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deleted162650
Where in the F do you work??We'll usually have at least one a week
Where in the F do you work??We'll usually have at least one a week
No way nebs and topical work in this pt.Do it all the time. Works really well if the patient is cooperative. We usually do it to drain PTAs. Do it similar to an awake FOI after nebs +/- topical. When patients hold the VL, they can go a lot deeper than you’d think. I’ve also done it on patients with trismus. It’s gives you a free look to know “ok, chip shot, fine to go.”
Holding the blade upside down? I cannot compute that without thinking it's digging into the roof of the mouth. Please explain.Interesting-- I wouldn't have thought that the nebs/topical lidocaine would work if there was blood in the field.
Some of my co-residents suggested doing a VL with him sitting up and holding the blade upside down-- I may have been able to do that and used the fiber as a driveable stylet.
Holding the blade upside down? I cannot compute that without thinking it's digging into the roof of the mouth. Please explain.
Interesting-- I wouldn't have thought that the nebs/topical lidocaine would work if there was blood in the field.
Some of my co-residents suggested doing a VL with him sitting up and holding the blade upside down-- I may have been able to do that and used the fiber as a driveable stylet.
No way nebs and topical work in this pt.
Interesting-- I wouldn't have thought that the nebs/topical lidocaine would work if there was blood in the field.
I have done DLs with patients sitting up from the side of the bed. Not often, but was taught that by an old school doc for whatever reason. Comes in handy occasionally. Rarely really.Sorry, not upside down. Just sitting up. Kinda upside down to you.
I'm going to give you the benefit of the doubt that you're not just being argumentative in this caseAnd how would you discern anxiety/pain from progressing hemorrhagic shock in this case?
Blind nasal anyone? Why has no one mentioned this? One of the CRNAs used to love doing this when airways were difficult and she had pretty good success.
I'm going to give you the benefit of the doubt that you're not just being argumentative in this case
Not only is tachycardia a non-specific sign, even in the classical trauma teaching it's one of the later signs of hemmorhagic shock. I'd expect it to be coupled with altered mental status, hypoxia from poor V/Q mismatch, significantly low BP (think systolic in the 60s and 70s). Cool and clammy is one of the best and most underrated signs out there. When you see enough of these traumas you get the feel between the one who's getting ready to crump and the one that is just recovering from the literal shock of what just happened. The GSW that can't swear at you is the one you worry about. This kid obviously tolerated an AFOI while leaning forward and following instructions. He's far away from crumping.
Also this may be just my opinion, but while people can die from stupid induction doses, it's much more often poor resuscitation and a lack of vasopressor that does them in. Induce with whatever agent you want, but if you put a guy on PPV who's absolutely depleted without a pressor and fluids nearby they're going to code. It's not the white stuff that kills them, it's the lack of purple.
I don't think of a young guy who's hemorrhaged to a heart rate of 120 as typically being significantly altered or hypotensive. The "classical teaching" tables I'm familiar with wouldn't typically either. Don't have a boatload of experience here though. Agree with your latter point
Maybe, but the injury sounds way lateral. I was thinking of topicalizing the nose myself, use a little versed, get tube in nose, turn a little/a lot lateral on the bleeding side, get someone to really suction orally and then sedate with ketamine to keep breathing and drive the tube in.The risk is that it may stir up more bleeding or make the injury worse.
Right. I don't see how we're disagreeing. The question is what would you use other than heart rate to identify a crashing hemorrhagic patient. The OP's case is more like your average OR neck dissection than the carotid blowout. A skilled physician can identify the difference and tailor their plan accordingly.Yes I'm familiar with that table. 120 is right between II and III and a younger guy is going to be more prone to augmenting their SVR to keep their BP up
One of my thoughts reading the stem was topicalization of the nares and as much of the posterior oropharynx as possible, insert a nasal tube 80-90% of the way, put the fiber though the tube, go though cords, and drive it the rest of the way homeMaybe, but the injury sounds way lateral. I was thinking of topicalizing the nose myself, use a little versed, get tube in nose, turn a little/a lot lateral on the bleeding side, get someone to really suction orally and then sedate with ketamine to keep breathing and drive the tube in.
Surprised no one else brought that up.
