Two cases are described in Pre-hospital Emergency Care of severely burned patients who were impossible to adequately ventilate after tracheal intubation until they underwent escharotomy by a pre-hospital physician.
The review that follows reminds us of some intersting escharotomy facts:
circumferential extremity burns can cause limb ischaemia
abdominal burns can cause elevated intra-abdominal pressure and ischemic bowel
neck burns can cause tracheal and jugular venous compression
chest burns can cause respiratory compromise
one previous study showed that chest and abdominal escharotomies significantly decreased intra-abdominal pressure, retention of carbon dioxide, and central venous and inferior vena caval pressures while significantly increasing serum oxygen concentration and systolic blood pressure.
escharotomies may be performed on multiple body parts, including the extremities, the digits, the chest, the abdomen, the neck, and the penis
neck escharotomy is a relatively simple procedure that involves an incision of the skin eschar longitudinally in the anterior midline from the chin to the sternal notch
although different ways of doing chest escharotomies have been described, in the two reported cases in this article the procedure only involved longitudinal incisions, with good immediate effect.
Of note, neither of the physicians concerned had seen or done an escharotomy before. I’m adding this to my list of life-saving surgical interventions that are technically straightforward to perform, cannot always wait for another specialist to do, and happen too rarely to train for in the traditional way (ie being taught on a patient under supervision prior to the first time you do one). Out-of-hospital chest escharotomy: a case series and procedure review Prehosp Emerg Care. 2010 Jul-Sep;14(3):349-54
A thorough review of the emergency medicine sedation literature showed there is only one reported case of pulmonary aspiration during emergency procedural sedation, among 4657 adult cases and 17 672 paediatric cases reviewed. The authors of the review remind us that the often (inappropriately in the ED) quoted American Society of Anesthesiology guidelines for fasting prior to general anaesthesia are based on questionable evidence, and there is high-level evidence that demonstrates no link between pulmonary aspiration and non-fasted patients. There is no reason to recommend routine fasting prior to procedural sedation in the majority of patients in the Emergency Department.
An accompanying editorial points out that like other systematic reviews, the methodological flaws of the studies examined are likely to have limited the conclusions of this review.
The review authors and the editorialist agree that despite the lack of evidence linking fasting status to aspiration, selected patients believed to be significantly more prone to aspiration may benefit from risk:benefit assessment prior to sedation.
Something I learned from reading the review: ‘ it is now recognised that asymptomatic aspiration of gastric contents occurs physiologically during normal sleep‘. How about that. Pre-procedural fasting in emergency sedation Emerg Med J. 2010 Apr;27(4):254-61
Hospitals and medical personnel performing high volumes of procedures demonstrate better patient outcomes and fewer adverse events. The relationship between rescuer experience and patient survival for out-of-hospital endotracheal intubation is unknown.
An American study analysing 3 statewide databases with 26,000 records aimed to determine the association between endotracheal intubation experience and patient survival.
In-the-field intubators were EMS paramedics, nurses, and physicians, although paramedics performed more than 94% of out-of-hospital tracheal intubations. Although all air medical rescuers may use neuromuscular- blockade-assisted (rapid sequence) tracheal intubation, select ground EMS units are allowed to use tracheal intubation facilitated by sedatives only; the rest are done ‘cold’.
Patients in cardiac arrest and medical nonarrest experienced increased odds of survival when intubated by rescuers with high procedural experience. In trauma patients, survival was not associated with rescuer experience.
The odds of survival for air medical trauma patients were almost twice that of other patients, which may be related to the use of neuromuscular- blocking agents by air medical crews, or due to more specialised critical care training. The authors suggest that rescuers should perform at least 4 to 12 annual tracheal intubations. Out-of-Hospital Endotracheal Intubation Experience and Patient Outcomes Ann Emerg Med. 2010 Jun;55(6):527-537
The Carotid RevascularizationEndarterectomy vs. Stenting Trial (CREST) compared the outcomes of carotid-artery stenting with those of carotid endarterectomyamong over 2500 patients with symptomatic or asymptomatic extracranial carotid stenosis.
The authors offer the following conclusions:
Stroke was more likely after carotid artery stenting.
