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Glidescope Tips

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Tips on Advancing the Endotracheal Tube

New GlideScope® users often achieve an excellent view with the
GlideScope® but may experience some difficulty advancing the
endotracheal tube. This may be caused by two factors:

The first factor is excessive lifting or pushing of the glottis by
the GlideScope® blade. Maximum laryngeal exposure may not
facilitate intubation; reducing the elevation applied to the laryngoscope
may make inserting the endotracheal tube easier.

The second factor is the angulation of the tip of the endotracheal
tube. A GlideScope® Rigid Stylet (PN 0800-0309) that is
designed to match the angulation of the GlideScope® blade is
now available. The GlideRite® (PN 0830-0075) endotracheal
tube soft tip technology may make passage of the endotracheal
tube easier and less traumatic. Please contact a Verathon Medical
™ representative for more information.

If using a malleable stylet, we recommend bending the tip of the
stylet to at least 50–60° to match the angle of the GlideScope®
blade. An angle that is larger than 60° may make it difficult for
some users to advance the endotracheal tube.

Other methods of configuring the stylet have been developed by
GlideScope® users worldwide and have proven to be effective.
For more information on alternative methods of stylet configuration,
please contact your Verathon Medical™ representative.


GlideScope® Video Laryngoscope

Stylet

GlideRite™ Endotracheal Tube



Bend the proximal tip of the stylet.

If using a malleable stylet, the proximal tip of the stylet may be
bent backwards to permit one hand operation of the endotracheal
tube. The GlideScope® Rigid Stylet is already designed to
be used in this manner, as shown in the illustration below.

Introducing the endotracheal tube.

The endotracheal tube should be introduced behind or immediately
adjacent to the GlideScope® blade. The proximal end of
the endotracheal tube should be carefully introduced between
the vocal folds. The operator should take care not to damage the
cuff, teeth or oropharynx during insertion.

Withdraw the stylet 5 cm (2").

Using the right hand, advance the endotracheal tube while simultaneously
withdrawing the stylet with the thumb. The stylet
should be withdrawn approximately 5 cm (2"). This straightens
the tip of the endotracheal tube and permits it to enter the larynx
while the stylet continues to provide rigidity to the body of the
endotracheal tube.

The Checklist

Atul Gawande's article in the New Yorker, "The Checklist", is a gread read. Scot was nice enough to make a copy for me.

He introduces the complexity of critical care medicine by giving the accounts of two survivors - one of accidental hypothermia and the other of intraoperative hemorrhage, sepsis and line infection. He then descirbes how the concept of checklists to manage such complexity came to us from the Boeing "Flying Fortress". You see, it wasn't until the very complex B-17 that checklists were needed to ensure pilot error was reduced.

Peter Pronovost is cited as the father of medical/icu checklists - in particular for central line associated bloodstream infections.

Our own ICU CLABs/CLABIs rates have dropped very impressively with the institution of a central line checklist. Coming soon to an ED near you?

Infectious Illness in the Emergency Department

Skin and Soft Tissue

1. Moran, Gregory J., Krishnadasan, Anusha, Gorwitz, Rachel J., Fosheim, Gregory E., McDougal, Linda K., Carey, Roberta B., Talan, David A., the EMERGEncy ID Net Study Group, Methicillin-Resistant S. aureus Infections among Patients in the Emergency Department N Engl J Med 2006 355: 666-674

2. Gabillot-Carré M, Roujeau JC. Acute bacterial skin infections and cellulitis. Curr Opin Infect Dis. 2007 Apr;20(2):118-23.

Angela M. Mills and Esther H. Chen, Are Blood Cultures Necessary in Adults With Cellulitis?, Annals of Emergency Medicine, Volume 45, Issue 5, May 2005, Pages 548-549.



Meningitis

1. de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. New England Journal of Medicine 2002;347(20):1549– 56.

2. Michael T Fitch and Diederik van de Beek, Emergency diagnosis and treatment of adult meningitis, The Lancet Infectious Diseases, Volume 7, Issue 3, March 2007, Pages 191-200.

3. Karen E. Thomas, Rodrigo Hasbun, James Jekel, and Vincent J. Quagliarello The Diagnostic Accuracy of Kernig’s Sign, Brudzinski’s Sign, and Nuchal Rigidity in Adults with Suspected Meningitis. Clinical Infectious Diseases 2002; 35:46–52.

4. John Attia, MD, PhD; Rose Hatala, MD, MSc; Deborah J. Cook, MD, MSc; Jeffrey G. Wong, MD. Does This Adult Patient Have Acute Meningitis? JAMA. 1999;282:175-181.



Pneumonia

1. American College of Emergency Physicians. Clinical policy for the management and risk stratification of community-acquired pneumonia in adults in the emergency department. Ann Emerg Med. 2001 Jul;38(1):107-13.

Online PORT Score Calculator:
http://pda.ahrq.gov/clinic/psi/psicalc.asp


Online CURB Score Calculator:
http://www.icumedicus.com/clinical_criteria/pneumonia_severity_score.php

Ted on Diagnosis X

Mark your calendars, Ted's episode of Diagnosis X on The Learning Channel "Jumping the Gun" will air on Wednesday, Sept 19 at 10pm. If you miss it, it will come on later that night at midnight,

Central Line Documentation

We had poor communication in one case that had a central line placed in emergently in the ED but was not documented as such. The ICU did not replace this line and the patient developed an infection within 4 days.

