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Advanced Emergency Nursing Blog from AENJ
The concepts, concerns, clinical practices, researches, and future of Advanced Emergency Nursing.
Friday, March 27, 2015

This Blog episode concerns aspects of the concept of using the nose to obtain an airway or to ventilate emergency patients; it does not deal comprehensively with all aspects thereof that a specialist might do. Overlapping categories include the nasal natural airway; expiratory airway obstruction in sleep and resuscitation; Mouth to Nose resuscitation; airway adjuncts that traverse the nasal passage; intubation via the nasal route whether “blind” (auditory, tactile), visualized by laryngoscope or other optical/video/endoscopic device.



My first professional ambulance call was for three victims of Carbon Monoxide poisoning. A couple came home from an evening out and inadvertently left the car’s engine running in the garage below. Before the romantic portion could begin, the cat became ill. While attempting to call a veterinarian, the woman became headachy, dizzy, nauseous, and passed out. The man, too, was overcome. Fortunately, the upstairs landlords returned home, heard, and turned off the running engine, tried to telephone them, then unlocked and entered the flat and opened windows. They found the man breathing, but the woman was not. Mouth to mouth artificial respiration was given to the woman while help was called. The victims was awake and talking upon our arrival. The woman's elderly rescuer said “I couldn’t get her mouth open. What should I have done?” I replied that “You could either blow through the nose, or blow between the teeth.” Her rejoinder was “I didn’t think to blow through the nose, but, boy, did I blow between the teeth!


The nose in Early Modern Expired Air Resuscitation:

Early teaching in expired-air resuscitation was three-fold. Mouth to mouth for larger children, adolescents, and adults; mouth to nose if a good seal could not be obtained, or if the rescuer could not abide oral contact; and mouth to mouth and nose for infants and small children. Subsequently, the teaching was simplified and mouth to nose deemphasized and faded away.


Few people now remember that a strong early proposal in the move for expired air resuscitation was Mouth to Nose. (James O. Elam, MD, and associates, per Peter Safar, MD.) Advantages included: a good seal by a rescuer with a small mouth and a victim with a large mouth; excellent patency of the upper airway using head tilt and chin lift to tension the pharyngeal dilating muscles of the neck; gastric insufflation was less likely with the nasal cavities moderating the force of the airflow. It lost out, I think, to a slightly greater “eww!” factor than oral (which still suffers from the too-personal-contact-reluctance of the lay rescuer, as in “hands only CPR”), and to the more euphonious persuasion of “Mouth to Mouth” and “Kiss of Life.”


At that time, too, it was felt that the cause, or  —at least, the major focus of investigation, of Upper Airway Obstruction was the tongue. This followed on the oft-held old notion of the victim “swallowing his tongue,” and of early “rag and bottle anaesthetists” manipulating the head and neck or using “tongue-pulling forceps” to obtain an airway or stimulate respiration. Safar & Escarraga, inter alia, did studies of Mouth to Mouth and found that combinations of lifting the neck, tilting the head, and lifting the chin were necessary for any form of artificial respiration. They also proved that only expired air resuscitation guaranteed sufficient inflation volumes; that exhaled air was a suitable resuscitating gas; and that the operator would have continuous feedback from each breath.


Their focus was on developing a refined technique suitable for mass usage by the military who funded them and by the lay public. With each test of group instruction, simplifications would be made to streamline to what was practical by the public and most easily remembered. Therefore, early Mouth to Mouth training would include saggital views of the airway or articulated models demonstrating the lifting of the tongue.


In fact, of methods not using an adjunct, they had found that moth to nose gave consistently higher volumes, with ~no gastric insufflation, however, sometimes the public (but not professional) would flex the neck, and mandibular advancement was not a skill easily learned or remembered. [Ruben, Elam, Ruben, & Greene] A small incidence of palatal obstruction was found, but would be obviated by an open mouth with the oral method. Mouth to mouth, as they taught it, gave more than adequate volumes; using maximal head tilt with chin lift was more than 90% effective in opening the airway; was easier to teach and remember; and although gastric insufflation was not uncommon (all positive pressure methods produced some), it was felt that the dilatation was manageable with manual decompression of the stomach and possible cleaning of the airway. For unity of concept and presentation, it was decided to emphasize mouth to mouth for lay and all non-specialist professional rescuers.


Expiratory Airway Obstruction:

I wrote about “The ‘Poof’ Sign” in Clinical Tips # 44. In earlier studies, expiratory airway obstruction was estimated to be 1-4% occurrence, and was little written of. Much of anesthesiology technique was passed on by the apprenticeship of residency. Now, there is an enlarging body of data from modern writings and from study of Obstructive Sleep Apnea. Increased prevalence may, in part, be due to the larger habitus and aging of our population than in the leaner population of the 1950s and ‘60s. In the convenience samples then, expiratory airway obstruction was found in . . . the older, more obese, patients. Surprise.


Now, we know that airway obstruction is most often palatal, or multilevel, and may include retrolingual, and hypopharyngeal. It is the vibration of the palate which gives common snoring its characteristic sound.


Expiratory airway obstruction may well have been frequently misdiagnosed as it can produce breath-stacking and ball-valve obstruction that impedes any airflow with mask ventilation if neither a nasal nor an oral airway is used and the lips have closed under the mask. It would seem as if air couldn’t go in, but it was because the air already given couldn’t get out (and the chest and stomach were maximally expanded).


The desperate mask-ventilator would clasp the mask all the tighter, until it was removed, lips were parted and an oral airway inserted. Once an exhaust route is provided, expiratory airway obstruction cannot occur.


The nose in basic resuscitation:

In an ambulance service for which I worked as a Paramedic at a time when although trained in intubation, it was not yet permitted; our principle device was a nasopharyngeal airway with an oversized 15mm endotracheal tube connector. It did not fail us, whether the patient was large faced and bull-necked, or cachectic and edentulous. With head tilt, chin lift, and lip/nostril closure, we could quickly ventilate with a bag that remained in place while doing single-person CPR. This “Modified Nasal Trumpet” [Beattie], {of which more to come in another blog}, was already “an old anesthesia trick,” although not yet published.


Modern recommendations for difficult mask ventilation are to use three airways: two NPAs and one OPA, and of course, good positioning and excellent mask technique using two hands when available. This fits with experience, and does much to lift the palate, and separate lips, teeth, tongue, and pharynx with maximal airway flow characteristics. (NPA X2 = >cross section area than single OETT. OPA added prevents lips->pharynx obstruction; together, the three may ~seal upper airway.)


