Archive for the ‘resus’ Category

Face Mask Capnography

December 28th, 2015
by reuben in resus

Guest post by Terrance McGovern End-tidal capnography is frequently used in the ED for monitoring patients at risk for hypoventilation.  Some departments stock the luxury oral/nasal sampling devices, but many of us have to make due with a nasal-only apparatus or fashion our own using a nasal cannula; these will not capture CO2 exhaled from the mouth. You can easily use a conventional face mask to build a capnometer that will continuously sample nasal and oral exhaled breaths, and provide supplemental oxygen.    If you use a non-rebreather mask with both exhalation valves activated, you must keep the reservoir insufflated with oxygen. To deactivate the exhalation valves, peel off the rubber gasket pictured most prominently in step 4. If you provide high-flow oxygen, this will dilute the exhaled CO2 and the ETCO2 number will be artificially low, but the waveform is intact–if the wave amplitude is too small, change the monitor scale from max of 50 (default on most monitors) to max of 20. Thanks to Brendan Milliner for his assistance/face.   addendum: similar setup described by an obscure author in the air medical journal.

  In acrobat format. Thanks to pandrus for his assistance.

  Ten minute screencast describing an expanded ABCs mnemonic. Mobile phone optimized cheat sheet at Slides. Audio. Resus Room pic.

The Usual State of Readiness

September 26th, 2012
by reuben in heuristic, resus

  Emergency providers are routinely called upon to react to complex scenarios that demand specific life-saving maneuvers, immediately and without warning.  The most important impediment to performing well in these situations is your own catecholamines, and the most important catecholamine reduction strategy is preparation. The extent to which you are prepared to immediately react is your usual state of readiness, and it has two parts: cognitive and material. Cognitive readiness requires that you consider emergency scenarios and decide on a plan. This starts with a textbook (by textbook I of course mean the internet) and reading what others think you should do in a given emergency scenario. The hard part of cognitive readiness is keeping up with the endlessly changing, endlessly disagreeing opinions, and deciding how to shape them into a plan that you like and that works for you in your environment. Logistics are key. As medical knowledge expands forever faster, perhaps the most important knowledge of all is knowing what you need to know, and knowing what you can look up. This is not an either/or so much as a spectrum of how close information needs to be to your brain. There are plans that have to live in your brain (management of a completely obstructing airway foreign body), facts that you can take 30 seconds to look up (weight-based dose of atropine), and lists that you can review at your desk (the differential diagnosis of anisocoria). Memory fails when catecholamines are high; planning for emergency scenarios involves the development and deployment of…

This patient suffered a brady-asystolic arrest and a transvenous pacer was placed in the emergency department. We are accustomed to relying on the monitor’s ECG tracing to determine heart rate; however, a good pulse oximeter waveform better reflects the number of perfusing beats. Note the heart rate, as measured by the pulse ox, is reported in purple in the upper-right corner of the monitor. At this point we had achieved electrical capture but not mechanical capture. Watching the pulse oximetry graph is a slick way to guide pacemaker insertion. Cardiac sonography and placing a finger on the patient’s neck to assess the pulse are alternatives.   Strayer Transvenous Pacemaker Instruction Sheet  

Quick Epinephrine Drip

November 26th, 2009
by reuben in resus

I take a milligram of crash cart epi, just because it’s the most available and already in a syringe, and put it into a 1 liter bag of NS. Attach to IV and titrate to effect using the knob. If the patient has a full or mostly-full bag of IVNS already hanging, I’ll just grab the crash cart epi and dump it in. Nothing could be faster. 1 mg epinephrine in 1000cc NS = 1 microgram/cc 20 drops/cc therefore 2 drops per second = 6 mcg/min

standard pink IV: 20 gauge (.8 mm) x 30 mm angiocath max flow rate = 60 ml / minute standard green IV: 18 gauge (1 mm) x 30 mm angiocath max flow rate = 105 ml / minute standard grey IV: 16 gauge (1.3 mm) x 30 mm angiocath max flow rate = 220 ml/min procedural IV: 18 gauge x 64 mm angiocath max flow rate = 85 ml/min medial (blue) & proximal (white) lumen of triple lumen catheter: 18 gauge x 190 / 180 mm max flow rate = 26 ml/min distal (brown) lumen of triple lumen catheter: 16 gauge x 200 mm max flow rate = 52 ml/min cordis / introducer: 8.5 french (2.8 mm) x 100 mm max flow rate = 126 ml / minute max flow rate with pressure bag @ 300 mmHg: 333 ml / minute   from ETM course large bore IV access showdown                     from Traylor 2016 ACEP Abstract