For the Sake of the Trach: Tracheostomy Basics & Complications in the ED

Clinical scenario: You’re working in the ED when you receive a pre-arrival page: 62 y M with trach in respiratory distress, unable to obtain sats, ETA 5 min.  As you are setting up suction in the resuscitation bay, EMS arrives with a pale, elderly male gasping for air.  What's your next move?

Review: Although (hopefully) not something we see in the emergency department every day, this is absolutely something we need to be comfortable stabilizing, if not definitively managing, on our own. In order to have a better understanding of tracheostomy complications, it’s important to understand some terminology and anatomy first.  

Differentiating tracheostomies from laryngectomies 
A critical piece of information to obtain in patients with a tracheostomy is to determine whether or not they have had a laryngectomy as well. A tracheostomy is simply an opening in the trachea created with an incision through the anterior neck. Some reasons for needing a tracheostomy include chronic mechanical ventilation, maxillofacial trauma, or upper airway obstruction such as from a mass. A laryngectomy—usually performed on patients with laryngeal cancer—is a complete removal of the larynx with separation of the airway from the mouth, nose, and esophagus. Since there is no connection between the mouth and the patient’s airway, laryngectomy patients can NEVER be orally

intubated. Outwardly, a laryngectomy patient looks like any other patient who has had a tracheostomy, so it is impossible to tell if a patient has had a laryngectomy simply by looking at his or her neck. While occluding the stoma of a patient who has only had a tracheostomy may not cause complete loss of the ability to ventilate (assuming that have at least a somewhat patent upper airway), occlusion of the stoma in a larygectomy patient will absolutely in all cases make it impossible for the patient to breathe, since the stoma is the only possible connection to the lungs in a laryngectomy patient. Despite being a “never” event, attempts at oral ventilation on a laryngectomy patient have been reported in the past [1].   If a patient with a total laryngectomy requires bagging and the trach tube is displaced, the stoma is the only way to ventilate them.  As an initial measure, an laryngeal-mask airway or neonatal mask can be applied to the stoma and used for bagging.


Tracheostomy basics 
To better understand tracheostomies in general, some basics are worth reviewing. Tracheostomies can be performed percutaneously at the bedside in the intensive care unit or surgically in the operating room. Various methods for a tracheostomy exist, but the neck incision is usually made midway between the cricoid cartilage and the sternal notch, well below where a cricothroidotomy is usually performed, and the trachea itself may be opened with a vertical or horizontal incision. A few safety features are sometimes integrated into the tracheostomy: stay sutures and Bjork flaps. Stay sutures are temporary sutures placed through 2-3 tracheal rings that allow for the trachea to be pulled back up to the skin should decannulation occur. This allows for visualization and easier reinsertion of the tracheostomy tube, thereby decreasing the risk of creating a false passage if the tracheostomy tube needs to be reinserted before the tract fully matures in about 7 days. Stay sutures are usually removed after 7 days, so patients presenting to the ED are not likely to have these. A Bjork flap is an upside-down U-shaped section of trachea that not only creates the tracheostomy, but the free edge of the flap is sutured to the skin of the neck, essentially creating a path for tracheostomy tube reinsertion and reduces the risk of creating a false passage when reinserting a tracheostomy tube prior to tract maturation [2]. 

Tracheostomy Tube Features 
Tracheostomy tube designs vary widely but most tracheostomy tubes have a number of parts in common. A few important details to know about every tube include the size of the tube, the brand or type, and whether or not the tube has a cuff. For example, when speaking with a consultant, one might say, “this patient has a size 6 cuffed Shiley.” The cuff is an important feature of many

tracheostomies as it allows for the airway to be sealed off, allowing for positive pressure ventilation and reducing the risk of aspiration. Deflating the cuff will allow the patient to breath through his or her mouth to some degree (assuming a patent upper airway), which serves as a backup for ventilation should the tube become occluded. Having the cuff down also allows for the patient to phonate when they occlude their tracheostomy tube, since air will be able to pass around the deflated cuff and tube through the vocal cords. Some tracheostomy tubes will have both an outer cannula and inner cannula, which allows for the inner cannula to be removed and cleaned or replaced without changing the entire tracheostomy tube. The downside to having an inner cannula, however, is that the effective inner diameter of the tube is decreased, so the patient may experience increased resistance to airflow.