Avoidance and detection of Expiratory Airway Obstruction:

  • Beware of lip closure under the facemask: open the patient’s lips; keep them separated with an oral airway, if tolerated; use an NPA.
  • Avoid downward pressure that flexes the neck. OPAs/NPAs can occlude against tissue (reposition), or obstruct with vomitus (clean, replace).
  • Beware of smaller volumes exhaled than insufflated; watch for breath-stacking. Maintain maximum Triple Airway Maneuver throughout the entire respiratory cycle. Watch for hyperinflation of chest, without expiratory fall. Look for gastric distention. Note loss of CO2 tracing on the capnograph or color-change failure on a litmus paper type CO2 detector. [Buffington]
  • If expiratory obstruction occurs, open circuit and provide exhaust; if need be, assist exhalation with bilateral thoracic squeeze. Resume with OPA/NPA, SGA or ETT.
  • Capnography (waveform)/capnometry at first opportunity and throughout the ventilatory support. Be alert to changes in waveform. This, I hold, is Gold Standard performance. [Buffington]

NTI largely supplanted by RSI:

Current resuscitation practice focuses on the oral route for airway management and intubation. It’s the bigger hole with a view, and more room to manipulate. Rapid Sequence Induction has made it easier to use without “gassing the patient down by mask” (inhalation anesthesia) or fighting trismus. Experientially, I have had open-cone ether induction: RSI is easier for the patient to undergo, as unconsciousness is achieved in seconds.


Another reason that NTI is less often used than formerly is that in the 1980s and 1990s it was a mainstay for intubation of the person at risk for cervical spine injury wearing a cervical collar. Some would even do primary cricothyrotomy or tracheotomy. Subsequent research and experience shows that while some cervical spine movement occurs with direct laryngoscopy, it appears that with Manual Inline Stabilization, the anterior portion of the rescue collar could be loosened and direct laryngoscopy carefully done without clinically significant injury. A prepared RSI seems safe. Consider fiberoptic intubation, but this may be difficult after trauma. [Hung & Murphy]


First intubation for anesthetic:

It is no longer necessary, as it was for the first endotracheal anesthesia by Macewen in 1878, to teach an awake patient in several sessions to tolerate crawling the tube down through the mouth digitally while Macewen’s finger lifted the epiglottis to pass the tube. [Brandt]


In 1913, direct laryngoscopic intubation became better known from the work of Chevalier Jackson and by Henry H. Janeway.  A heyday for nasotracheal intubation would come with work by Sir Ivan Magill and others treating the WWI soldiers with needed maxillofacial reconstruction. Doing so avoided the oral surgical field while providing an airway for long surgeries and intubation could be done at a lighter plane of anesthesia. He became so adept that frequently he would ask someone to turn around for something only in that moment to intubate the patient before the person turned back. Indeed, many authors hold that NTI can be done blindly only in a spontaneously breathing patient (with the sound of air flow to guide the tube), yet it was not uncommon for him to intubate apneic patients.


Issues; Pro:

  • Blind nasotracheal intubation can be done without instruments. Just bring a tube.
  • The curved tube easily follows the path to the trachea.
  • Skilled intubators can achieve a +/- 90% success rate.
  • Avoids injured oral tissues, teeth, and surgical field.
  • Useful with cervical ankylosing spondylitis, etc.
  • Allows preservation of spontaneous breathing.
  • When secured, is very protected and unlikely to move.
  • May be done in upright or awkward positions.

Issues; Con:

  • The tube will be smaller than can be passed per oris.
  • Rough passage may cause epistaxis, false passage through mucosa, or shear off a turbinate. (Gentleness, smaller tube, rotation, vasoconstricting decongestant, lubrication, will aid in prevention.)
  • Coagulopathy requires careful consideration; relative contraindication.
  • Sinusitis can occur in long intubation. Cover with antibiotic.
  • Many authors feel NTI is absolutely or relatively contraindicated with potential basilar skull fractures; there is also opinion arguing that airway protection trumps the extreme rarity of this complication. [Marlow, TJ;  Rosen, CL; Walls, RM]

Aids to glottal entry of the endotracheal tube:

If tube doesn’t enter glottis easily:

―if patient is capable, have him take large inhalation to open cords;
―partially inflate cuff to elevate tip
―downward manipulation of the Thyroid Cartilage to provide a better angle of entry;
―use a “trigger tube” (e.g., Mallinckrodt Endotrol to shorten radius, or a directional stylet;
―direct laryngoscopy and advance tube with Magill’s Forceps;
―use an optical/video stylet/flexible bronchoscope to steer the tube  and visualize tube entry.)


Why use the nose?

We’ve heard, or been through, tales of early EM when BNTI was the fall-back for awkward intubations before EM could claim credentialing for RSI. So, why should we bother thinking of it, or develop any skill in it?


Paralysis doesn’t open every oral cavity. Consider: small mouth; perioral scarring;  TMJ problems; retrognathic jaw;  maxillofacial injury; sharp, irregular, rotten dentition; cancer of mouth or throat; Ludwig’s Angina; Angioedema; Cervical Ankylosing Spondylitis; laryngoscope failure.

Do you know how many mm of interdental opening you need for your direct or video laryngoscope, or your “rescue” LMA/SGA?


Narrow oral space:

Incidentally, in our shop, when we began to buy capital budget difficult airway equipment, our first choice was the Levitan FPS optical stylet to facilitate intubation with an opening no greater than the diameter of the endotracheal tube.


Passing behind the tongue:

The arcuate trajectory of the nasotracheal route gets behind the bulky tongue and naturally lines up with the glottis for passage. This aids in nasendoscopic inspection of the airway or using a flexible bronchoscope (whether traditional fiberoptic or video CMOS tip) to railroad the tube into the trachea. Sometimes, delivery of the tube behind the palate, base of tongue, and any associated pathology or masses is just easier this way.


When breathing should not be stopped:

There are also patients with dynamic airway obstructions in whom one should maintain spontaneous respiration and not ablate respiratory drive; whose waning catecholamines are preserving breath and life. [militarymd]


Induction and paralysis, sometimes even just topical anesthetic, may collapse the area.


Even the common advice “take a deep breath” can alter the pressure mechanics and collapse the area, when one should have cautioned “take slow careful breaths, as through a straw, and use the air; don’t go fast or hard.” Keeping spontaneous breathing keeps a bridge unburned. [militarymd]


Augmenting detection of airflow:

Nasal intubation is most often thought of when the patient is spontaneously breathing. It’s said of air-hungry desperate patients that they practically suck the tube in. The classic technique of ear to endotracheal tube and listening for greatest air flow is simplest, but vomit in the ear has happened.


