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 …

Anatomic Dead Space Affects Hypoventilation

Having a tidal volume close to, or smaller than the patient’s dead space can lead to significant hypercarbia, hypoxia, and respiratory failure. This article discusses the concept of dead space and it’s clinical use in recognizing hypoventilation and preventing hypoxia and hypercarbia. Read More …

GlideScope Technique For Intubation In Small Mouths

The GlideScope can be difficult to use in a patient with a small, narrow mouth. This article discusses a technique for improving successful intubation in that type of patient. Read More …

Difficult Intubation In A Newborn

The unanticipated difficult neonatal intubation in L&D greatly complicates neonatal resuscitation. This discussion highlights the approach to difficult ventilation & intubation in the newborn. #FOAMED Read More …

Announcing My New Book: Pediatric Airway Management: A Step-by-Step Guide

At long last, after two years of writing (and rewriting),  illustrating, and  filming  on-line videos, I’m excited to announce the publication of my new book Pediatric Airway Management: A Step-by-Step Guide. Anyone who rarely cares for children tends to be anxious when faced with a small child’s airway. This is true even if they are comfortable with adult airway management.

My goal for this book is to demystify basic pediatric airway management. I want to give you the skills you need to recognize when a child is in trouble and act quickly to safeguard that child, including helping them breathe if necessary. My sincere wish is that this new book helps in the care of our littlest patients, no matter where they are. Read More …

NITROUS OXIDE: SHOULD WE USE IT?

When I was training, we used nitrous oxide on just about every anesthetic. It was easy to use. It was inexpensive. It didn’t tend to effect hemodynamics so it was useful in less stable patients when combined with an opioid. It helped speed induction through the second gas effect. It was not metabolized so renal and liver insufficiency were of less concern.

However, a lot more is now known about the pharmacologic disadvantages, and potential harm, of nitrous oxide in certain patients. N2O interferes with the B12/folate pathway and methylates DNA. This discussion reviews some of those patients at risk of harm from nitrous oxide exposure during anesthesia. 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 …

When Learning Intubation Is Hard

Learning to intubate is easier for some people than for others. Sometimes, no matter how knowledgeable you are about the theory of the technique, the novice can still struggle to bring it all together to pass the endotracheal tube. The anatomy can be confusing. Understanding how to place the laryngoscope blade and manipulate that anatomy can be challenging. And all the while you must be ever vigilant to protect those precious front teeth, avoid hypertension and tachycardia, and breathe for the patient at regular intervals. This article discusses 4 chief technical barrier to learning to intubate. Read More …

Not All Airway Emergencies Need Intubation

An emergency department physician I met the other day shared with me an experience from her hospital  that offers a good example of the fact that there are many different ways of managing an airway emergency in a child that don’t involve intubation. Medical management can sometimes avoid some of the risks of losing the airway that intubation might impose. Read More …

Remember That Respiratory Failure Is Not Always Due to Lung Failure

While assisting ventilation and protecting the airway are first priorities to stabilize a patient, treating the cause of the respiratory failure may require more than just ventilation and/or intubation. In fact, treating the cause can sometimes help you avoid the progression of respiratory distress to respiratory failure. If you don’t consider a potential problem or cause, you’re not going to be able to diagnosis it. This is a case of respiratory failure caused by hypovolemic shock and hypoglycemia in a child. Read More …

Exhaling During Manual Ventilation Is As Important As Inhaling

One of my readers recently asked a very important question about ventilating a patient with a bag-valve-mask device: “Is there an outlet for the expired air of the patient?” The answer is yes. When ventilating a patient we are concentrating, and rightfully so, on watching the lungs expand and verifying that we hear breath sounds. It is just as important to verify that your patient can exhale. All ventilation devices have a built in pressure relief valve, also called a pop-off valve, which allows you to balance the force needed to expand the lungs with the ability to the patient to passively exhale. Failure to allow exhalation can lead to patient injury from barotrauma. Read More …

Communication In A Crisis: A Case of Respiratory Depression In A Child:

When I’m teaching airway management to my Perioperative/OR nurses, I often recount the story of management of a young child’s postoperative respiratory depression. In addition to illustrating the importance of evaluating ventilation in addition to oxygenation, this case shows how good communication makes management of a critical event more effective. 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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MacGyvering In Anesthesia

I used to love the old TV show MacGyver, which featured an inventive hero who frequently had to improvise some clever device from ordinary objects in order to beat insurmountable odds and save the day. The concept was so popular that the word MacGyver became a verb. Oxford Dictionaries state that to “MacGyver” is to make or repair something “in an improvised or inventive way, making use of whatever items are at hand”.

As I have traveled the developing world on medical missions I have often had to reinvent ways to do the things I take for granted in my sophisticated operating room, such as producing PEEP from some suction tubing and a bottle of water. (see story here)

But being able to improvise is just as important in the settings of the more modern hospital. This article describes two examples of having to improvise for an anesthetic. Read More …

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 …

Avoiding Pediatric Drug Errors

Pediatric medication errors are distressingly common. This article discusses various ways to reduce the risk of administering an incorrect medication dose to a child. Read More …