Mount Sinai Emergency Medicine Ultrasound

As promised, here are selected references from today’s talk on Airway Management Mythology. Thanks to the organizers of the International Conference on Emergency Medicine (ICEM) for the invitation to speak.

Some of the topics discussed are supported by plenty of evidence (ie the use of RSI as an intubation technique), some were simply fun to discuss (holding your breath while intubating) and some remain quite reasonably controversial (the use of etomidate for RSI in sepsis).

I highly recommend visiting Dr. Reuben Strayer’s blog for a brief and enlightening discussion of the use of rocuronium for RSI. Also, Dr. Scott Weingart’s EMCrit blog and podcasts are an excellent source for ED critical care topics. Finally, The Airway Site contains links to key airway management references as well as information on the Difficult Airway Course.

Selected References:

• Farmery AD, Roe PG: A model to describe the rate of oxyhemoglobin desaturation during apnoea. Br J Anaesth 1996; 76:284-91
• Naguib et al. Optimal dose of succinylcholine revisited. Anesthesiology 2003; 99:1045-1049
• Bozeman et al. A comparison of rapid sequence intubation and etomidate-only intubation in the prehospital air medical setting. Prehosp Emerg Care: 2006; 10:8-13
• Sackles et al. Airway management in the emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med 1998; 31:325-332
• Li J et al. Complications of emergency intubation with and without paralysis. AJEM 1999: 17(2); 141-143
• Mallon WK et al. Rocuronium vs. succinylcholine in the emergency department: A critical appraisal. JEM 37(2); 183-188
• Strayer RJ. Rocuronium vs. succinylcholine revisited. JEM 2010 Apr 22. [Epub ahead of print]
• Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study, Lancet 369 (2007), pp. 920–926.
• Bobrow et al. Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest. Ann Emerg Med. 2009;54:656-662.
• Brimacombe JR and Berry JM. Cricoid pressure. Can J Anaesth. 1997 Apr;44(4):414-25

Bret Nelson and Mt. Sinai’s director of Disaster Preparedness and Prehospital Care, Kevin Chason, collaborated on this pilot study on use of Prehospital FAST and Aorta US which showed that paramedics can obtain and interpret these studies.

Visual Diagnosis Case from JEM.  Bret and Ted discuss a case of appendicitis confirmed with ultrasound after CT was not conclusive.

Bret Nelson recently filmed a webinar on critical care ultrasound at Gulfcoast Ultrasound Institute in Florida. He discussed evaluation of the hypotensive patient, incorporating Scott Weingart’s RUSH exam as well as other literature on acute assessment of the heart, IVC, FAST exam, and pleura.
Information on the webinar is available at Gulfcoast.

References for a variety of hypotension evaluations are included below, as well as a few screenshots from the webinar!

• UHP protocol
  • Rose JS et al,  Am J Emerg Med 2001 (PMID: 11447518)
• Trinity Protocol
  • Bahner D,  JDMS 2002
• RCT of ultrasound in hypotension
  • Jones AE et al, Crit Care Med 2004 (PMID: 15286547)
• FATE: Focused Assessed Transthoracic Echocardiography
  • Jensen et al, Eur J Anaesthesiol 2004 (PMID: 15595582)
• FEER: Focused Echocardiographic Evaluation in Resuscitation
  • Breitkreutz et al, Crit Care Med 2007 (PMID: 17446774)
• CAUSE: Cardiac Arrest Ultrasound Exam
  • Hernandez et al, Resuscitation 2008 (PMID: 17822831)
• RUSH: Rapid Ultrasound in Shock and Hypotension
  • Weingart et al, emCrit.org 2008, EMedHome 2009
• ACES: Abdominal and Cardiac Evaluation with Sonography in Shock
  • Atkinson et al, Emerg Med J 2009 (PMID: 19164614)
• RUSH: Rapid Ultrasound in Shock
  • Perera P et al, Emerg Med Clin N Am 2010 (PMID: 19945597)

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Bret Nelson returned to Singapore this month to join the faculty for a WINFOCUS introductory ultrasound course. Over fifty registrants from all over Singapore were in attendance, representing emergency medicine, critical care, surgery, internal medicine, anesthesia, and nephrology. Many thanks to Dr. Francis Lee, course director as well as Dr. Toh Hong Chuen who organized many of the course logistics.

More pics of the conference and Singapore after the break!

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