One can pull off the tube of one’s stethoscope and insert that in the ETT instead. A whistle-cap, The Beck Airway Airflow Monitor (BAAM), on the tube can amplify breathing to the listener [Bruen]. Anesthesiologists have also used the respiratory stimulant Doxapram.


The Capnography Sensor can be attached to the ETT and the tube guided by “sniffing” the CO2. [Mentzelopoulos]


If respirations are shallow, one suggestion is to gently occlude lips and the contralateral nostril to divert full flow to the naris being intubated. [High]


Tips for Nasal Passage of Tubes:

  • Internal size of passage does not necessarily correlate with the external size of the nostril, patient’s little finger, or any other purported sign.
  • Ask patient which side has easier airflow. If in doubt, check forceful exalation through each.
  • Inspection, and tube entry, are eased by lifting and flattening the tip of the nose towards the top of the head.
  • If time permits, apply cocaine, phenylephrine or oxymetazoline to constrict the mucosa. Lidocaine sprays or nebulization can numb the passage. Both agents can be in the nebulizer.
  • The Right Nostril is usually attempted first, as for most of the population it is larger than the left. However, septal deviation or other problems may make it unusable. Airflow testing may help.
  • Usually, a 30 Fr | 7.5 mm NPA or ETT will pass easily and be adequate in average adults, but may be ± 0.5 mm. If there is swelling or encroachment, it may be necessary to go smaller: choose what will pass without injury.  

    A Timely smaller tube that passed easily is more valuable than a larger tube after the airway closes!
      There are CT images where the only open space is an inexpensive PVC tube that got there just in time.
    [Gerkin] Priceless.
  • Use a soft tube: latex, silicone, or PVC softened in warm water. Lubricate well. Using lidocaine jelly helps comfort. Squirting jelly into the chosen naris before passage insures that lubricant will be there when the tube arrives, rather than dragged off the tube as it pushes through. If time permits, dilatation with a smaller then a larger NPA may be possible.
  • Slide, and rotate gently as needed, any tube horizontally along the medio-inferior of the floor of the nose towards the occiput. Do not point upwards towards the vertex and cribiform plate, or laterally, thus shearing off the turbinates.
  • Gentle, steady, firm pressure pushes the tube through. If hung up within the nose, try rotating the bevel, once passing the block return to normal positioning.
  • Advance the tube (if an NPA) to a point just short of the glottis (~10 mm). If too long, it may impact the epiglottis into the glottis, or provoke laryngospasm. If too short, or migrates retrograde, may not provide sufficient airway behind the base of the tongue.
  • With NPAs, ensure there is a generous flange, or a safety-pin passed through it, (an oversize 15 mm endotracheal tube connector will also suffice while allowing direct connection to a BVM or ventilator) and secured to the face to prevent aspiration or retropulsion outwards by a wakening patient tonguing the tube.
  • Use capnography and pulse oximetry to assure awareness of patient status, failure of ventilation, or loss of airway throughout the period of care. Any patient requiring airway support should be continuously observed by a competent provider.

Technique for BNTI:

See Levitan-Emergency Physicians Monthly, Levitan-AirwayCam, High, below, as a start, then consult other textbooks, or local consultants.


NTI Assisted by Direct or Video/Optical Devices:

Standard techniques as for specific device.


Difficulty passing Arytenoid Cartilages during ETT delivery {not NTI specific}:
Ideally, use a non-bevel tip ETT, e.g., Parker/GlideScope, or the smooth silicone hemispherical tip ETT from FasTrach Intubating Laryngeal Mask Airway that avoid or glide over the cartilages without injury. If a beveled ETT, then rotate 90° to left to allow wedge shaped tip to center; if fails, rotate 90° again (total 180°) to move bevel fully left. Some have succeeded with slow full rotation (360°). Always be gentle!


Confirming endotracheal placement:

In addition to the usual required methods and documentation, remember that, most likely, your patient will still be breathing. Feel the airflow, see the mist, notice the lack of phonation, and auscultate the chest rise. How simple.



Brandt, L. (1987). The first reported oral intubation of the human trachea. Anesthesia & Analgesia, 66(11), 1198-1199.
**Account of the first intubation for a surgical anesthetic, rather than 18th century resuscitation.


McLachlan, G. (2008). Sir Ivan Magill KCVO, DSc, MB, BCh, BAO, FRCS, FFARCS (Hon), FFARCSI (Hon), DA,(1888-1986). The Ulster medical journal, 77(3), 146.

**Excellent single article summary of Magill’s life, inventions and career.


Marlow, T. J., Goltra, D. D., & Schabel, S. I. (1997). Intracranial placement of a nasotracheal tube after facial fracture: a rare complication. The Journal of emergency medicine, 15(2), 187-191.

**CT image illustration. Yes, we’ve all heard about it.


Rosen, C. L., Wolfe, R. E., Chew, S. E., Branney, S. W., & Roe, E. J. (1997). Blind nasotracheal intubation in the presence of facial trauma. The Journal of emergency medicine, 15(2), 141-145.
**Reviews relative risks of BNTI in facial trauma.


Walls, R. M. (1997). Blind nasotracheal intubation in the presence of facial trauma—Is it safe?. The Journal of emergency medicine, 15(2), 243-244.


Levitan, Richard M. Nasal Intubation. June 6, 2011. Emergency Physicians Monthly website.

**Nice short review of NTI.

Levitan, Richard M. website.


Ontario EMS Nasal Tracheal Intubation Video on the YouTube Channel of Ontario EMS.

Bruen, Charles  Nasotracheal Intubations with the BAAM Device ResusReview

**Brief review of the "whistle" device.


High, Kevin, Kevin High, RN, EMT, MPH, MHPE. (March, 2002) Emergency Care Essentials: 'Nasal Intubation Strategies'.

**Tips from author at Vanderbilt University LifeFlight, EM Faculty, and Trauma Resuscitation Mgr.


Cheryl Lynn Horton, MD, Calvin A. Brown III, MD, Ali S. Raja, MD, MBA, MPH

Trauma Airway Management J Emerg Med. 2014;46(6):814-820 on

**Example trauma case report requiring airway control; the decision process, algorithms, and alternatives, outcome.


Rogue Medic. 2011. Should EMS Use Nasotracheal Intubation?

**Argues for broad intubation skills for paramedics in a quality program, and that nasotracheal intubation, as per Ron Walls, MD, is not overly risky in facial trauma.


