Massive Hemorrhage Post-Tonsillectomy

The initial emergency medicine management of post-tonsillectomy bleeding

Case

A ten year old boy presents with significant bleeding from his mouth and nose. He is learning forward, and although blood is rapidly pouring onto the stretcher, he is able to tell you his name. Two very anxious appearing parents are at the bedside, and are able to tell you that he had a routine tonsillectomy performed 5 days ago…

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Respiratory distress in the patient with a tracheostomy (update)

A summary of the emergency medicine approach to respiratory distress in the patient with a tracheostomy

This is an update of a previous version of this post. I am reposting to coincide with the release of a new textbook that I am pretty excited about. The textbook is the Resuscitation Crisis Manual. It provides very succinct action scripts for the major emergencies that we see. It is exactly the textbook that I always wanted in residency, but didn’t exist. The absence of this kind of resource was exactly the reason that I started First10EM. (Perhaps, in the future, Scott can just keep me up to date on his projects. If I had just waited a couple years, I could have had the textbook without feeling like I had to write it by myself.) I wrote the “Tracheostomy Emergencies” chapter of the book – hence the decision to repost this topic. (I guess I should note that I don’t get anything for writing that chapter, so I don’t have any financial conflicts of interest – just intellectual biases.)

If you want to hear more about the book, check out this EMCrit podcast.

Case

A 45 year old man, well known to your department because of a prior anoxic brain injury and multiple complications including a permanent tracheostomy, is brought in by ambulance from home in respiratory distress. You know from prior conversations with the family that the patient is to receive full, aggressive medical management. He is using every accessory muscle that you can see, his respiratory rate is 55, and his oxygen saturation is 87% on room air…

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Guidelines on intubation in critically ill patients

Some key take home points from a new guidelines on airway management in critically ill patients

Just as I set the last blog post in the airway series to post, a fantastic guideline was published on intubation in critically ill adult patients. It covers most of the content I tried to cover in those posts, and probably does a much better job. I recommend that everyone take the time to read it. I have already covered a lot of this information in the airway series, but as a way of reinforcing the lessons from those posts, I thought I would go through my personal takeaways from this document.

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Emergency Airway Management Part 5: Post intubation care

A guide to managing patients in the immediate post-intubation period

Case

A 55-year-old man was found unconscious in the bathroom by his family. He has a GCS of 7. His vital signs on arrival are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. After using basic airway maneuvers to temporarily stabilize his airway, you were able to take the time to appropriately resuscitate and pre-oxygenate him, prior to proceeding with intubation. You pass the tube easily on the first attempt. Looking around the room for someone to high-five, you realize your team is waiting for your instructions for the ongoing care of this sick patient…

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Emergency Airway Management Part 4: Cricothyroidotomy (surgical front of neck access)

An approach to managing the emergency department patient in a can’t intubate can’t oxygenate scenario

Case

A 55 year old man was found unconscious in the bathroom by his family. After appropriate resuscitation and pre-oxygenation, you determine that there are no major predictors of difficulty, and so proceed with RSI. On 2 attempts at laryngoscopy, both direct and video, you cannot visualize the cords. The LMA won’t sit properly, and now his oxygen saturation is 70% despite your best attempt at bag valve mask ventilation…

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Emergency Airway Management Part 3: Intubation – the procedure

An approach to intubation in the emergency department

Case

A 55 year old man was found unconscious in the bathroom by his family. He has a GCS of 7. His vital signs on arrival are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. After using basic airway maneuvers to temporarily stabilize his airway, you were able to take the time to appropriately resuscitate and pre-oxygenate him. His vital signs are now a heart rate of 105, a blood pressure of 122/77, a respiratory rate of 16, and an oxygen saturation of 100% with a non-rebreather set at flush rate and nasal prongs at 15 L/min. However, he remains unconscious and you think it is now time to proceed with intubation…

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Emergency Airway Management Part 2: Is the patient ready for intubation?

An approach to managing important pre-intubation physiology

Case

A 55 year old man was found unconscious in the bathroom by his family. He has a GCS of 7. His vital signs on arrival are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. Although he was originally making sonorous noises, after elevating the head of the bed to 30 degrees, inserting a nasopharyngeal airway, and applying a jaw thrust, he is breathing quietly at 23 breaths a minutes, and his oxygen saturation has climbed to 92% with facemask oxygen…

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