Please document if you did or did not use MAXIMAL STERILE BARRIER precautions in the procedure note and also please communicate this to the accepting service. This is vitally important.

Thanks for your help!

Shkelzen Hoxhaj, MD, MPH

Access - Lecture Bibliography

Ambesh Manuever Volume 95(6), December 2001, pp 1377-1379.

Costantino TG et al. Ultrasonography-guided peripheral intravenous access versus traditional approaches in patients with difficult intravenous access. Ann Emerg Med 2005 Nov; 46:456-61.

Brannam L et al. Emergency Nurses Utilization of Ultrasound Guidance
for Placement of Peripheral Intravenous Lines in
Difficult-access Patients Academic Emergency Medicine 2004; 11:1361–1363.

Lewin, M et al. Humming Is as Effective as Valsalva’s Maneuver and
Trendelenburg’s Position for Ultrasonographic Visualization
of the Jugular Venous System and Common Femoral Veins doi:10.1016/j.annemergmed.2007.01.024

Leung G et. al. Real-Time Ultrasonographically-Guided Internal Jugular Vein Catheterization in the Emergency Department Increases Success Rates and Reduces Complications: A Randomized, Prospective Study. Annals of Emergency Medicine Volume 48, Issue 5, November 2006, Pages 540-547

Higgs Z et. al. The Seldinger technique: 50 years on. Lancet. 2005 Oct 15-21;366(9494):1407-9. Epub 2005 Jul 20.
Derek A. Riebau, James F. Selph & Adrian A. Jarquin-Valdivia: Acute Ischemic Strokes after Central Line Placement: The Internet Journal of Emergency and Intensive Care Medicine. 2005; Volume 8, Number 2
Albrecht et al. Applied anatomy of the superior vena cava—the carina as a landmark to guide central venous catheter placement British Journal of Anaesthesia 92(1): 75. (2004)
Stonelake PA, et al. The carina as a radiological landmark for central venous
catheter tip position. British Journal of Anaesthesia 96 (3): 335–40 (2006)

Maury E et. Al. Ultrasonic Examination – An alternative to chest radiography after central venous catheter insertion. Am J Resp Crit Care Medicine Vol 164 pp403-405

Maki DG et. al. Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet 1991 Aug 10;338(8763):339-43.

Kitgawa N et. al. Proper Shoulder Position for Subclavian Venipuncture A Prospective Randomized Clinical Trial and Anatomical Perspectives Using Multislice Computed Tomography. Anesthesiology 2004; 101:1306 –12.

Veenstra DL et. al. Efficacy of antiseptic-impregnated central venous catheters in preventing catheter-related bloodstream infection: a meta-analysis. JAMA. 1999 Jan 20;281(3):261-7.

Osma S et. al. Efficacy of antiseptic-impregnated catheters on catheter colonization and catheter-related bloodstream infections in patients in an intensive care unit. J Hosp Infect. 2006 Feb;62(2):156-62. Epub 2005 Nov 22.

Robers & Hedges Clinical Procedures in Emergency Medicine

emcrit.org

A Visit from Ron

If you aren't reading Nick Genes' EM Journal Club Blog, then you ought to be. The comments section on each article reviewed contain great discussions, mostly by our residents. It was great to see Ron Walls chime in from Boston. Check out the comments on Dexamethasone for Headache here.

LWBT AMA AND ELOPED PATIENTS

If a patient left before being triaged or put into a bed: Dispo and condition = LWBT. This will probably be diagnosis too. They never made it to a treatment area.

A patient had an AMA discussion and chooses to leave against advice: Dispo and condition= AMA. The Diagnosis is whatever the diagnosis is.

A patient left from the treatment area before completion of treatment, but there was no discharge discussion: Dispo and condition = eloped. Here the diagnosis is as good as you can make it, depending on your contact with the patient.

Eloped should be EVERYONE that made it to the treatment area but left before the discharge decision/ discussion. If they were suitable for d/c but never got papers, you may make dispo discharge, but document they left without papers. If you saw the patient, even from across the room, you should document what you can.

Also- Just to clarify: It is a waste of time to say "remove from board" without putting a Diagnosis/ dispo and condition on the chart.

If someone was sent to L and D, they still need a Diagnosis/ dispo and condition before being removed. This should generally be the senior or north attending job. You may touch base with the charge nurse so she can communicate these to you.

2006 MSH ED ANTIBIOGRAM

Some highlights from the ED Antibiogram:

MSSA:	cefazolin	100% sensitive
MRSA:	vancomycin	100% sensitive
Strep Pneumo:	Ceftriaxone	100% sensitive
Strep Pneumo (meningitis):	Vanco	100% sensitive
E Coli:
	macrobid	98% sensitive
	ceftriaxone	97% sensitive
	zosyn	97% sensitive
Pseudomonas:
	cefepime	100% sensitive
	zosyn	100% sensitive