Myocardial infarction was more likely after carotid endarterectomy, but the effect on the quality of life was less than the effect of stroke.
Younger patients had slightly fewer events after carotid-artery stenting than after carotid endarterectomy; older patients had fewer events after carotid endarterectomy.
The low absolute risk of recurrent stroke suggests that both carotid-artery stenting and carotid endarterectomy are clinically durable and may also reflect advances in medical therapy.
A case is reported of a stroke patient who aspirated his nasopharyngeal airway, resulting in coughing and desaturation. After iv propofol and topical anaesthesia to the oropharynx and hypopharynx, it was seen on laryngoscopy to be within the trachea but could not be retrieved with Magill forceps. Instead, his doctors inserted a well lubricated 14 Fr foley catheter through the lumen of the tube, inflated the balloon, and pulled it out. Retrieval of Aspirated Nasopharyngeal Airway Using Foley Catheter Anesth Analg. 2010 Apr;110(4):1245-6
In a randomised study of more than 1072 patients for emergency intubation using rapid sequence induction, single-use metal blades were associated with fewer failed first attempts and fewer poor grade laryngeal views than reusable metal blades. Improved illumination may be a factor. Comparison of Single-use and Reusable Metal Laryngoscope Blades for Orotracheal Intubation during Rapid Sequence Induction of Anesthesia Anesthesiology. 2010 Feb;112(2):325-32
Patients with symptomatic severe carotid artery stenosis do better with carotid endarterectomy than with medical therapy alone. Surgical complications such as bleeding and cranial nerve damage make the alternative strategy of carotid stenting attractive, but a new randomised trial of 1710 patients with over 50% stenosis and symptoms suggests otherwise.
In favour of stenting, there was one event of cranial nerve palsy in the stenting group compared with 45 in the endarterectomy group, and fewer haematomas of any severity in the stenting group than in the endarterectomy group (31 vs 50 events; p=0.0197).
However the incidence of stroke, death, or procedural myocardial infarction was 8.5% in the stenting group compared with 5.2% in the endarterectomy group (72 vs 44 events; HR 1.69, 1.16-2.45, p=0.006). Risks of any stroke (65 vs 35 events; HR 1.92, 1.27-2.89) and all-cause death (19 vs seven events; HR 2.76, 1.16-6.56) were higher in the stenting group than in the endarterectomy group. Three procedural myocardial infarctions were recorded in the stenting group, all of which were fatal, compared with four, all non-fatal, in the endarterectomy group.
The authors point out that longer term follow up remains to be looked at, but that carotid endarterectomy should remain the treatment of choice for symptomatic patients with severe carotid stenosis suitable for surgery. However most patients had no complications from either procedure and stenting is also likely to be better than no revascularisation in patients unwilling or unable to have surgery because of medical or anatomical contraindications. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial Lancet. 2010 Mar 20;375(9719):985-97
In a retrospective study of 45,284 penetrating trauma patients, unadjusted mortality was twice as high in the 4.3% of patients who underwent spine immobilisation, compared with those who were not immobilised.
An accompanying editorial comments: ‘The number needed to treat with spine immobilization to potentially benefit one penetrating trauma patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66.‘ Spine immobilization in penetrating trauma: more harm than good? J Trauma. 2010 Jan;68(1):115-20
A case is described of a 12 month old who completely obstructed her airway from an inhaled plastic ketchup container. As she did not improve with backslaps or chest thrusts her father, a physician, suctioned her airway using his own mouth (intermittently spitting out secretions) until the obstruction was relieved and the object removed. Something to think about if you’re at the end of your own child’s choking algorithm and you have no airway equipment with you. Maneuver for the recovery of a foreign body causing a complete airway obstruction: illustrative case. Pediatr Emerg Care. 2010 Jan;26(1):39-40
Medical students and junior doctors were successfully taught correct airway management positioning for intubation on a manikin when told to position the manikin in the best position to win a running race, where the chin wins the race. (The so-called ‘win with the chin’ position). This was superior to the traditional ‘sniff the morning air’ position. "Intubate Meee!!" Teaching airway management to novices: a simulator manikin study comparing the ‘sniffing position’ and ‘win with the chin’ analogies Br J Anaesth. 2010 Apr;104(4):496-500