Jacobs, P., & Grabinsky, A. (2014). Advances in prehospital airway management. International Journal of Critical Illness and Injury Science, 4(1), 57–64. doi:10.4103/2229-5151.128014

**Broad review of the spectrum of current out-of-hospital airway management.


Deshmukh, S. R., Gadkari, C. P., Badwaik, G. M. & Bhure, A. R. (2014) EFFECT OF ENDOTRACHEAL TUBE CUFF INFLATION AND HEAD POSITION ON THE SUCCESS OF BLIND NASOTRACHEAL INTUBATION. International Journal of Current Research and Review, 6 (13), 24-30.

**Examines experimentally in surgery patients the effect of maneuvers to increase success in BNTI.


Barton, E. D., & Bair, A. E. (2008). Ludwig’s angina. The Journal of emergency medicine, 34(2), 163-169.

**Case review and discussion of airway management in Ludwig’s Angina.


Buffington, C. W., Wells, C. M., & Soose, R. J. (2012). Expiratory upper airway obstruction caused by the soft palate during bag-mask ventilation. Open Journal of Anesthesiology, 2012, 2, 38-43 doi:10.4236/ojanes.2012.22010 Published Online April 2012

**Significant major piece important for understanding. Highly recommended.


W. H. Rosenblatt and W. Sukhupragarn, “Airway Management,” In: P. G. Barash, B. F. Cullen, R. K. Stoelting, M. K. Cahalan and C. M. Stock, Eds., Clinical Anesthesia, Lippincott and Williams & Wilkins, New York, 2009, pp. 751-792.

**"One useful, albeit poorly characterized, maneuver that can aid in face mask ventilation is the expiratory chin drop. When positive pressure inspiration is successful, but is not followed by passive gas escape during expiration, allowing phasic head flexion and reducing chin/jaw lifting will often improve gas egress.”


Fortuna, Armando. <armando.fortuna@UOL.COM.BR> 2006 - "On blind nasal intubation" in ANESTHESIOLOGY Digest - 28 Jan 2006 (#2006-51) <ANESTHESIOLOGY@harpo.MED.YALE.EDU> Archived in Author's Collection
**Personal observation of Magill's work in 1962 recounted.


Jiang, Y., Bao, F. P., Liang, Y., Kimball, W. R., Liu, Y., & Zapol, W. M. (2011). Effectiveness of Breathing through Nasal and Oral Routes in Unconscious Apneic Adult Human Subjects. Anesthesiology, 115(1), 129.

**”Direct mouth ventilation delivered exclusively via the nose is significantly more effective than that delivered via the mouth in anesthetized, apneic adult subjects without muscle paralysis.”


Liang, Y., Kimball, W., Kacmarek, R., Zapol, W., & Jiang, Y. (2008). Nasal ventilation is more effective than combined oral-nasal ventilation during induction of general anesthesia in adult subjects. Anesthesiology-Hagerstown, 108(6), 998-1003.

**”Nasal mask ventilation was more effective than combined oral-nasal mask ventilation in apneic, nonparalyzed, adult subjects during induction of general anesthesia.” Suggests that it be considered.


Safar P, Escarraga LA, Chang F: Upper airway obstruction in the unconscious patient. J Appl Physiol 1959; 14:760-4
**Eighty anesthetized nonparalyzed patients in clinical and X-ray study. Airway loss in flexion, favors supine head/neck extension, oral airway; opposes prone position, expiratory obstruction may have contributed to partial obstruction when lips closed; one patient noted to have complete expiratory obstruction in optimal position.


Ruben HM, Elam JO, Ruben AM, Greene DG: Investigation of upper airway problems in resuscitation: 1. Studies of pharyngeal x-rays and performance by laymen. Anesthesiology 1961; 22:271-9
**Recounts investigations and developments, internationally, in expired air resuscitation teachings. A real case and simulations of “rigid victims” “emphasized the importance of the nasal route of inflation as an alternative to mouth-to-mouth techniques.”

** “In not a single case did the two-handed head-tilting fail to open the pharynx, and inflation through the nose revealed no limiting obstruction. When nasal respiratory obstruction was encountered exhalation through the mouth was always possible.”

** “Chin-lift, jaw-lift, and. head-tilt maneuvers all produce a satisfactory upper airway in flaccid subjects. The head-tilt method is preferable when the mouth-to-nose procedure is indicated, i.e., trismus, convulsions, and gastric distension.” “For the chance rescuer, the head-tilt method is  simpler, safer, more versatile, and less apt to aggravate complications involving gastric contents. Hyperextension of the patient’s head by one hand on the forehead and the other on the chin is recommended for both mouth-to-mouth and mouth-to-nose resuscitation by laymen.”


Kristensen, M. S. (2011). Ultrasonography in the management of the airway. Acta Anaesthesiologica Scandinavica, 55(10), 1155-1173.

**A useful reference for evaluating airway problems and tube placement.


Reber, A., Wetzel, S. G., Schnabel, K., Bongartz, G., & Frei, F. J. (1999). Effect of combined mouth closure and chin lift on upper airway dimensions during routine magnetic resonance imaging in pediatric patients sedated with propofol. Anesthesiology, 90(6), 1617-1623.

**Examines, under MRI, the effect of airway maneuvers during titrated propofol as for MRI exam or procedural sedation.


Safar, P., & Redding, J. (1958). The" tight jaw" in resuscitation. Anesthesiology, 20, 701-702. [N.B. The link is to correspondence edited by Stuart C. Cullen as "Current Comment" with the lead essay being "Orotracheal intubation in the Lateral Position." Scroll down for the Safar & Redding piece.
**This article lead to the conclusion, cited next, in which mouth to nose is disregarded.


SAFAR, P., AGUTO-ESCARRAGA, LOURDES., DRAWDY, L., McMAHON, M. C., NORRIS, A. H., & REDDING, J. (1959). The Resuscitation Dilemma*. Anesthesia & Analgesia, 38(5), 394-405.
**"Emphasis on the use of the nasal passageway because of the possibility of a "tight jaw" seemed unwarranted. [cite Safar, P. et al., op. cit.] The preferred mouth-to-mouth method (fig. 6) was effective also in the presence of a "tight jaw" and the nasal passage was found to be less patent than the oral passage."


Hillman, D. R., Walsh, J. H., Maddison, K. J., Platt, P. R., Kirkness, J. P., Noffsinger, W. J., & Eastwood, P. R. (2009). Evolution of changes in upper airway collapsibility during slow induction of anesthesia with propofol. Anesthesiology, 111(1), 63-71.

**Research results of airway changes while titrating propofol (similar to ED deep sedation).


Kempen, P. M., (2010). Airway collapse or closure via the soft palate as mechanism of obstruction in sedated patients?. Anesthesiology, 112(2), 496-497.

