EMCrit Podcast - Emergency Critical Care

Darren Braude, Aiway and EMS master from New Mexico demonstrates the use of a bougie to make the cric procedure MUCH easier. For more great Braude magic, see his site at airway911.com.

This video demonstrates the fiberoptic styler-aided cric. In this case he is using a Levitan Scope, but an adult bonfils or any other rigid fiberoptic should work fine.

Here is my video on performing open cricothyrotomy in 3 situations: with a trach set and an assistant, with a trach set when alone, and when you only have a scalpel.

Ok, Ok, I promise this is the last airway episode for at least a little while. I am perhaps a bit obsessed. Had this show in the works for a while. The cric is the last barrier between a failed airway and death. EM docs need to be able to perform this procedure without hesitation. This requires training and practice until you can perform the procedure in

So after the intubation video went up on emrap tv, I got a flurry of emails telling me how cool the concept is, but questioning who this would actually be usable on. To answer that question, we first must discuss who actually requires intubation. If you wait until the patient is apneic, then of course you can't use awake intubation. The idea is to intubate before the patient stops breathing.

Dr. David Schriger gave a fantastic lecture on risk in emergency medicine at the ALL LA Conference. If you have not heard it, go and listen now; it is vitally important to our specialty. This is a brief EMCrit rant on some of my thoughts on the lecture.

Young patient, lactate of 5.2, pneumonia... You know what you're supposed to do--put in the central line and start early goal directed therapy. Problem is, most people can't see sticking a central line in a patient that does not need pressors and otherwise looks well. Yet these patient have an annoying habit of going on to decompensate and perish. Well now there may be another way. Thanks to an article just published in JAMA, we may have a path to non-invasive treatment of severe sepsis. In this EMCrit Podcast, I interview Dr. Alan E. Jones, author of the article, Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. Then I discuss how this article changes the game when it comes to caring for severe sepsis patients.

Pushing some ativan followed by vecuronium is no longer an acceptable strategy to manage post-intubation sedation. A good analgesia and sedation package is essential if you care about your patient's comfort and well-being. We need to move to PAIN-FIRST paradigm. Optimize analgesia and then add in sedative agents as a bonus. In this episode of the EMCrit Podcast, I expand on a previous rant to discuss the optimal way to handle routine post-intubation patients and some special scenarios you may encounter.

Your patient is pale and diaphoretic. Blood pressure is 70/50. Heart rate is 178. EKG shows atrial fibrillation... What are you going to do??? Yeah, yeah the Pavlovian ACLS response--You cardiovert. Wonderful, except it didn't change a thing. Now what? In this episode, I discuss the crashing atrial fibrillation patient.

Intubation is a sexy procedure, there is no doubt about it. NIV does not have the glamour; it's not nearly as cinematic. But for the patient, to spend 30 minutes on a NIV mask is preferable to a couple of days on the ventilator. In this episode, I discuss some of the basic ideas and methods of NIV.

Emergency awake intubation in a patient with a difficult airway

So you have a patient with intracranial bleeding or you have a high pre-ct suspicion of intracranial bleeding and they are taking coumadin, aspirin, or clopidogrel. Should you reverse them? If so, how?

Hi folks, Sorry about the voice--got a cold off those damn ED keyboards Thanks to my friend Reuben, this week we'll talk about the asthmatic patient that codes while on the vent The DOPE mnemonic gives you a path to figure out why a patient is desaturating (If anyone knows who created the DOPE mnemonic, please add a comment or send me an email.) If the pt is asthmatic, add an "S" to make DOPES The "S" stands for Stacked Breaths--and it's the first thing to address. Address it by disconnecting the vent circuit. Don't think about it, don't dither, just disconnect the vent. "E" is for equipment. Attach a BVM hooked up to O2 and you'll eliminate ventilator equipment failures. "D" is for tube displacement. Verify the tube with ETCO2, either qualitative or quantitative. "O" reminds you to check for obstruction of the tube. See if you can put a suction cath all the way down. If all of these don't fix the problem, then consider "P" for pneumothorax. Lung sounds are not always definitive. Throw on the UTS if you have the time. Otherwise perform bilateral finger thoracostomies. What the hell is that, you say? Listen to the podcast. Then you can read more about it in this article C.D. Deakin, G. Davies and A. Wilson, Simple thoracostomy avoids chest drain insertion in prehospital trauma, J Trauma 39 (2) (1995), pp. 373–374. Tech Code (please ignore) YQAVYRPWGPHA

To PEEP or not to PEEP, that is the question...in the management of the severe asthmatic

Video for the Laryngoscope as a Murder Weapon Lecture