Tracheostomy tube complications 
Setting up for the patient
Patients with tracheostomy tubes will on occasion present to our emergency department, and as the initial responders to these emergencies, it is important to be aware of the common or potentially life threatening complications associated with tracheostomy tubes. In the patient who is not rapidly decompensating, eliciting a brief history focused on the tracheostomy tube should be performed. Necessary details such as when the tracheostomy was placed, what size tube the patient uses, and why the tracheostomy was needed may be management altering pieces of information. When the patient arrives to the ED, supplies and equipment should be assembled in anticipation of potential worsening of the patient's complication. Personal protective equipment (face shield, gloves, fluid-resistant gown), suction catheters, Yankauer suction, replacement tracheostomy tubes (of the same and also one size smaller), tracheostomy tube ties, and a supplemental oxygen source should all be at the bedside ready for immediate use. Endotracheal tubes with intubating equipment (if the patient has a patent upper airway) should be readily available as well, if not at the bedside. 


Tracheostomy tube obstruction
Secretion buildup will often result in a narrowing of the effective tube diameter, commonly leading to increased resistance to flow and manifesting as respiratory distress in the patient. Inadequate suctioning, poor hydration, and decreased mobility are all risk factors for obstruction from secretions. The initial step in patients with a possible tube obstruction is to attempt passing a suction catheter through the tracheostomy tube. Instilling a few milliliters of sterile saline may help loosen secretions. If the suction catheter cannot be passed easily beyond a few centimeters or the length of the tube, the tube may either be obstructed or dislodged. In tubes with an inner cannula, the inner cannula should be removed and inspected or replaced, but if there is still resistance to passing a suction catheter, the tracheostomy tube is likely dislodged with the distal tip in the soft tissues of the neck and will need to be removed immediately and replaced [2]. 


Accidental decannulation
Although most patients will have a mature tracheostomy tract when they present to the ED, it is prudent to ask when the tracheostomy was placed. Tracheostomies that are less than 7 days old presenting with a decannulation of the tube should never be replaced blindly because of the risk of creating a false passage upon reinsertion. In a patient with a mature tract, he or she should be optimally positioned for reinsertion, preferably laying supine with a shoulder roll to extend the neck, which will help align the tissue planes and mimic the position by which the tracheostomy was originally created (likely supine on a operating table). Preoxygenating the patient oronasally or via the stoma will reduce the risk of oxygen desaturation should any difficulties arise during the procedure. Always use an obturator or introducer if available to avoid injuring the soft tissues with the end of the tracheostomy tube. Water-soluble lubricant or a lidocaine containing jelly should be applied to the tube. Holding the tube and obturator as one unit, the tube should be inserted with the tip initially pointed perpendicular to the stoma and then gently curved downward into the trachea following the bend of the tube. If the tube has been out of the stoma for more than several hours, the stoma may have begun to stenose and require dilation by an otolaryngologist prior to reinserting a tube. A chest x-ray should be performed to confirm placement. Alternatively, if available, a nasopharyngoscope or bronchoscope can be used to directly visualize the carina via the tracheostomy tube, which would guarantee proper tracheal placement.  For a video demonstration, see this you tube video.


Bleeding from the tracheostomy
Tracheostomy bleeds can be from a number of possible sources. Superficially, the skin underlying the flange of the tracheostomy tube should be checked, as malpositioning of the tube or patient may result in pressure ulceration. The tracheostomy tube may need to be removed to fully inspect the stoma and surrounding skin, and local bleeding can be controlled with pressure or topical silver nitrate. Often, granulation tissue, which are new growths of connective tissue and small blood vessels, can arise from the stoma site, or even within the trachea itself. Minor bleeding from around the stoma can similarly be treated with pressure or silver nitrate. Granulation tissue within the trachea is diagnosed by direct visualization with a nasopharyngoscope or bronchoscope, and needs to be definitively treated by ENT, usually by cauterization. Other potential sources of tracheostomy bleeding may come from the tube eroding into the thyroid vessels, thyroid gland, or tracheal wall. A tracheoinnominate fistula is perhaps the most feared complication of a tracheostomy tube and occurs when the tip of the cannula erodes through the anterior tracheal wall and into the innominate artery. This rare condition occurs in less than 1% of all patients with a tracheostomy tube but carries a mortality rate approaching 100% given the catastrophic bleeding into the airway. Approximately 75% of patients with a tracheoinnominate fistula will present within 3 to 4 weeks of tracheostomy tube placement, and some of these patients will have an initial "sentinel bleed" that may be relatively minor before developing massive hemorrhage [2,4]. Hemorrhage in these cases can be temporized by hyperinflating the cuff of the tracheostomy tube or endotracheal tube placed through the stoma as an attempt to tamponade the bleeding. These patients will need emergent thoracic and ENT consultation. Endovascular embolization of the innominate artery may be another option in these patients and has been demonstrated to be successful in a few case reports [5]. 