Right. I don't see how we're disagreeing. The question is what would you use other than heart rate to identify a crashing hemorrhagic patient. The OP's case is more like your average OR neck dissection than the carotid blowout. A skilled physician can identify the difference and tailor their plan accordingly.
I would have no problem with the patient going to the OR with anesthesia and ENT or trauma. Very reasonable answer. There’s a lot of reasonable choices here. I just think the “step aside lowly ER doc” attitude doesn’t help anyone.
Yes, I get worried. And the comments above are offensive. Have you not seen Ricky Bobby? Saying “no offense” before an offensive stament doesn’t make it not offensive. You don’t know know our average day or workflow. Spending a couple weeks in the ED as a med stud or resident isn’t a decent sample size. Further, I wasn’t talking crap, I was just pointing out there is a huge difference in anesthesiologists. We rotate trauma airways with anesthesia. I’ve seen more than one patient that was a little more tachy than I like get a big slug of prop then code by some CA2/CA3 who was too big for their britches. I generally only see attending anesthesiologists when patients crump in pacu (sometimes my patients board there) - let’s just say there seem to variable competency levels.
As far as my plan goes, I really wish I could see exactly where the holes are and see the patient (is he mega-fat/does he have a neck) First thing I would do is 1) mark the neck 2) give some product and 50 mcg fent 3) gather supplies and 4) talk him down. I have no idea how they have an EBL on someone who was shot outside the hospital, so I don’t believe that, especially given his vitals. I think you give this guy a big dose of anything and he codes. I would give the patient a yanker and ask them to suction their pharnyx as much as possible if he’s agreeable. I agree, this is urgent/emergent, but this isn’t push drugs and go since he’s not dying in front of you. I think from there you have a few options. If the wound is high end and the surgical resident is providing actual tamponade and you can fit a blade in the mouth, I think RSI isn’t crazy. My biggest concern with RSI here is that you aren’t going to be able to BVM if not immediately intubated, but that’s why you have the neck marked. Honestly, I’d consider having him hold a cmac blade if he could and taking a look at what I see with the bronchoscope.
Oh god here we go again. Can’t we all just acknowledge that there are good ER docs and bad ER docs- and good anesthesiologists and bad anesthesiologists, but *ON AVERAGE* the specialty which does airways, simple and not so simple, multiple times per day for years on end, writes books about airways, holds conferences on airways, who’s at the forefront of advanced airway device development, is, again, *ON AVERAGE*, going to better in a scenario like this?
Oh god here we go again. Can’t we all just acknowledge that there are good ER docs and bad ER docs- and good anesthesiologists and bad anesthesiologists, but *ON AVERAGE* the specialty which does airways, simple and not so simple, multiple times per day for years on end, writes books about airways, holds conferences on airways, who’s at the forefront of advanced airway device development, is, again, *ON AVERAGE*, going to better in a scenario like this?
Indeed, there are also a fair number of EM and CCM guys who put on those conferences and it’s fair to describe them as airway experts. But the skill gap between them and the EM and CCM folks who attend their conferences looks like the Pacific Ocean compared to the skill gap between them and the average anesthesiologist who has a varied, moderate to high acuity practice.
Nope, you got is twisted. That was the EM/CCM doc who said that. Not Ronin.Maybe we're just talking past each other. Got the impression you were saying this patient would be hypotensive and significsntly altered if they had a HR of 120 from hemorrhage, think it'd be likely theyd just be clammy with a narrow PP. Agree with your overarching point
I didn't see that either, but maybe I missed it? I didn't see where this turned into EM versus Anesthesia until he/she (EM) guy said it was so. I think it's offensive to them because they are also trained to think "they" are the airway experts.No one said that. You're simply not equivalent at airway skills. I don't know why that is offensive to so many EM physicians.
Not if the surgeon is doing his or her job and putting pressure where the bleeder is.What's the concern of vigorous coughing in dislodging a clot here from thr gsw?
I didn't see that either, but maybe I missed it? I didn't see where this turned into EM versus Anesthesia until he/she (EM) guy said it was so. I think it's offensive to them because they are also trained to think "they" are the airway experts.
Pound for pound, we do A LOT MORE AIRWAY TOTAL than they. However, there's gotta be something to be said about the fact that they probably do more TRAUMATIC airways than we.