**Comment upon above article.


Hillman, D. R., Walsh, J., Maddison, K., Platt, P. R., Noffsinger, W. J., & Eastwood, P. R. (2010). Airway Collapse or Closure via the Soft Palate as Mechanism of Obstruction in Sedated Patients? Reply. Anesthesiology, 112(2), 497-497.

**Reply to Kempen’s comment.


Morikawa S, Safar P, DeCarlo J. 1961. INFLUENCE OF THE HEAD-JAW POSITION UPON UPPER AIRWAY PATENCY. Anesthesiology, Mar-Apr 1961.

**X-Ray study of pharyngeal patency for Mouth to Mouth found total expiratory obstruction without inspiratory obstruction in 7 of 68 patients despite maximal head tilt. Breath-stacking occurred until inspiration could no longer be done; opening the mouth relieved the obstruction. Attributed to soft palate obstruction. Oral inflations with obstruction were always correctable with jaw lift, improving head tilt, or OPA. Complete obstruction despite head tilt with lips closed occurred in 4 patients, of whom 3 were corrected with jaw displacement, and 1 required an OPA.


Hillman, D. R., Platt, P. R., & Eastwood, P. R. (2003). The upper airway during anaesthesia. British journal of anaesthesia, 91(1), 31-39.

**Excellent study and review of the physiology of the unconscious anesthetized patient (conditions similar to RSI in emergency patients).


Atul Malhotra, Yaqi Huang, Robert B. Fogel, Giora Pillar, Jill K. Edwards, Ron Kikinis, Stephen H. Loring, and David P. White "The Male Predisposition to Pharyngeal Collapse", American Journal of Respiratory and Critical Care Medicine, Vol. 166, No. 10 (2002), pp. 1388-1395. doi:  10.1164/rccm.2112072

**The authors found increased pharyngeal length and area, and larger soft palate area in men, which led to their conclusion (in part): "This study suggests that there are clearly definable differences in upper airway anatomy between men and women, with little to no difference in muscle activation/control. Furthermore, on the basis of computational modeling, we believe that the anatomic differences observed can significantly impact airway collapsibility and may, in part, explain the male predisposition to OSA."


Vroegop, A. V., Vanderveken, O. M., Boudewyns, A. N., Scholman, J., Saldien, V., Wouters, K., ... & Hamans, E. (2014). Druginduced sleep endoscopy in sleepdisordered breathing: Report on 1,249 cases. The Laryngoscope, 124(3), 797-802.

**Palatal collapse was seen most frequently (81%). Multilevel collapse was noted in 68.2% of all patients. The most frequently observed multilevel collapse pattern was a combination of palatal and tongue base collapse (25.5%). . . . The prevalence of complete collapse, multilevel collapse, and hypopharyngeal collapse increased with increasing severity of obstructive sleep apnea (OSA). Multilevel and complete collapse were more prevalent in obese patients and in those with more severe OSA. Both higher BMH and AHI values were associated with a higher probability of complete concentric palatal collapse.


Beattie, C. (2002). The modified nasal trumpet maneuver. Anesthesia & Analgesia, 94(2), 467-469.
**Describes the use of an NPA with added Murphy’s Eye and 15mm endotracheal tube connector as beneficial in several difficult airway situations.


“militarymd.” “The Student Doctor Network Forums: “Someone almost died” - Discussion in 'Anesthesiology' started by militarymd, Apr 25, 2006.
**Discussion of actual clinical case of dynamic airway obstruction and its implications. Do not miss. Instead of “big deep breaths”, it can be wise to urge slow smooth breaths.


Gillespie, N. A. (1950). Blind nasotracheal intubation. Anesthesia & Analgesia, 29(6), 217-222.

**This vintage piece included as by a classic and noted practitioner (English, then later at University of Wisconsin) for a view of the time and its memoir quality.


Mentzelopoulos, S. D., Augustatou, C. G., & Papageorgiou, E. P. (1998). Capnography-guided nasotracheal intubation of a patient with a difficult airway and unwanted respiratory depression. Anesthesia & Analgesia, 87(3), 734-736.


Gerkin, R., Sergent, K. C., Curry, S. C., Vance, M., Nielsen, D. R., & Kazan, A. (1987). Life-threatening airway obstruction from rattlesnake bite to the tongue. Annals of emergency medicine, 16(7), 813-816.
**Timely intubation: the PVC ETT was the only open space in an encroached airway for three days.


Hung, Orlando; Murphy, Michael F. Management of the difficult and failed airway. McGraw-Hill Medical, 2008. Section 14.4.14 and pp 212-219 passim.
**Nasal intubation reviewed and of risks in cervical spine injury.


Tom Trimble, RN CEN
All opinions are solely those of the author.




Saturday, February 28, 2015

The February holidays have an interesting history and have undergone change. Washington’s Birthday is now most commonly called (in different spellings) “Presidents Day.” Lincoln’s Birthday, never a Federal holiday but widely celebrated on a State basis, now seems subsumed (even with all Presidents in many minds), in Presidents Day, while the Reverend Dr. Martin Luther King, Jr., is celebrated as the “other” holiday.


There are increasingly many writings upon the health of our Presidents either factual or speculative, and even in contention whether the office is inherently detrimental to wellness and longevity of its occupants. Difficulties abound as such matters were often secret, not observed by medically informed writers, and inability to examine the patient or perform an autopsy not done at the time.


George Washington

Washington’s robust constitution had endured a number of fevers, malaria, dysenteries, smallpox, “rheumatism,” dental problems, in his life. His care of others included being a “great vaccinator” to ward off smallpox. His fatal illness, probably supraglottitis, treated by methods of the day, included four blood-lettings to a total of 80 ounces (~35-40% of blood volume), purgatives, induced diaphoresis, and counter-irritant poultices (a blister of cantharides {Spanish Fly} to the neck, and wheat bran to the legs) to reduce the inflammation; a demulcent mixture nearly choked him. Dr. Elisha Dick (37 years old) objected to the bleedings (the first by the plantation’s blood-letter at Washington’s request prior to the physicians’ arrival, the sec{Spanish Fly}ond by the physicians upon arrival) but was overruled by the two elder physicians for the latter two, and his proposal for tracheotomy was likewise rejected. A fourth doctor didn’t arrive until the morning after the death but also knew tracheotomy, and in fact proposed revival of the corpse by rewarming, tracheotomy, and transfusion of lamb’s blood; Mrs. Washington did not agree.