Cardiac arrest
Suppose a patient with a tracheostomy is brought into the emergency department with CPR in progress. Provided that the patient's stoma remains patent, a small cuffed endotracheal tube (e.g. a 6.0 tube) can be inserted through the stoma to ventilate a tracheostomy patient in this code scenario. Intubation of the stoma is not only is much faster than attempting oral intubation, but also avoids the potential attempt at oral intubation on a laryngectomy patient (which, again, should never occur) if his or her medical history is unknown. A laryngeal mask airway (LMA) can be placed over the stoma to ventilate if an endotracheal tube is not readily available, but the patient's mouth and nose should be covered if upper airway patency is unknown. Alternatively, should the stoma be stenosed (for example, if the tracheostomy tube has been out for hours) and the patient is known to have a patent upper airway, the stoma can be occluded and the patient can be ventilated with bag-valve-mask via the mouth and nose. 


Take Home Points 
Tracheostomy complications can quickly become life-threatening, and knowing some basic concepts about tracheostomies can allow us to better respond to and take care of patients with these complications. As with any patient, getting an adequate history should be the first step, and in particular, knowing if the patient has had a laryngectomy can prevent the “never event” of an orotracheal intubation attempt. Before performing any interventions on a patient where there is time to set up (i.e. on a relatively stable patient), one should gather appropriate equipment such as personal protective gear, extra tubes, and suction. Finally, consider the potential for a tracheo-innominate fistula in a bleeding tracheostomy patient given the extremely high associated mortality. 

Submitted by Phil Chan, PGY-3
Faculty Reviewed by jason wagner  (@TheTechDoc)
Everyday EBM Editor: Maia Dorsett (PGY-4, @maiadorsett) 

References

[1] El-Sayed IH, et al. Identifying and Improving Knowledge Deficits of Emergency Airway Management of Tracheotomy and Laryngectomy Patients: A Pilot Patient Safety Initiative. Int J Otolaryngology. 2010;2010:1-7.
[2] Morris LL, et al. Tracheostomy Care and Complications in the Intensive Care Unit. Crit Care Nursing. 2013;33(5):18-30.
[3] D. Doyle J, Scales DC. Tracheostomy. In: Hall JB, Schmidt GA, Kress JP. eds. Principles of Critical Care, 4e. New York, NY: McGraw-Hill; 2015. http://accessmedicine.mhmedical.com/content.aspx?bookid=1340&Sectionid=80032214. Accessed September 24, 2015.
[4] Epstein SK. Late Complications of Tracheostomy. Respir Care 2005;50(4):542-549.
[5] Hamaguchi S, Nakajima Y. J Vasc Surg. 2012;55:545-547

Consultant Teachings No. 1: Acute Neuromuscular Respiratory Failure

Clinical Scenario: You are working in EM 2. It’s 3 AM and a 32 year old woman is roomed with the chief complaint of shortness of breath. She has been getting progressively more short of breath for the past 2 days. She’s also noticed that she just can’t keep her eyes open, though her right eyelid droops more than her left. You notice her head is falling forward. When you question her about that, she says she has had trouble holding it up for 4 days. Your general exam is normal, with no wheezing and normal heart sounds. Her neuro exam shows weakness on eye closure, neck flexion, and neck extension. She has no weakness anywhere else.

Clinical Question: How should acute neuromuscular respiratory failure be evaluated and managed?

