Podcast 553: Airway Management in the Hypoxic COVID-19 Patient (Recorded 4/3/20)
Release Date: 04/06/2020
Episode 926: Supraventricular Tachycardia
Emergency Medical Minute
Contributor: Taylor Lynch MD Supraventricular tachycardias (SVTs) arise above the bundle of His The term SVT includes AV nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), atrial tachycardia, atrial fibrillation, atrial flutter, and multifocal atrial tachycardia AVNRT is the most common form of SVT Paroxysmal Spontaneous or provoked by exertion, coffee, alcohol, or thyroid disease More common in women (3:1 women:men ratio) HR 160-240 Narrow complex with a normal QRS Unstable patients receive synchronized cardioversion at 0.5-1 J/kg ...
info_outline
Episode 925: Table Sugar for Tongue Entrapment
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Pediatric case study where the child’s tongue was stuck in the opening of a hard plastic drink lid Entrapment restricts circulation which causes fluid to build and the tongue becomes more edematous with time There is a risk of ischemia with prolonged entrapment Initially tried 2% viscous lidocaine for analgesia and lubricant The ER recognized that this mucosal, edematous tongue could benefit from the trick for ostomies and rectal prolapses → table sugar! Sugar granules absorb water which decreases tissue edema This option...
info_outline
Episode 924: Pregnancy Cold Remedies
Emergency Medical Minute
Contributor: Megan Hurley, MD Educational Pearls: Fevers Tylenol Up until 20 weeks NSAIDs are ok but after 20 weeks they are contraindicated Can limit the amount of amniotic fluid produced Can lead to growth restriction Can cause premature closure of the ductus arteriosus Cough Cough drops Humidifier Guafenesine and dextromethorphan (Mucinex) is not well studied but is probably ok with caution in certain circumstances such as post-tussive emesis causing poor PO intake and weight loss Congestion Flonase (Fluticasone nasal spray) Nasal rinses Humidifier 1st...
info_outline
Episode 923: Blunt Cerebrovascular Injury
Emergency Medical Minute
Contributor: Travis Barlock MD Educational Pearls: Assessment of head and neck vascular injury due to blunt trauma Symptomatic patients require screening head and neck CT angiography EAST guidelines include the following criteria for a screening CT angiography in blunt head trauma: Unexplained neurological deficits Arterial nosebleed GCS < 6 Petrous bone fracture Cervical spine fracture Any size fracture through the transverse foramen LeFort fractures type II or type III EAST guidelines include a grading scale for vascular injury: Grade I: Luminal irregularity...
info_outline
Episode 922: Chest Tube Irrigation
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Hemothorax: blood in the pleural cavity, most commonly due to chest trauma Treatment: thoracostomy tube for blood drainage helps to avoid clotting, scarring, and infection A recent study looked at patients with hemothorax who either received or did not receive thoracic irrigation with saline Evaluated incidence of secondary intervention, such as video-assisted thoracoscopic surgery (VATS), for persistent hemothorax Patients who received irrigation had a slight decrease in secondary intervention frequency Multi-center study -...
info_outline
Episode 921: Pediatric Hypoglycemia
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: When it comes to hypoglycemia, the age dictates possible causes Neonate: Hormonal deficiency Congenital Adrenal Hyperplasia (21-hydroxylase deficiency, 11β-hydroxylase deficiency) Primary or Secondary Adrenal Insufficiency leading to cortisol deficiency Hypopituitarism Inborn errors of metabolism Systemic infection (Under 30 days old should trigger a full infectious workup) Toddler Accidental ingestions Sulfonylureas such as glipizide or glyburide Older children Addison’s Disease (Hypocortisolism) ...
info_outline
Laboring Under Pressure Episode 3: Hypertensive Disorders of Pregnancy with Dr. Kiersten Williams
Emergency Medical Minute
Contributor: Kiersten Williams MD, Travis Barlock MD, Jeffrey Olson MS3 Show Pearls Hypertensive disorders of pregnancy are one of the leading causes of maternal mortality worldwide. Hypertension (HTN) complicates 2-8% of pregnancies The definition of HTN in pregnancy is a systolic >140 or diastolic >90, measured 4 hours apart There is a range of HTN disorders Chronic HTN which could have superimposed preeclampsia (preE) on top Gestational HTN in which there are no lab abnormalities PreE w/o severe features Protein in urine Urine protein >300 mg in 24 hours Urine...