Agreed. Can you clarify if you are still a resident or attending though?The EM and anesthesia personalities and culture are very different. I personally don't like the stereotypical EM personality "I'm so cool and so bada**". They seem to attract those adrenaline junkies and they wanna do everything. Anesthesiologists honestly wanna do the least as possible lol. We make things look pretty easy most of the times. But I do have to admit, I have a lot of respect for the EM as a specialty. I have learned a lot from Levitan (who is EM trained) and EMCrit/Pulmcrit websites. I think anesthesiologists are experts at airways of course but it's true that EM will see more traumatic airways but in general, anesthesiologists see much more variety of airways. Even in the world of ENT, they are great at the surgical airway of course and FOB, but they aren't comfortable in general knowing how to safely handle a critically ill patient. That's why they are the surgical airway experts, and anesthesiologists are the non-invasive experts.
Agreed. Can you clarify if you are still a resident or attending though?
I know I want to do the leastest and get paid the mostest!! Who's with me?
Yes, I get worried. And the comments above are offensive. Have you not seen Ricky Bobby? Saying “no offense” before an offensive stament doesn’t make it not offensive. You don’t know know our average day or workflow. Spending a couple weeks in the ED as a med stud or resident isn’t a decent sample size. Further, I wasn’t talking crap, I was just pointing out there is a huge difference in anesthesiologists. We rotate trauma airways with anesthesia. I’ve seen more than one patient that was a little more tachy than I like get a big slug of prop then code by some CA2/CA3 who was too big for their britches. I generally only see attending anesthesiologists when patients crump in pacu (sometimes my patients board there) - let’s just say there seem to variable competency levels.
As far as my plan goes, I really wish I could see exactly where the holes are and see the patient (is he mega-fat/does he have a neck) First thing I would do is 1) mark the neck 2) give some product and 50 mcg fent 3) gather supplies and 4) talk him down. I have no idea how they have an EBL on someone who was shot outside the hospital, so I don’t believe that, especially given his vitals. I think you give this guy a big dose of anything and he codes. I would give the patient a yanker and ask them to suction their pharnyx as much as possible if he’s agreeable. I agree, this is urgent/emergent, but this isn’t push drugs and go since he’s not dying in front of you. I think from there you have a few options. If the wound is high end and the surgical resident is providing actual tamponade and you can fit a blade in the mouth, I think RSI isn’t crazy. My biggest concern with RSI here is that you aren’t going to be able to BVM if not immediately intubated, but that’s why you have the neck marked. Honestly, I’d consider having him hold a cmac blade if he could and taking a look at what I see with the bronchoscope.
I prefer to use O2 over suction for FOI, just remember to stop blowing the O2 when you get to the cords or you risk pneumothorax.One of my attendings also had the good suggestion to use blow-by O2 out of the fiberscope to clear blood/secretions. I hadn't thought of this either.
That is nonsense. A healthy 19 year old presenting with trauma is not going to have an adrenal crisis from etomidate and if he did hydrocortisone is relatively harmless when given in short duration. Best argument exists in sepsis however bad sepsis patients are probably going to end up on stress dose hydrocortisone anyways so not really seeing a negative there either.Whatever. Whoever needs to feel expert on something, go home, close the door and exhibit your expertise. This arrogance on patients’ fate is unacceptable to me.
And also this etomidate thing is so ****ing ridiculous. U already hand pts to icu in a disadvantage. Show some love to their adrenals. They might save them at the end.
Just remember propofol + phenylephrine equals etomidate
You guys have a lot of good insights. I definitely did not mean for this to become an Anesthesia vs. EM thread.
My takeaways are that I was probably right to not sedate this guy. Whether I should have called for an in-OR awake trach is something I'll consider in the future. I figured I got a free look with an AFOI before having to go down the surgical airway route.
One of my attendings also had the good suggestion to use blow-by O2 out of the fiberscope to clear blood/secretions. I hadn't thought of this either.