Literature Review:
Neuromuscular respiratory failure is relatively rare but constitutes a medical emergency with significant morbidity and mortality, particularly with delays in recognition. The most common causes are acute inflammatory demyelinating polyneuropathy (e.g. Guillain-Barre syndrome, GBS) myasthenia gravis (MG), motor neuron disease (e.g. amyotrophic lateral sclerosis, ALS) and some forms of myopathy. A study in Northern Ireland found the causes of acute respiratory failure due to neuromuscular conditions were GBS (62%), MG (18%), ALS (9%), then a variety of other conditions (2, 3). Early recognition of these conditions by history and physical exam, combined with specific bedside testing, can help appropriately triage and manage these patients. GBS has an incidence of 1-4 per 100,000 and represents the most common cause of acute paralysis. It is also often missed early in the disease, with patient’s requiring an average of 2 ED visits before diagnosis [1]. GBS can progress from symptom onset to respiratory failure in 48 hours, so early identification is important. The mechanism of respiratory failure is loss of activity of the diaphragm and accessory muscles of respiration, and can often be complicated by aspiration due to craniobulbar weakness. The diaphragm is innervated by the phrenic nerve, derived from the C3-5 nerve roots (remember: “C3, 4, and 5 keep you alive”).

The initial evaluation should begin with a careful history, including the time from symptom onset to ED presentation. When taking the history, it is important to ask specifically about:

1) Drooping eyes (ptosis)

2) Double vision (diplopia)

3) Change in speech (breathy or nasal)

4) Difficulty swallowing including nasal regurgitation (food/liquid coming out the nose)

5) Fatigue with chewing

6) Head drop (inability to support their head)

All of these can be findings of bulbar and high cervical spine pathology, and can be warning signs for impending respiratory failure. The history should also include characterization of weakness in other places (i.e. leg or arm weakness), sensory symptoms (ascending numbness or paresthesias) and autonomic symptoms (new-onset orthostatic symptoms, bowel or bladder retention/incontinence, changes in sexual functioning).

On physical exam, after doing a routine medical exam, specifically test:

1) Eye movements (looking for impairment of extraocular musculature)

2) Eye closure strength

3) Mouth closure strength

4) Tongue strength and palate elevation

5) Assess for a weak cough

6) Neck flexion and extension strength

7) Breath count (ask the patient to count up at a rate of one number per second after taking a full breath. This is a crude estimate of vital capacity, with each number being ~100 ml.)

Numbers 1-5 detect craniobulbar weakness. Neck flexion and extension are well correlated with diaphragmatic strength. Neck flexion weakness correlates with impaired respiratory function, while neck extension weakness should be considered a warning sign of impending respiratory failure.

Laboratory testing: History and exam should guide testing, but a full set of screening labs is generally appropriate (CBC, BMP, HFP). Other bloodwork that can be obtained include CK, TSH, and ESR [4].

Respiratory therapy should measure forced vital capacity (FVC) and negative inspiratory force (NIF). FVC < 20 ml/kg (~ 1- 1.5L) or NIF < -30 cm H20 are warning signs for impending respiratory failure [5].  It is important to discuss the effort provided and the quality of the lip seal with the respiratory therapist that performs the testing.

If there is evidence of severe diaphragmatic weakness (very weak neck extension or low NIF/FVC), it is reasonable to check an ABG or VBG for hypercapnea and a respiratory acidosis, consistent with inadequate ventilation.

If there are signs of impending respiratory failure, it is important to determine if non-invasive ventilation (e.g. BiPAP) or intubation and mechanical ventilation is most appropriate. This is a decision that should be made with the consulting neurologist and with the admitting ICU. However, if the objective findings (NIF/FVC and ABG) or trajectory (rapid deterioration) are poor, it is reasonable to electively intubate in the ED instead of an emergent intubation in the ICU.  Concurrent craniobulbar weakness and/or a weak cough are relative contraindications for use of non-invasive ventilation given the increased risk of aspiration.


Intubation in patients with neuromuscular weakness carries special risks.   In myasthenia gravis, due to a complex interaction between the number of ACh receptors at the neuromuscular junction, antibodies inhibiting those receptors, and the effects of treatment such as plasmapheresis and enzyme inhibitors, neuromuscular blockade can have unpredictable effects.

