Carepoint Journal Club- Neurology
Emergency Medical Minute
Carepoint Journal Club is a quarterly series with discussions about a medical topic, brought to you by Carepoint's Emergency Physicians.
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Podcast 1009: Prevention for Recurrent UTI
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: UTIs are commonly seen in older women We often see them taking long-term prophylactic antibiotics because of common recurrence. Around 20-30% of older women who develop a UTI have a recurrence due to either diagnostic failure, treatment failure or non-compliance with treatment. UTI signs and symptoms Burning sensation when urinating Strong urge to urinate Urinating often and passing small amounts of urine. Pelvic pain There are currently more guidelines and studies on treatments to prevent these...
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Podcast 1008: Acupuncture for Low Back Pain in Older Adults
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Back pain is a common presenting complaint in the emergency department. Challenges arise when tailoring care to elderly populations using standard medical therapy: Muscle relaxants carry the risk of CNS depression or anticholinergic effects such as urinary retention and confusion. Pain medications such as opiates have side effects including constipation, respiratory depression, and hypotension. NSAIDs carry a risk of GI bleeding and worsening kidney function with chronic use. A randomized clinical trial assessing the effects...
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Podcast 1007: Caffeine Pharmacology
Emergency Medical Minute
Contributor: Travis Barlock, MD Educational Pearls: Caffeine Geography and Types: Caffeine is found throughout the world and has evolved independently in various plants that are not evolutionarily related through direct lineage, but rather demonstrate convergent evolution (i.e. different species evolve the same traits). These plants use caffeine as an insecticide. Examples of caffeine sources include coffee, tea, yerba-mate, guaraná, cacao, and yaupon holly. Roughly 85% of Americans are estimated to consume caffeine daily. Caffeine Pharmacology in...
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Podcast 1006: Cannabinoid Pharmacology
Emergency Medical Minute
Contributor: Travis Barlock, MD Educational Pearls: Endocannabinoid System: THC binds CB1 and CB2 receptors in neurons and immune cells Δ9-Tetrahydrocannabinol (THC) is the main psychoactive compound in cannabis CB1 and CB2 receptors typically bind endogenously-produced 2-arachidonoylglycerol (2-AG) and anandamide (AEA) to regulate pain, stress, and inflammation THC similarly binds CB1 and CB2, leading to the cannabinoid high: euphoria, paranoia, anxiety, analgesia, anti-inflammation, and appetite, among a variety of others Ingestion via edibles, vice inhalation via smoking,...
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Podcast 1005: Balanced Fluid vs Normal Saline in Pediatric Patients
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: There has long been many questions about which IV fluid is best for ED resuscitation Multiple adult studies have shown no clear benefit of balanced fluid vs normal saline A large pediatric randomized clinical trial published in April compared balanced fluid vs normal saline in children with septic shock The study included about 9,000 patients from 47 emergency departments in five countries Patients with septic shock were randomized to receive either balanced fluid or normal saline The primary outcome was adverse kidney event...
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Carepoint Journal Club: Occlusion Myocardial Infarction
Emergency Medical Minute
Carepoint Journal Club is a quarterly series with discussions about a medical topic, brought to you by Carepoint's Emergency Physicians.
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Podcast 1004: Sinus Arrest Post TAVR
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: Conduction abnormalities are a common and clinically significant complication in patients who undergo transcatheter aortic valve replacement (TAVR) Clinical Features The most common abnormalities include high grade AV block and new onset LBBB Due to the close proximity of the aortic annulus to the AV node and His-Purkinje system More common in males, the elderly, and those with pre-existing conduction disease (RBBB or LBBB) Sinus pauses and sinus arrest are a rare post-TAVR rhythm disturbances Temporary...
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Podcast 1003: Nasal Intubation
Emergency Medical Minute
Contributor: Alec Coston, MD Educational Pearls: What are nasal intubations and when do we use them? Nasal intubations function similarly to oral intubations with the end goal of passing an endotracheal tube (ETT) through vocal cords and into the trachea to allow for a patent and secure airway, but differ in the main access point for the ETT (nare v.s. mouth). Nasal Intubations are seldom preferred to oral intubations as they carry risk for inducing bleeding from trauma to the nasal passages. Indications for nasal intubations include: Anatomical abnormalities that may make...