Thomas Jefferson

In a controversial book, author Norm Ledgin argues that Jefferson’s many quirks and intensity are a pattern that he feels is most consistent with Asperger’s Autism or  a High-Functioning Autism. He gained this insight as the father of a son with Asperger’s.


Abraham Lincoln

Lincoln’s lankiness has been ascribed to Marfan’s Syndrome, but this is disputed. He suffered from depression and grief at the death of his son, Willie. His appearance greatly aged during the course of the Civil War. The mental problems of his wife, Mary Todd Lincoln, were a significant burden in his life. The first doctor to care for Lincoln at Ford’s Theater was Charles A. Leale, an army surgeon. Decompression of the brain by manual removal of wound clot features in the care.


James A. Garfield

The shooting of Garfield and his course over eighty days before his death greatly affected the nation and its emotions.  Ironically, Robert Todd Lincoln, son of President Lincoln, was present in the Garfield’s group at the shooting.  The medical care was predicated on an incorrect assessment of the internal trajectory of the bullet which wasn’t found or removed until autopsy. Alexander Graham Bell, inventor of the telephone, devised a metal detector to locate the bullet; its lack of success is thought due to interference of the metal bedsprings, as it was  later found functional; this would be an early attempt at diagnostic “imaging.” During the course, there was much infection, starvation to a weight loss of one hundred pounds, multiple organ failure, and rupture of an aneurysm to the splenic artery.


Grover Cleveland
In 1893, out of concern for any public reaction during a financial depression and fight over the monetary Gold Standard, Cleveland arranged for surgery to be done secretly while on a yacht off Long Island during a supposed vacation. This was done for a tumor of his palate, and involved partial removal of his maxilla; a second surgery placed a hard rubber dental prosthesis that restored the disfigurement and speech difficulty.


William Howard Taft

Taft is known for his morbid obesity, and hypertension. He often had daytime somnolence, even falling asleep on his feet. After leaving  the presidency, with diet and “physical culture,” he lost eighty pounds easing his obstructive sleep apnea, and moderating his blood pressure, thereby improving his alertness and work performance (he became Chief Justice of the Supreme Court); and extending his life span to 72 years.


Woodrow Wilson

Wilson suffered several strokes, and was isolated in the White House by his second wife, Edith, who allowed only herself and his physician to see him. This led to (inter alia) failure to ratify the League of Nations treaty, a paralysis of the executive branch and Cabinet, and accusations to this day that Edith “was running the government.” After five months, the public became aware and Wilson began to make appearances at Cabinet meetings. The Constitution did not provide who or how the determination of inability to serve was to proceed, and no one attempted it. This period, and several others of other Presidents, is considered to be a major reason for adoption of the Twenty-Fifth Amendment to the Constitution in 1967.


Calvin Coolidge

Often remembered for being taciturn, he had an effective career before as Massachusetts Governor. He succeeded to the Presidency upon Harding’s death by heart attack. He finished that term, and ran for a second term. His son, Calvin, Jr., died of sepsis from an infected blister on his foot resulting from a tennis game at the White House. Coolidge’s despondency and grief, blaming himself for being too involved in politics and inability to save his son, became life-altering major depression, losing all zest and feeling that the light had gone out of his life.


Franklin D. Roosevelt
The only President to be elected to a third and fourth term (which now is precluded by Constitutional Amendment), is well-known for his polio (the full extent of his paralysis being concealed from the public), Roosevelt had bad hypertension which progressed to cardiac disease and was worn-out during World War II, with noticeable periods of illness and decreased effectiveness at and subsequent to the Yalta Conference. He survived only four months into his fourth term, dying of a massive hemorrhagic stroke in Warm Springs, Georgia, where he would vacation and do physical therapy. This left Harry S. Truman to become President, complete the war; devise post-war demobilization, recovery; and deal with a Cold War of occupation, espionage, and Korean “Police Action.”


Dwight D. Eisenhower

Eisenhower “smoked like a furnace” at four packs a day during World War II, although he quit, cold turkey, at 56 years of age. September 23rd, 24th, and 25th of 1955, he experienced chest pains, resulting an anterolateral MI “the size of an olive.” He directed that the public be told everything; probably the first occurrence of such disclosure. The stock market panicked with a 6% drop in Dow Jones (~$14 Billion). His eventual death was due to Congestive Heart Failure, but he had endured “at least seven heart attacks, fourteen cardiac arrests;” ventricular aneurysm giving rise to his first stroke (subtherapeutic PT); COPD with O2 prn during his last three years of Presidency; Cholelitihiasis with sixteen stones at cholecystectomy; Crohn’s disease with SBO and ileotransverse anastomosis upon resection. (DuPont). He was among the first to receive DC defibrillation, and Bretyllium. He survived 14 years after his first MI. An adrenal pheochromocytoma was found on autopsy.


John F. Kennedy
Kennedy is now known to have Addison’s disease, diagnosed in 1947 but always kept secret, chronic back pain requiring many meds and several surgeries, hypothyroidism. He was at risk if there was a physical crisis, and two endocrine disorders suggest an autoimmune disorder. The impact of his polypharmacy on functional ability is debated.


This selection of presidential health and histories calls to mind the last words of Alexander the Great: “I am dying with the help of too many physicians.”


Clearly, modern medicine, had it existed at the time would have benefitted the victims. Additionally, there is the pervasive problem of multiple providers, disagreement, deference to the illustrious patient, a wish to be associated with the care of august persons, a tendency to secrecy, and less than adequate care than would be provided others.


While the absolute likelihood of being involved in such an incident is exceedingly small, it is always possible with travel and public appearances being an essential part of the Presidency.


As March is nearly here, remember: "The Ides of March is here." March 15 is the anniversary of the assassination of Julius Caesar. And, too, bear in mind the old injunction "Memento mori."




PBS NewsHour: Despite what you think, Presidents Day doesn't include Lincoln. February 16, 2014.


DuPont, Drew, MD, MSPH. "Illness in the White House: The Health of US Presidents" (no date) pdf of ppt from Internet source, not currently indexed.


Healthline Editorial Team [writers]; Kruick, George, MD MBA. [Editor]. Presidential Diseases. [2013]


A History of Death and Illness in the White House: U.S. Presidents' Disabilities (1993) C-Span interview of Robert E. Gilbert, author of The Mortal Presidency. Published on Jan 27, 2015.


PBS NewsHour” Dec. 14, 1799 The excruciating final hours of President George Washington. December 14, 2014.


PBS NewsHour: Bloodletting, blisters and the mystery of George Washington’s death. December 15, 2014.