Image source: http://jama.jamanetwork.com/article.aspx?articleid=200737

Myasthenia patients have net loss of AChR at the neuromuscular junction (see Figure), making these patients relatively resistant to succinylcholine.  However, in cases where myasthenic crisis is treated with plasmapharesis, which also incidentally rcmoves the enzymes required for breakdown of paralytic agents, patients can have very  prolonged neuromuscular blockade.  While the effect of succinylcholine can go either way, patients with myasthenia gravis can be extremely sensitive to nondepolarizing blockade (one study found that the effective dose of vecuronium in MG was 1/5 that in controls) [6,7].

 In addition to the unpredictable effects of neuromuscular agents, patients with neuromuscular weakness is general are at higher risk of developing critical illness myopathy following exposure to paralytics. Avoidance of any paralytic is the goal when intubating a patient with MG, so consider using topical lidocaine with a sedative such as propofol [8]. Patients with GBS often develop significant autonomic dysfunction, with concomitant extreme swings in blood pressure and heart rate [9]. Autonomic dysfunction can be exacerbated during intubation. It is important to avoid treating these swings in blood pressure and/or heart rate unless there is evidence of end organ damage. Treating these rapid swings places the patient at a high risk of iatrogenic injury when their blood pressure or heart rate spontaneously rebounds and this rebound is exaggerated by the medications provided.

Clinical Take home:1) Have a high index of suspicion for neurologic causes of respiratory failure.
2) Check craniobulbar and neck flexion/extension strength in patients in whom you suspect neuromuscular pathology.
3) Check NIF/FVC and an ABG on any patient with a suspected neuromuscular condition and dyspnea.
4) Intubate with a reduced dose of non-depolarizing agent or preferably no paralytics at all
5) Expect heart rate and blood pressure swings, especially during intubation. Don’t treat them unless there is end-organ damage, as they are likely to spontaneously resolve.

Submitted by Alex Dietz, Neurology PGY-3
Additional Review by Jennifer Griffith
Faculty Reviewed by Robert C. Bucelli (Neurology)

Everyday EBM Editor: Maia Dorsett

References:
[1]Noto A, Marcolini E. Select topics in neurocritical care. Emerg Med Clin North Am 2014;32:927-938.
[2]Carr AS, Hoeritzauer AI, Kee R, et al. Acute neuromuscular respiratory failure: a population-based study of aetiology and outcome in Northern Ireland. Postgrad Med J 2014;90:201-204.
[3]Pfeffer G, Povitz M, Gibson GJ, Chinnery PF. Diagnosis of muscle diseases presenting with early respiratory failure. J Neurol 2014.
[4]Flower O, Bowles C, Wijdicks E, Weingart SD, Smith WS. Emergency neurological life support: acute non-traumatic weakness. Neurocrit Care 2012;17 Suppl 1:S79-95.
[5]Lawn ND, Fletcher DD, Henderson RD, Wolter TD, Wijdicks EF. Anticipating mechanical ventilation in Guillain-Barré syndrome. Arch Neurol 2001;58:893-898.
[6] Roppolo, L. P., & Walters, K. (2004). Airway management in neurological emergencies. Neurocritical care, 1(4), 405-414.
[7]Martyn JA, White DA, Gronert GA, Jaffe RS, Ward JM. Up-and-down regulation of skeletal muscle acetylcholine receptors. Effects on neuromuscular blockers. Anesthesiology 1992;76:822-843.
[8]Della Rocca G, Coccia C, Diana L, et al. Propofol or sevoflurane anesthesia without muscle relaxants allow the early extubation of myasthenic patients. Can J Anaesth 2003;50:547-552.
[9]Rabinstein AA, Wijdicks EF. Warning signs of imminent respiratory failure in neurological patients. Semin Neurol 2003;23:97-104.

Expert Commentary: Troubleshooting Hypoxia on the Vent

In emergency medicine education, we tend to focus on establishing the airway but spend less time discussing the aftercare and managing the ventilator.  While we have spent more time on this recently, thanks to Brian Fuller and his research on the importance of low tidal volume ventilation in the ER (see EM Journal club summary and podcast from February 2014),  most of us are still more comfortable putting the ET tube in than managing the vent.