Really? Let’s then start doing all our inductions with etomidate!!! There is a reason we don’t. Before jumping into calling statements as nonsense, read the shortest version I can quote for you (since you are quite impulsive) “the butterfly effect of etomidate”. Adrenal crisis just FYI can develop in various settings, not only sepsis. and also steroid are not as harmless as you think.That is nonsense. A healthy 19 year old presenting with trauma is not going to have an adrenal crisis from etomidate and if he did hydrocortisone is relatively harmless when given in short duration. Best argument exists in sepsis however bad sepsis patients are probably going to end up on stress dose hydrocortisone anyways so not really seeing a negative there either.
How many ICU patients have you taken care of that got etomidate inductions? Speechless indeed maybe take your own advice about expertise...Really? Let’s then start doing all our inductions with etomidate!!! There is a reason we don’t. Before jumping into calling statements as nonsense, read the shortest version I can quote for you (since you are quite impulsive) “the butterfly effect of etomidate”. Adrenal crisis just FYI can develop in various settings, not only sepsis. and also steroid are not as harmless as you think.
Speechless.
Almost every pt that arrives in ICU straight from ED intubated has received etomidate. Sometimes, they get ketamine and together with that a seizure lolHow many ICU patients have you taken care of that got etomidate inductions? Speechless indeed maybe take your own advice about expertise...
You think ketamine causes seizures too? 🙁Almost every pt that arrives in ICU straight from ED intubated has received etomidate. Sometimes, they get ketamine and together with that a seizure lol
I’m all about personalized care... and each patient is different and indeed a very very small minority might qualify for some etomidate or to state it better does not qualify for propofol (even in cardiac cases we rarely use etomidate to your surprise)...however, in the ED, every pt is induced the same way...with etomidate (and this is not an exaggeration). This is exactly what I wanted to emphasize, that not everyone needs etomidate.You think ketamine causes seizures too? 🙁
I think you might be overemphasizing small effects here in the larger picture of disease. A horribly shocked patient (which is definitely not present in this case) has a very narrow therapeutic window with induction (assuming they are stable enough to even get an induction agent). Whipping out propofol and phenylephrine for someone in, say, severe acute right heart failure from a PE is not a good move compared to ketamine or etomidate. I have yet to see any compelling evidence that etomidate does anything that impacts overall care in the ICU (including the paper you quoted which is intimating at possible effects but is relying on retrospective data analysis and all the cases were based on OR inductions and clearly the effect size is so small they need massive samples to find it).
CCM has a a huge amount of gray zone when it comes to data which is where clinical expertise comes in. Maybe in anesthesia literature there is some kind of outcomes data (I am not familiar with this) but in CCM literature there really is not compelling evidence that etomidate is going to make a patient worse so I would refrain from claiming you have the holy grail of 'data' on your side.
Novel but hear me out. 20ketamine at a time, then shove in an lma awake ish. That can semi replace the tamponading finger plus hopefully divert the blood away from the airway to give you 1 shot at FOB thru the lma?Created a throwaway account for this, because I've already asked for input from several people at my institution and it would be pretty easy to ID me:
Carrying the airway/trauma pager earlier this week. Get a page about "Level 1 trauma, GSW". I go down to the ED and I see dozens of people around the trauma bay, and a teenage male sitting up in a stretcher, blood pouring from his mouth. He has a GSW that entered in his R tonsil and exited the R external auditory canal. The trauma resident has a fistful of kerlix in the guy's mouth and is holding pressure to the R side of his oropharynx. She says "I have a pulsating artery just under my finger". He's apparently lost at least 400cc so far. They just gave 1U and are hanging another. The kid looks panicked but is able to nod yes/no.
The kid's vitals are as follows: HR 125, BP 98/60, RR 30, SpO2 98%. The trauma attending says "anesthesia, you're doing this one".
Discuss.
I honestly don't think I've ever given more than 20-25mg, and that was to a stable patient coming to the OR for a scheduled case.What I don't get is why the ED guys give 40 mg of etomidate.
Data is fluid and always changing. What’s enAlso I am talking with data, you are talking with personal impressions. I’m not claiming expertise on anything. The data speaks for itself.
The nurses at my last gig would always grow up 40 of Etomidate and I would always ask them who in the world gives 40 mg of Etomidate? And the answer would be “you’d be surprised.” That place was scary AF.I honestly don't think I've ever given more than 20-25mg, and that was to a stable patient coming to the OR for a scheduled case.