George Washington Eyewitness Account of his Death © 2013.  Part of “Health and Medical History of President

George Washington.”


Vadakan, VV. (2002) The Asphyxiating and Exsanguinating Death of President George Washington. Permanente Journal. Spring 2004. Volume 8; Number 2.


Curfman, DR . The Medical History of the Father of our Country - General George Washington. The Order of the Founders and Patriots of America. ©2015. Articles


Schmidt, P. J. (2002). Transfuse George Washington!. Transfusion, 42(2), 275-277.


Ledgin, Norm. Diagnosing Jefferson: Evidence of a Condition that Guided His Beliefs, Behavior, and Personal Associations (2000  Future Horizons. ISBN-10: 1885477600


Leale, Charles A., MD.  Report of Dr. Charles A. Leale on Assassination, April 15, 1865. The Papers of Abraham Lincoln. .


“Is there a surgeon in the house?” Papers of Abraham Lincoln researcher discovers report of Dr. Charles A. Leale, first physician to reach Lincoln at Ford’s Theatre. June 5, 2012 News report and transcript of the manuscript “true copy” of Dr. Leale’s report of the assassination and medical care of President Lincoln. (above item; photographs of manuscript)


Sotos, John G. Taft and Pickwick; Sleep Apnea in the White House. Chest ®. September 2003. V.124 (3) 1133


 "The Death of President Franklin Roosevelt, 1945." EyeWitness to History, (2008).


Dallek, Matthew. (2012?) Franklin Delano Roosevelt—Four-Term President—and the Election of 1944.  The Gilder Lehrman Institute of American History.


Rogers, William Warren. “The Death of a President, April 12, 1945: An Account from Warm Springs” Reprinted from The Georgia Historical Quarterly, Vol. LXXV, No. 1, Summer 1991.


Heaton, L. D., Ravdin, I. S., Blades, B., & Whelan, T. J. (1964). President Eisenhower's Operation for Regional Enteritis A Footnote to History. Annals of surgery, 159(5), 661.


Wright, J. (2008). Cameos of Terror–Four US Presidents and a Senator. The Medscape Journal of Medicine, 10(7), 170.


PBS NewsHour. President Kennnedy’s Health Secrets. (Interview of a physician and an historian who had reviewed Kennedy’s health records at the Kennedy Library.) Transcript. November 18, 2002.


Dallek, Robert. “The Medical Ordeals of JFK. The Atlantic Monthly. December 2002. Article drawn from An Unfinished Life: John F. Kennedy, 1917-1963; Little Brown. Medical review by Jeffrey Kelman, MS MD. The above interview is with the authors and concerning this book.


Interviews: "Pulling Back the Curtain" (November 14, 2002) Interview in The Atlantic Monthly (Atlantic Unbound) concerning the development of the above article and book.


Groves, J. E., Dunderdale, B. A., & Stern, T. A. (2002). Celebrity patients, VIPs, and potentates. Primary care companion to the Journal of clinical psychiatry, 4(6), 215.


Tom Trimble, RN CEN
All opinions are solely those of the author.

Monday, January 26, 2015

When I was a Paramedic, there were two bêtes-noirs (black beast) calls that I did not wish to encounter. The first would be a birth upon the third floor up, with a prolapsed cord, as maintaining displacement pressure and carrying the stretcher on the stairs would be so awkward. The other, not discussed today, would have been to be confronted with an absolute need for an unavoidable cricothyrotomy, as there was no protocol to do one at all. (Either a Hero, or "the schmuck who used to work here.")


Another crew did have the prolapsed cord case, and resolved the issue by carrying Mom's stretcher down the stairs head-first providing steep reverse Trendelenburg's position (not clear if genupectoral position was used) to take pressure off the cord. All went well. Not in the textbook, but it worked.


Usually, in the ED, the simple and great goal is to get the parturient upstairs to OB-GYN, if you have one, as soon as possible. Sometimes, you can't just get away with a smile, wave, and hearty “Good Luck!” spoken.


Always, the concern is that not just one patient is being treated, but two. Whether, the problem is chronic or incidental disease or a trauma in a gravid patient; a complication of the pregnancy; morphological changes of pregnancy that impact the care that you would give for an emergency condition; placental abruption or praevia; fetal demise, or a disaster of the labor,  delivery, or post-partum; --You may be the best available or timeliest provider.


Here, then, are some links for Third Trimester Emergencies. Keep your ultrasound handy. Verify your own laws and protocols for your practice before instituting change. Understand the application of the EMTALA law (Emergency Medical Treatment and Active Labor Act [USA]) to your situation. Know and mobilize your resources and referral centers that might send a team.


Montefiore & NYMC Phelps Family Medicine Residents have some obstetric presentations for you.


Management of Cord Prolapse & Shoulder Dystocia [ppt] Eliza Rivera-Mitu, RN, MSN


Cord Prolapse - Perinatal Services British Columbia [pdf]


Umbilical cord prolapse A plan for an ob emergency

By Sharon T. Phelan MD, Bradley D. Holbrook MD September 01, 2013


Umbilical Cord Prolapse and Other Cord Emergencies Marybeth Lore, MD


Complications of Labor and Delivery by Jeanie Ward


Pulmonary Embolism: Evaluation in the pregnant patient. (2014) Emergency Care Institute, New South Wales.


Gist, R. S., Stafford, I. P., Leibowitz, A. B., & Beilin, Y. (2009). Amniotic fluid embolism. Anesthesia & Analgesia, 108(5), 1599-1602.


Third Trimester Bleeding [ppt] Scott Ramshur, MD


Third trimester bleeding [ppt] Tom Archer, MD MBA UCSD Anesthesiology


Kinney-Ham, L., Nguyen, H. B., Steele, R., & Walters, E. L. (2011). Acute aortic dissection in third trimester pregnancy without risk factors. Western Journal of Emergency Medicine, 12(4), 571.


Western Journal of Emergency Medicine, Vol 15 Issue 6 has five articles related to pregnancy.



Munnur, U., de Boisblanc, B., & Suresh, M. S. (2005). Airway problems in pregnancy. Critical care medicine, 33(10), S259-S268.


Mhyre, J. M., & Healy, D. (2011). The unanticipated difficult intubation in obstetrics. Anesthesia & Analgesia, 112(3), 648-652.


California Maternal Quality Care Collaborative. Preeclampsia/ Eclampsia - Emergency Department Resources.  {3 abstracts}


Luckett-Gatopoulos, S. (2014) Tiny Tip: PRE-eclampsia.


Nickson, C. Postpartum Emergencies. Life in the Fast Lane.


