear and Nose Foreign Bodies “It is all about the tools.” Clin Pediatr (Phila). 2005;44(8):665-670. doi:10.1177/000992280504400803. Chisholm EJ, Barber-Craig H, Farrell R. Chewing gum removal from the ear using acetone. J Laryngol Otol. 2003;117(4):325. doi:10.1258/00222150360600995. White SJ, Broner S. The use of acetone to dissolve a Styrofoam impaction of the ear. Ann Emerg Med. 1994;23(3):580-582. Singer AJ, Sauris E, Viccellio AW. Ceruminolytic effects of docusate sodium: a randomized, controlled trial. Ann Emerg Med. 2000;36(3):228-232. doi:10.1067/mem.2000.109166. Bledsoe RD. Magnetically adherent nasal foreign bodies: a novel method of removal and case series. Am J Emerg Med. 2008;26(7):839.e1-e839.e2. doi:10.1016/j.ajem.2008.01.036. Dolderer JH, Kelly JL, Morrison WA, Penington AJ. FOREIGN-BODY RETRIEVAL USING A RARE EARTH MAGNET: Plast Reconstr Surg. 2004;113(6):1869-1870. doi:10.1097/01.PRS.0000119869.01081.1C. Yeh B, Roberson JR. Nasal magnetic foreign body: a sticky topic. J Emerg Med. 2012;43(2):319-321. doi:10.1016/j.jemermed.2010.02.013. Fundakowski CE, Moon S, Torres L. The snare technique: a novel atraumatic method for the removal of difficult nasal foreign bodies. J Emerg Med. 2013;44(1):104-106. doi:10.1016/j.jemermed.2012.07.070. Chan TC, Ufberg J, Harrigan RA, Vilke GM. Nasal foreign body removal. J Emerg Med. 2004;26(4):441-445. doi:10.1016/j.jemermed.2003.12.024. Cook S, Burton M, Glasziou P. Efficacy and safety of the “mother’s kiss” technique: a systematic review of case reports and case series. Can Med Assoc J. 2012;184(17):E904-E912. doi:10.1503/cmaj.111864. Gregori D, Morra B, Snidero S, et al. Foreign bodies in the upper airways: the experience of two Italian hospitals. J Prev Med Hyg. 2007;48(1):24-26. This post and podcast are dedicated to Linda Dykes, MBBS(Hons) for her can-do attitude and collaborative spirit.  Thank you for sharing your knowledge, experience, and heart with the world.

In today's VetGirl podcast, we review a study published out of North Carolina State University and University of Georgia on the use of positive-pressure ventilation (PPV) in dogs sand cats with congestive heart failure (CHF).

In today's VetGirl podcast, we review a study published out of North Carolina State University and University of Georgia on the use of positive-pressure ventilation (PPV) in dogs sand cats with congestive heart failure (CHF).

NIST researcher Steve Kerber answers questions about recent Positive Pressure Ventilation tests.