Luckily for us, here at WashU we have some EM-Critical Care wise guys who can teach us a thing or two, and today we share with you Brian Fuller's method for trouble-shooting hypoxia on the vent, forwarded to us by PGY-3 Brendan Fitzpatrick:

>>From: Fitzpatrick, Brendan
>>To: Fuller, Brian
>>Subject: vent desats

Dr. Fuller,

Good working with you last night. I was trying to recall how you broke down desats on the vent last night, but somewhere between little sleep and my kids' halloween parade, I've lost the finer points.

In all your free time, would you mind jotting down what you told me so I can review it?

thanks,

Brendan

 
>From: "Fuller, Brian"
>To: "Fitzpatrick, Brendan"
>Subject: RE: vent desats

For the purposes of acute deterioration (in the form of hypoxia) on the ventilator, we are gonna talk about two airway pressures: peak pressure and plateau pressure. As an aside, mean airway pressure is the average pressure over one cycle of inspiration and expiration. It is largely governed by PEEP and I:E ratio. It really governs oxygenation- higher it is, more you open up stiff alveoli in sick vented patients.

Peak pressure is the summation of pressure generated from: 1) tidal volume and compliance; 2) resistance and peak inspiratory flow; and 3) PEEP
 
Plateau pressure is a reflection of compliance. Think "how stiff the lungs are"; or "how much transalveolar stretch is occurring".
Compliance is ∆ volume/∆pressure. Specifically, tidal volume/(plateau pressure - PEEP)




So the first thing I do when somebody becomes acutely hypoxic on the ventilator is to look at their peak airway pressure:

1. If decreased: you have an air leak or the patient is hyperventilating/tugging hard and therefore pulling the airway pressures down. Air leak would be something like: bronchopleural fistula, the chest tube you just put in has a leak in the system, your ETT has migrated or cuff has a leak and air is escaping.

2. If increased: see above- this could either be primarily a compliance or resistance problem. So your next step is to look at the plateau pressure to figure out where the problem lies.

If no change in plateau, you therefore have a bigger difference between the peak pressure and the plateau pressure than existed before the hypoxic event. See above for what governs these pressures, so you can tell that this is therefore a resistance problem. Think: airway obstruction from bronchospasm, clogging of the ETT with secretions, kinking of the ETT.

If plateau pressure is also increased, you now have a situation where the peak and plateau pressures both increased. See above for what governs these pressures, so you can tell that this is therefore a compliance problem. Think: pulmonary edema, abdominal distention, pneumothorax, atelectasis, etc.

3. If no change: think "Something made my patient hypoxic but didn't change my airway pressures." Not a lot of stuff does that. Think: pulmonary embolism, PFO.

Sometimes it is difficult to figure out "Is the ventilator and my ventilator settings the problem, or is this a patient problem?" If you remove the patient from the ventilator, and therefore take that out of the equation, bag them and they get better, it is probably a ventilator problem. If you bag them and they stay bad, it is probably a patient problem.

Hope this helps. Hit me back with questions PRN.

Feel free to share with others.
Be good man.
B


For those of you who like pictures, here is a visual representation of the algorithm:

Want to do a little more reading or watching about this? Life in the Fast Lane had a nice review of Pulmonary Mechanics.  I recommend the second Eric Strong video on pulmonary pressures as a supplement to understanding the above material (and hell, it only takes 9 minutes to watch).

Expert Commentary by Brian Fuller
Visual aids by Maia Dorsett (@maiadorsett), PGY-3 
Expert inquiry, sharing skills and parenting by Brendan Fitzpatrick, PGY-3.

#FOAMed Digest No. 6: Ain't Nobody Got Time For That

Welcome back, FOAMheads! My apologies for the delay this week. I ended up being a bit busier than I expected, which not coincidentally brings me to the theme for today's entry.

Sometimes you have a lot on your plate and may not be able to set aside a large chunk of time to watch/listen to a 30-minute-plus podcast. But that doesn't mean you don't have time to get your learn on! This time around, we'll highlight some of the best FOAMed sources of short-and-sweet educational pearls. Easily digestible for the highly-distractible mind of the EM trainee.

There is no moment like the present -- let's get started!

