Case #7-1: Rapid Sequence Intubation (RSI) for Rookies and Reviewers

A 39M is BIBA, boarded and colored, with altered mental status.  He was found down at the bottom of a flight of stairs.  130/75, 92, 14, 99%, afebrile, GCS 12 (3 Eyes, Verbal 4, Motor 5), no focal neuro deficits.  He has a hematoma on his forehead.  All of a sudden, during your secondary survey, he sits up in bed and becomes combative but purposeless.  He's easily restrained with haldol.  Now what?

Web 2.0 Resources Used:
Life in the Fast Lane
EM Basic
Penultimate
EM Lyceum

I'm an intern, and have recently begun transition shifts in which I get first shot at all department intubations.  In order to handle situations like the one above, I needed to be prepared.

How did I prepare?

Chris Nickson recently updated his Own the Airway! tutorial on Life in the Fast Lane.  This is an amazing resource which teaches airway management by organizing free videos borrowed from other sites.  The format is very user friendly.

But, the LITFL resource is missing a key element in RSI - the drugs!

Steve Carroll's straightforward and useful EM Basic podcast on airway management served as a good introduction.  Before listening to the podcast, I took screenshots on my iPad of the shownotes, and pasted the pictures into a Penultimate notebook.  I wrote my own notes on top of the shownotes while I listened.

To learn more about RSI drugs, I read the EM Lyceum posts on RSI pharmacology.  EM Lyceum links you to the primary literature to be able to intelligently form opinions on controversial topics yourself.

EM Lyceum

I realized quickly that every Web 2.o resource above referenced the clasic text, Walls' Emergency Airway Management.  I ordered it from amazon, and read it cover to cover. 

"The patient might have a head bleed, he needs to be intubated, but we don't want to raise his ICP," I said.  We'll use a weight of about 80kgs: give him 120mg of lidocaine and 250mcg of fentanyl .  Then push 25mg of etomidate, and 120mg of sux, in that order," I said confidently. 

I intubated him, gave him another 50mcg of fentanyl and started him on a 2mg/min propofol drip.  He was then rushed off to CT.

- Case 7-2 will discuss rapidly accessible bedside RSI resources for your phone or tablet

Case #6 - Face Block

Case #6: Face Block

A 38M presents to the ED after getting hit in the face with a treebranch while riding a bike downhill through the woods.  The patient has multiple superficial lacerations on his forehead, maxilla, and on the pinna of the ear.  No LOC or neurological deficits. CT of the face shows no bony injuries.  Tetanus UTD.

Web 2.0 Resources used:
EMProcedures
MedScape Procedures

This guy basically needed his whole face anesthetized.  My attending suggested I do a number of blocks, many of which I had never done.  I opened my free Medscape App on my iPad and surfed through the various blocks under the anesthesia tab.  I use this app for all procedures that I either have never done before or those I need a refresher for.  For the various blocks, the app provides good photos of entry points and also gives good nerve distribution maps.

After the shift, I watched the series of videos on EMProcedures given by EM residents at Mt. Sinai.  Through video, I learned the blocks I would need to anesthetize the entire face.  I booked-marked the site on my iPad and my phone.  Now I can pull them up at any time if I want to use video rather than written word and photos.

Case # 5 - Late Night Urology Consult

A 65+ year old male with BPH had an abdominal surgery earlier that day.  After each of his last 3 surgeries he had developed urinary retention and went home with a Foley.  This time, he was sent home from the PACU without a Foley.  He presented to the ED with what looked like a soccer ball under his t-shirt.  He had not urinated since the operation.

Web 2.0 Resources used:

• UC Irvine iTunes U series on Ultrasound
• EM:RAP - December 2011
• Genius Scan
• Evernote

Foley attempts in our ED failed by a seasoned nurse, myself, the surgery intern, and finally by the chief surgery resident (who's service had done this guy's surgery and had pulled the intraoperative Foley).

The week before, I watched a lecture by the ultrasound director at UC Irvine, Dr. Christian Fox.  It was directed toward medical students, but I am a novice at ultrasonography, so it was perfect for me.  Dr. Fox said the bladder is like a box - so 3 dimensional measurements of W x Lx H will give you a pretty accurate reading.  He also told me that a bladder shouldn't hold much more than 1/2 L, so when I measured out 0.9 L, I was concerned.

I took out my Genius Scan app on my iPad, and snapped a picture of the bladder on the ultrasound screen, complete with measurements, and saved it to Evernote.

The patient was in pain, and he wouldn't take another Foley attempt unless it was by a urologist. Many of my co-interns dread making calls like this, but I was inspired. I had just listened to a very entertaining EM:RAP episode on testicular torsion given by Dr. Gary Tamkin and Dr. Mel Herbert.  They effectively remind us to be clear and unemotional with our consultants; tell them what you need. I sat down to page the urology consult at 2:50 AM.  As I picked up the phone I also pressed send on my iPad, and emailed the picture saved in Evernote to his email address.

"Are you seriously calling me to place a Foley?" he said.  "Tell surgery to do it."

- They already tried

"So get a senior to do it,"

- He already tried

"Why couldn't you get it in?"

- That's why I'm calling you.  I need you to tell me.

"Are you sure there's even urine in his bladder?

- Check your email

"What?"

- Check your email; I sent you a picture of his bladder with 900 cc of urine in it

"It's 2 AM!"

- The dashboard says you are on call

"I am!"

- Oh, good, I'll see you in a few,

[click]

I overheard the urologist telling the patient something about how the 16Fr is his 7 iron. I think that's a good thing, but I'm not sure; I hate golf.  Either way, the patient got his Foley, and it returned about 890 cc of urine.  Only off by 10cc - not bad.