PHARM Podcast 26 – Australian Emergency Perspective July 2012 with Dr Amit Maini and Dr Andy Buck
Andy and Amit in the resus bay!
Tune in to hear Amit, Andy and I discuss current affairs in EM and Critical Care for July 2012!
Hi folks!
This episode with Dr Amit Maini and Dr Andy Buck, Australian Emergency Physicians doing locum work in the TopEnd of Australia, Darwin, in the Northern Territory.
Check out Amit’s own superlative EM/CC blog site called ED Trauma Critical Care .
Andy has his excellent teaching website for Emergency medicine. You must add it to your online reading list!
On this episode we discuss some hot EM/CC topics currently being debated on the blogsphere and twitterverse!
1.The Crash Airway – survival tips and hard learnt lessons from the resuscitation room
2.Chest pain assessment Australian ED practice and possible role of CT coronary angiograms
FURTHER READING AND SHOW NOTE REFERENCES
Mr EmCrit, Dr Weingart delivers a great podcast on bougies and surgical cric preparedness
Dr Andy Buck wrote this awesome article on managing airways in obese patients!
My article I wrote in Australian Rural Doctor Magazine, June 2012 on Aeromedical Retrieval and importance of effective communication Aeromedical Retrieval article June 2012
Improving verbal communication in critical care medicine
Graded Assertiveness Scenarios exercise
CT coronary angiography for safe discharge of patients with possible acute coronary syndrome
Stay safe and enjoy the interview
Minh
Now on to the Podcast
Right Click and Choose Save-as to Download the Podcast.
Hi Minh,
The only thing to make clear about laryngeal fractures is a needle/surgical cric is not necessarily going to get you out of trouble. In fact the go to surgical airway is a tracheostomy in laryngeal fractures, an infinitely more difficult skill then the surgical cric we all talk about as our get of jail free card. Its interesting how difficult airway algorithms finish at surgical cricothyroidotomy but that is likely to fail in a laryngeal fracture. My choice would be an awake flexible fibreoptic intubation, however, this is a very challenging case. Anatomy in fractures is complex and difficult to negotiate distally. Just because you can view the glottic opening with a VL doesn’t mean the tube will pass as often the anatomical disruption is distal and hence my preference for flexible scope. The blood makes this case even more difficult and you need an anaesthetist at the top of their game. Use of the berman airway will make life easier and get you to the larynx and certainly reduce the amount of blood in your visual field. But a high expectation of failure should be maintained! Plan for failure, ENT surgeon would be my preference but not always logistically available. My plan B here (given my experience with tracheostomies on ICU) would be a 14g cannula well below the cricoid ideally between 2-3 tracheal rings. Use for oxygenation and then used for wire placement and seldinger technique for single dilator tracheostomy. Must emphasise my plan B is not ideal and an experienced surgeon is my preference. If all else fails do your best with scalpel, finger and bougie. Get lots of adrenaline into the subcutaneous tissues to help with the bleeding. To be honest a breathing patient with an upper airway injury (or more commonly experienced ludwig’s angina/FB in the airway/epiglotitis etc) is your friend so don’t paralyse them and force an uncontrolled action in the face of challenging anatomy. All of the above interventions can be done awake with local, and maybe sedation whether that be ketamine or sevoflurane (for skilled hands only).
Keep up the good work Minh!
Pete
thanks Peter. Nice commentary!
Awake tracheotomy a reasonable option in laryngeal injury, but not for faint hearted!
URGENT AWAKE TRACHEOTOMY FOR IMPENDING AIRWAY OBSTRUCTION
http://www.sciencedirect.com/science/article/pii/S0194599806035972
Great link!
Just shows in experienced hands how safe the awake surgical airway is. To have no long-term complications in so many cases is impressive!