Bilateral Tension Pneumothorax: Harder To Diagnose

Tension pneumothorax is a life-threatening emergency. This article discusses several iatrogenic bilateral tension pneumothoraces occurring during intubation and emergency airway management. Read More …

PostObstructive Pulmonary Edema

Patients with postobstructive pulmonary edema (or P.O.P.E.) develop sudden, unexpected and potentially life-threatening pulmonary edema after relief of airway obstruction.  It can be mild or severe. My first experience with it was in 1983. The Case In 1983, we didn’t have pulse oximetry, end-tidal carbon dioxide monitoring or even automated Read More …

Intubation During Cardiac Resuscitation

Intubating patients during cardiac resuscitation is often challenging because of the circumstances surrounding the intubation. Excitement and apprehension accompany this life saving effort. In addition, The patient is often in a less than optimal position while chest compressions are in progress. You usually find the patient in one of two awkward positions: on the ground or in a bed. This article discusses techniques to better manage intubation during cardiac resuscitation, especially with the patient in an awkward position. Read More …

Airway Emergency: Start With The Basics of Airway Management

A case of “can’t intubate- can’t ventilate is discussed which illustrates the importance of always using good techniques of basic airway management. Read More …

Finding PEEP In a Bottle (of Water): Thinking Outside The Box

As you read this I am flying to Honduras with International Relief Team on a head and neck surgery medical mission. I will attempt to post mission updates from the hospital compound, pending internet connections. Participating in a medical mission to the developing world is never easy.

Medical personnel trained in a high tech environment take for granted the complex monitoring devices, multiple choices of drugs, and plentiful support peronnel which simplify our job. When medical volunteers travel to the developing world they are often unprepared for the potential hazards produced by outdated technology, unfamiliar and sometimes poorly maintained equipment, poor sanitation, limited supplies, and a malnourished, often poorly educated population.

Let me give you an example of one rather exciting case from early in my volunteer experience in which I had to reinvent PEEP using some suction tubing and an irrigation bottle filled with water.
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Hair Style Can Impact Intubation

Last weekend I spent time with the charity group Healing Little Heroes at the San Diego Rady’s Children’s Hospital, and Ronald McDonald House. The mission of Healing Little Heroes Foundation is to help pediatric patients in hospitals and outpatient settings to heal emotionally and mentally by appearing as Superheroes. My good friend, and general surgeon, Justin Wu, dressed below as Darth Vader, set up the Foundation.

On this day we arrived in full Star Wars costumes to entertain the kids and their families. I’m dressed as Queen Amidala. Which brings me to the topic of today’s conversation. Can hairstyle impact your intubation or even your anesthetic management? The answer is yes. For example, there is no question that if Queen Amidala needed emergency intubation, that her hairstyle would get in the way. Read More …

Intubation With Airway Bleeding and Massive Emesis

During intubation, any liquid in the mouth that obscures the view of larynx not only hinders visualization, it risks aspiration. We’re used to being able to rapidly suction the mouth clear or secretions, blood, or vomit and then have a clear view of the larynx. But sometimes, either because of continued profuse bleeding or massive emesis, fluid continues to accumulate while we’re watching. How can you manage this situation and successfully intubate? This article discusses two prior cases and offers suggestions on intubation when massive emesis or blood interfere with visualization. Read More …

Help! My Anesthesia Machine’s Not Working!

There is nothing quite as scary as being in the middle of administering an anesthetic and having your anesthesia machine fail. In my 36 years of anesthesia practice I’ve had this happen to me a few times. Knowing how to quickly troubleshoot your machine, and knowing how to protect your patient are important, potentially life-saving skills. It helps to have thought through the steps to rescue the situation before it happens to you. This article discussed the steps you should take if your machine fails. Read More …

Codeine Risk In Children, Especially Those With Sleep Apnea

Although the initial FDA warnings about potentially fatal codeine overdose in children were released in 2012, I’m recently discovered that a few of my surgeon and nursing colleagues were still unaware of the potential risks. This article reviews some of the risks of using codeine in the pediatric population as well as the patient’s at highest risk for potentially fatal respiratory depression. Read More …

Potential Tongue Ischemia with LMA Supreme

When we place anything in the mouth, be it an endotracheal tube, oral airway or LMA, we are typically extremely careful to protect the teeth. We take care to avoid cutting the lips with the teeth. But we often take the safety of the tongue for granted. I recently recognized a potential problem while using an LMA supreme that could have caused tongue ischemia if not recognized and corrected. Read More …

To Extubate, Or Not to Extubate, That Is The Question

Deciding when to extubate a patient safely can sometimes be a difficult decision. Removal of an endotracheal tube when you are not sure of the diagnosis is a risk not to be taken lightly. This case discusses assessing extubation criteria in the face of ambiguous respiratory symptoms. Read More …

Tongue Necrosis From Endotracheal Tube Compression

Tongue necrosis from compression by an endotracheal tube or oral airway is a rare, but devastating complications when it occurs. It can occur with poor endotracheal tube positioning, flexed head and neck positioning, impaired blood flow, and shock. It is important to familiarize ourselves with this entity so that we as anesthesia providers can minimize the risks.
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Plastic In the Airway: An Unsuspected Aspiration Hazard

I saw a potential aspiration hazard in the OR today. How many times a day do we routinely peel plastic wrappers off of airway equipment? If I’m at the surgicenter, I might need 7 face masks, a variety of LMAs and endotracheal tubes and an oral airway or two. Take a look Read More …

Cardiac Arrest In The OR

Cardiac arrest in the OR is challenging both to recognize as well as to treat. You must be able to work the causal diagnosis in the face of some potentially complex anesthetic, surgical and comorbid combinations. At the same time you must perform a resuscitation, often in the face of ongoing surgery. Getting prepared for rare events is often more challenging than preparing for regular events. When a rare event happens the shock and fear induced by the event can erase protocol from the most prepared mind. This article shares learnings from my years of experience attending to emergency resuscitations and management of cardiac arrests in the OR. Read More …