info_outline
Episode 920: Pediatric Growth Estimates
Emergency Medical Minute
Contributor: Sean Fox, MD Educational Pearls: Newborns may lose up to 10% of their birth weight in the first week of life Weight loss is greatest in exclusively breastfed infants Should regain birth weight by age 2 weeks Newborns should gain an average of 30g (1 oz) per day in the first 3 months of life Some will gain more and some will gain less Infants double their birth weight by 6 months of life and triple their weight by 12 months A 1-year-old should weigh on average 10 kg (22 lbs) A 3-year-old should weigh on average 15 kg (33 lbs) 2-year-olds are between 10-15 kg...
info_outline
Episode 919: EKG Criteria for Adenosine
Emergency Medical Minute
Contributor: Travis Barlock, MD Educational Pearls: SVT: supraventricular tachycardia Pharmacotherapy for SVT includes drugs that block the AV node, such as adenosine EKG criteria before adenosine administration in SVT Regular rhythm Monomorphic: all QRS complexes are identical If the EKG is polymorphic, with QRS complexes displaying changing morphologies, it is unsafe to administer adenosine Adenosine can worsen polymorphic VTach and lead to VFib References Ganz, Leonard I., and Peter L. Friedman. “Supraventricular Tachycardia.” New England Journal of...
info_outline
Episode 918: Automated Blood Pressure Cuffs
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: How does an automated blood pressure cuff work? Automated blood pressure cuffs work differently than taking a manual blood pressure. While taking a manual blood pressure, one typically listens for Korotkoff sounds (turbulent flow) while slowly deflating the cuff. An automatic blood pressure cuff only senses the pressure in the cuff itself and specifically pays attention to oscillations in the pressure caused by when the pressure of the cuff is between the systolic (heart squeezing) and diastolic (heart relaxed) pressures. These...
info_outlineContributor: Dylan Luyten, MD
Educational pearls:
- Clinical management of COVID-19 is rapidly evolving, relying on case reports and clinical experience
- In just a month, the consensus around management of COVID patients with severe hypoxia has shifted from an early intubation strategy to other, non-invasive means
- Intubating early can quickly consume ventilator resources, require increased intensive care monitoring, and likely leads to longer hospital stays and once COVID patients are intubated, extubation can take days to weeks.
- In Italy, ventilator supplies were depleted leading to the use of helmet CPAP machines, which appeared to be effective in management of respiratory distress in COVID, though not available for use in the US
- Non-invasive ventilation such as CPAP/BiPAP is thought to increase risk to staff for infection via aerosolization, and has often been avoided in COVID patients
- High flow nasal cannulas appear to pose less of a risk of aerosolization of viral particles (especially when a surgical mask is placed over the patient’s nose, mouth and apparatus)
- Anecdotal evidence from NYC has shown success allowing conscious patients to maintain hypoxia on HFN, where they will self prone to help with lung recruitment, and seemingly do well despite persistent saturations in the 80s or less
- Hospitals around the country are moving away from the intubate early methodology in favor of high flow oxygen therapy as long as they are not having issues with work of breathing or other complications
- The pathophysiology of respiratory distress and hypoxia in COVID patients is evolving as well, and some presentations appear similar to disease processes such as high altitude pulmonary edema (HAPE) rather than acute respiratory distress syndrome (ARDS), in that patients are quite well appearing despite phenomenally low oximetry readings.
-
- These select patients appear to be excellent candidates for non-invasive means rather than an early intubation strategy
Editor’s note: do not take lightly that intubation is one of the highest risk aerosolization generating procedures, along with many peri-intubation procedures like suctioning, BVM, etc.
References
[1]. Sorbello, M. et al. The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice. Anaesthesia. 2020 Mar 27.
[2]. Giwa, AL. Desai A. Duca A. Novel 2019 coronavirus SARS-CoV-2 (COVID-19): An updated overview for emergency clinicians. Emerg Med Pract. 2020 May 1;22(5):1-28.
[3]. Ather B, Edemekong PF. Airborne Precautions. [Updated 2020 Feb 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan.
Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD
Photo Credit: New England Journal of Medicine