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Podcast 1002: Elder Agitation
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: What are the common causes of agitation in the elderly? Baseline dementia causing a behavioral disturbance Delirium precipitated by an acute medical problem such as a UTI, pneumonia, overdose/side effect of home medications, urinary retention, constipation, pain, hypoxia, electrolyte abnormality, etc. Exacerbation of a primary psychotic condition such as schizophrenia or bipolar disorder. What environmental changes can help reduce agitation? Maintain a quiet, calm, uncluttered environment Dim the lights Ensure the patient has their glasses,...
info_outlineContributor: Alec Coston, MD
Educational Pearls:
What are nasal intubations and when do we use them?
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Nasal intubations function similarly to oral intubations with the end goal of passing an endotracheal tube (ETT) through vocal cords and into the trachea to allow for a patent and secure airway, but differ in the main access point for the ETT (nare v.s. mouth).
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Nasal Intubations are seldom preferred to oral intubations as they carry risk for inducing bleeding from trauma to the nasal passages.
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Indications for nasal intubations include:
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Anatomical abnormalities that may make access through the mouth difficult (i.e. tumors, macroglossia, or rare dental hardware that clenches the jaw shut).
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Physiological states such as severe angioedema.
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Nasal intubations are often done with the patient awake and could be advantageous if the patient is presenting in a severely hypoxic state such that prolonged hypoxia in a traditional RSI protocol may be detrimental.
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A 2023 retrospective analysis in Germany found that nasal intubations were associated with requiring less sedation than oral intubations and had more spontaneous breathing during hospitalization than oral intubations.
How is a nasal intubation performed?
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Consider the use of an anxiolytic medication such as versed to calm the patient down but not fully sedate them.
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If there is adequate time without immediate patient compromise, consider glycopyrrolate to reduce airway secretions and dry up the mucous membranes.
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Consider the use of Afrin or other local vasoconstrictor in target nare to minimize epistaxis.
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Use 5% lidocaine ointment and lubricate an NPA and place it into the target nare. This will allow for local anesthesia as well as help to open up the nare slightly more.
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Take 5% lidocaine ointment and place it on a tongue depressor and move it around the back of the tongue, allowing it to further anesthetize the oropharynx.
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Remove the NPA and atomize/nebulize 4% lidocaine liquid into the nare and into the oropharynx for further anesthesia.
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Insert the ETT without the bronchoscope through the nare and allow it to pass about 10 cm until visible in the oropharynx. This allows for a “clean” plastic tunnel to pass the bronchoscope through.
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Advance both the ETT and bronchoscope, spraying lidocaine through the bronchoscope while advancing to allow for continued numbing.
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Pass the ETT through the cords and inflate.
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At this point, stronger sedation medications such as ketamine and propofol may be considered but the use of a paralytic like succinylcholine and rocuronium may not be needed to allow the patient to maintain their own negative pressure ventilation.
Which nare is the best to go through?
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Most patients will have their right nare be the best (away from the septal deviation) according to a meta-analysis by Tan et al.
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The right nare was generally associated with less epistaxis and lower intubation times.
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However, do not always default to the right nare, and test which nare is more patent by occluding one nare at a time and assessing which one is less resonant (less resonant = more patent).
Key Takeaway?
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Nasal intubations are rarer than oral intubations and can be more technically difficult, but may offer advantages in patients with difficult oral airways, but should never be first line.
References:
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Grensemann J, Gilmour S, Tariparast PA, Petzoldt M, Kluge S. Comparison of nasotracheal versus orotracheal intubation for sedation, assisted spontaneous breathing, mobilization, and outcome in critically ill patients: an exploratory retrospective analysis. Sci Rep. 2023;13:12616. doi:10.1038/s41598-023-39768-1
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Tan YL, Wu ZH, Zhao BJ, Ni YH, Dong YC. For nasotracheal intubation, which nostril results in less epistaxis: right or left?: A systematic review and meta-analysis. Eur J Anaesthesiol. 2021;38(11):1180-1186. doi:10.1097/EJA.0000000000001462
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Holzapfel L. Nasal vs oral intubation. Minerva Anestesiol. 2003;69(5):348-352.
Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan & Ahmed Abdel-Hafiz, NREMT-P
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