#FOAMed Digest No. 3: You Need Me On That Wall

Emergency Medicine physicians practice in a unique environment. We must synthesize plans for  diagnosis, management, and disposition while utilizing input from almost every subspecialty, and the ED is the ultimate proving ground for diagnostic tests and treatment modalities of every sort. Unsurprisingly, a fair deal of controversy and debate exists regarding the optimum management of patients. (For reference, see any Trauma Case Conference featuring Drs. Schuerer and Aubin.) The “best evidence” is often poor evidence. We in Emergency Medicine retain the rebellious spirit of our founders, and are always looking for new and innovative techniques. Some physicians are too quick to jump on the bandwagon, and others lag behind the curve when it comes to adopting new practices.

The selections this time around are not meant to tell you the best way to do things. The algorithms and practice patterns suggested are not universally adopted, written in textbooks, or taught as part of any standard curriculum. They are meant to promote thought, to prompt you to read the primary literature for yourself, to encourage you to seek the opinions of other experts on the subject, and to form your own conclusions. Hopefully they will inspire you to suggest new ideas to your seniors and attendings during your next shift – or even question ideas you think are unsound. Maybe, just maybe, they will even inspire a new research or QI project. FOAMed is by design perfectly adapted to assist you in this quest.

Ramblers, let’s get ramblin’.

Three Stars:

1. Ken Milne at the Skeptic’s Guide to Emergency Medicine pretty much sets the bar when it comes to FOAMed of the latest EBM topics. He asks his clinical questions in the PICO format, he applies a rigorous quality checklist when analyzing the available literature, and includes in his discussion other FOAMed experts (including on occasion our very own Chris R. Carpenter, a.k.a. “Captain Cranium”). This episode he turns his skeptical eye to a topic sure to generate heated discussions for years to come: tPA for stroke.

2. If there’s anyone that looms larger in the ED Critical Care world than Weingart, it’s Resuscitationist Extraordinaire Cliff Reid. His lecture from the SMACC Gold conference hit resuscitation dogma like an A-bomb, leaving irradiated bits of unfounded practice patterns strewn about the Outback countryside.

(EXTRA CREDIT: Reid’s talk from the original SMACC conference, “Making Things Happen,” should be required viewing for anyone wanting to be a Trauma Senior someday.)

3. If pediatric surgeons have come to accept ultrasound as a stand-alone diagnostic method for appendicitis, maybe there’s hope that someday ultrasound can also be used as a radiation-sparing technique for diagnosis of small bowel obstruction. Academic Life in EM has an excellent run-down of the technique and comparative research studies.
(EXTRA CREDIT: The book Evidence-Based Emergency Care, authored in part by our own Captain Cranium Chris R. Carpenter, has a chapter dedicated to the inferiority of plain films for SBO diagnosis. You can read it for free online via Becker Library.)

Oldie But Goodie:

I think here in a few more years this will reach “accepted standard practice” level, and maybe even “textbook” level, but it’s not there yet. It should be: there’s good evidence to show kayexelate doesn’t work, and may even cause harm. Let Weingart and the PaperChase fellows from EM:RAP give you the ammunition you need to stand up to any pesky floor seniors.

F(FN)OAMed:

In a very enlightening segment from this month’s EM:RAP, Rob Orman interviews a community ED practitioner, Dr. Cameron Berg, regarding his hospital’s new Accelerated Diagnostic Protocol for low-risk chest pain. While his exact algorithm hasn’t been externally validated and probably isn’t ready for prime-time at our shop, the evidence-based and pragmatic approach is certainly worth considering. And he provides links to almost all of his references in the show notes!

The Gunner Files:

1. The “Research & Reviews” segment on Life in the Fast Lane is worth checking out every week. A group of some of the brightest minds in the FOAMed world get together and spoon-feed us summaries some of the most relevant, practice-changing, or downright strangest papers in the EM literature.

2. Josh Farkas over at PulmCrit wrote an excellent piece laying out his argument for super-high-flow NC (think 30-45L!) as an acceptable method of preoxygenation before RSI. It’s also got a good rundown of apneic oxygenation using NC (which we all should be doing every time), and an enlightening counterpoint from the grand maester of ED Critical Care, Scott Weingart.

3. Pediatric EM expert Sean Fox provides an excellent summary of the neonatal ALTE on his blog Pediatric EM Morsels.

4. Two EM airway heavyweights, Rich Levitan and Reuben Strayer, slug it out in the ultimate Direct Laryngoscopy vs Video Laryngoscopy debate, posted to the Prehospital and Retrieval Medicine podcast hosted by Minh Le Cong.

5. All of us will be the bearer of the -07 phone at some point, and that means you better have your act together when discussing decision-making capacity. Bill Johnston, EMT-P and author of the excellent blog Prehospital Wisdom, shares his fundamentally sound and no-bullshit method for determining capacity in the field.

In the words of Ken Milne: “Meet ‘em, greet ‘em, treat ‘em, and street ‘em!”

Sam Smith, PGY-3

#FOAMed Digest No. 2: Breathless Love

Welcome back! Fresh new FOAMy goodness for you, this time with an emphasis on airway and pulmonary care. Let’s do it!

Three Stars:

1. No way around it: “Delayed Sequence Intubation” is the new hotness. If you want to be one of the cool kids, you better get on board. I’ll let the more graphically-minded folks at EMCurious lay it all out for you with a prototypical case. Don’t miss the links – more excellent FOAMed resources on DSI.

(And Weingart’s seminal paper on the subject is required reading at this point.)

(And, oh yeah, ketamine does NOT increase ICP. Let’s use these two systematic reviews 1 & 2 to stop the foolishness already.)

2. Someday you will need to perform a cricothyrotomy. Accept it as reality, and do everything you can to prepare for it. Start here, with Weingart’s lecture on the surgical airway delivered at the SMACC Gold conference last fall. This page from the EMCrit blog has compiled all sorts of great surgical airway resources from around the FOAMed world all in one spot, including can’t-miss stuff about the scalpel-finger-bougie technique and Weingart’s pre-intubation checklist. You should probably add it to your favorites list now.

3. Wouldn’t be a FOAMed Digest without getting a little off-topic, and Rick Body’s recent contributions over at St. Elmyn’s regarding ACS & “low-risk” chest pain in the ED are too good to pass up. Great post analyzing his recent paper, which concluded ED physicians simply aren’t capable of ruling out ACS in chest pain patients with an acceptable accuracy using only the clinical exam. Dr. Body also gives you a run-down of how to properly utilize high-sensitivity troponin in his talk from SMACC Gold.

(Link to Body's paper here.)

Oldie But Goodie:

By the end of our Ultrasound rotation, we can all diagnose pneumothorax with ultrasound at the bedside. It’s time to take it next-level. A-lines, B-lines, pneumonia vs edema…the experts at the Ultrasound Podcast help you figure it all out in a two-part 1 & 2 podcast.

F(FN)OAMed:

Sanjay Arora and Mike Menchine, hosts of the PaperChase segment on EM:RAP, summarize the current literature about how terrible we are at adequately sedating patients after RSI. Roc lasts longer than Sux – the patients won’t be able to tell us they need sedation!

(Links to relevant papers in the show notes.)

The Gunner Files:

1. Brett Sweeny at EMDocs provides an exhaustive review of FOAMed resources regarding permissive hypotension in trauma. Great lectures and podcasts from some of the brightest minds in EM & trauma surgery.

2. We’re seeing it already – asthma cases are starting to pile up over on the SLCH side. Luckiliy for you, Pediatric EM rockstar Andy Sloas just published an excellent podcast on the evaluation and management of asthma in the Peds ED.

3. Next time you’re consulting Ortho or Plastics for a hand injury, sound like you know what you’re talking about. The folks over at EMin5 hit you with the quick rundown on the neuro exam of the hand.

4. Last week, St. Elmyn’s helped the rooks get up to speed when it came to dealing with the dyspneic patient in the ED (and I bet the seniors learned a thing or two as well). This time, get your mind right when faced with a syncopal patient.

5. Who doesn’t love infographics? And if they actually help us learn something about managing septic patients, that’s just a bonus! Very well done by EMCurious, with embedded links to the relevant studies!

6. New podcast from R.E.B.E.L.EM, summarizing the results of a meta-analysis just published this month in Annals which concluded prehospital application of NIPPV in patients with severe respiratory distress regardless of cause reduced need for intubation (NNT 8) and in-hospital mortality (NNT 18). 

w00t prehospital medicine!
(Original pub here.)

That’s all, folks! Go get your learn on!

Sam Smith, PGY-3