Egan, D. J., Bisanzo, M. C., & Hutson, H. (2009). Emergency department evaluation and management of peripartum cardiomyopathy. The Journal of emergency medicine, 36(2), 141-147.


Shaikh, N. (2010). An obstetric emergency called peripartum cardiomyopathy!. Journal of Emergencies, Trauma and Shock, 3(1), 39.


Capriola, M. (2013). Peripartum cardiomyopathy: a review. International journal of women's health, 5, 1.


Fett, J. D. (2014). Peripartum cardiomyopathy: A puzzle closer to solution. World journal of cardiology, 6(3), 87.


Jeejeebhoy, F. M., & Morrison, L. J. (2013). Maternal cardiac arrest: a practical and comprehensive review. Emergency medicine international, 2013.


Dijkman A, Huisman C, Smit M, Schutte J, Zwart J, van Roosmalen J, Oepkes D. Cardiac arrest in pregnancy: increasing use of perimortem caesarean section due to emergency skills training? BJOG 2010;117:282–287.


Weingart, S., MD (reviewing presentation of Salil Bhandari; article link, videos, related links) EMCrit Conference Blast Winner: Peri-Mortem C-Section .


Reid, C (2011) Prehospital resuscitative hysterotomy op.cit.


Roe III, EJ, MD, MBA, FACEP, FAAEM, MSF, CPE. Perimortem Cesarean Delivery. (2014)


Sullivan, MG (2007) Time Is Critical for Success in Perimortem C-Section ACEP News.


Status Asthmaticus in Pregnancy from Life in the Fast Lane Literature Review by Dr Chris Nickson


     NEW Link added after initial posting of blog.
Geoff Jara-Almonte, MD and Hilary Fairbrother, MD  // Editor: Alex Koyfman, MD Resuscitation of the Pregnant Trauma Patient – Pearls and Pitfalls 2/6/2025


Desjardins, G. (2005). Management of the injured pregnant patient. Trauma. org.


Hill, CC. (2009) Trauma in the Obstetrical Patient.


Schwaitzberg, SD. (2013) Trauma and Pregnancy.


Roemer, B., et al. (2014) Trauma in the Obstetric Patient: A Bedside Tool. American College of Emergency Physicians.


Beauchamp, Luanna, MD FACOG (no date) Trauma in the Pregnant Female. [ppt] Eastern Idaho Regional Medical Center.


Kapadia, S., & Parmar, K. (2014). Antepartum Intrauterine Foetal Deaths In Third Trimester At A Tertiary Care Center. Emergency, 129, 80-1.


Fatima, U., Sherwani, R., Khan, T., & Zaheer, S. (2014). Foetal Autopsy-Categories and Causes of Death. Journal of clinical and diagnostic research: JCDR, 8(10), FC05.


Long, long ago, an Instructor gave the blithe and authoritative injunction to not worry about childbirth: "It's easy. It's just like catching a football." To this all-too-free assurance, there could only be one reply: "I've never seen a football come at me feet-first, or with a cord wrapped around its neck!"


Good Luck!


Tom Trimble, RN CEN
All opinions are solely those of the author.

Thursday, December 18, 2014

Mankind seems to like making lists. Grocery and to-do lists; “Lists of Ten” in the books “for Dummies” series; various “books of lists.” Moses and God had a discussion that was rendered as a list of Ten Commandments. Many professions impart important rules as “Ten Commandments.” Jokes about physicians and God aspiring to each other’s job, aside, there seem to be a quantity of “Lists of Ten.”


It is not only common in Medicine (remembering that Divinity, Medicine, and Law were the classic doctoral professions), the form occurs in many fields when someone wishes to convey a declarative, injunctive, pronunciamento on essential matters, often borrowing the literary tones of English from the King James Bible to add gravitas.


Here are some useful and informative commandments from many fields: ours; allied fields; those that are helpful with other committees or responsibilities; are socially practical; and may help cope with regulatory compliance and challenges by law.


All are links, therefore minimal citations are made. Chosen from available material, some links may seem to be odd choices, but give insight into the work of others, or may be a springboard for thought. All knowledge is useful, if carefully selected and applied correctly.


Effort has been made to stick to “Ten Commandments” sources, with few exceptions. As always, assure for yourself whether they are currently valid, appropriate, permitted, and safe for your practice.





Emergency Medicine

The Ten Commandments of Emergency Medicine

Wrenn, K., & Slovis, C. M. (1991). The ten commandments of emergency medicine. Annals of emergency medicine, 20(10), 1146-1147.




Advice to New Interns

(Commentary upon 10 Commandments of EM)


Ten Commandments of Emergency Medicine


Luke & Cusack

Cork Emergency Medicine 2014


The Derriford twelve commandments of emergency medicine: a model for good practice in a changing world, or a survival guide for new medical staff

Smith, J. E., Higginson, I., Guly, H. R., Grant, I. C., Belsham, P., Hicks, A., ... & Boon, D. (2008). The Derriford twelve commandments of emergency medicine: a model for good practice in a changing world, or a survival guide for new medical staff. Emergency Medicine Journal, 25(12), 824-826.




The Ten Commandments of Medical Emergency Management for Dentists


Pediatric Emergency Medicines

Ten Commandments of Pediatric Emergency Medicine

Givens T. The Ten Commandments of Pediatric Emergency Medicine. J Emerg Med. 2004 Aug;27(2):193-4. PubMed PMID: 15261366.



What are the ten new commandments in severe polytrauma management?
Kam, C. W., Lai, C. H., Lam, S. K., So, F. L., Lau, C. L., & Cheung, K. H. (2010). What are the ten new
commandments in severe polytrauma management. World J Emerg Med, 1(2), 85-92.`




The „10 commandments“ of pediatric trauma

[07. Kinder und Jugendliche im Schockraum]
(English & German)

Dr. med. Ruth Löllgen, OÄ, Notfallzentrum für Kinder und Jugendliche




Electrocardiography Pitfalls and Artifacts: The 10 Commandments

Baranchuk, A., Shaw, C., Alanazi, H., Campbell, D., Bally, K., Redfearn, D. P., … & Abdollah, H. (2009). Electrocardiography pitfalls and artifacts: the 10 commandments. Critical care nurse, 29(1), 67-73.




The Ten Commandments of Wound Management

Ernst, A., Herzog, M., & Seidl, R. O. (2006). Head and Neck Trauma: An Interdisciplinary Approach. Thieme.




Ten commandments of burn management

Gupta J L. Ten commandments of burn management. Indian J Burns 2012;20:7-10




Transfusion ten commandments



The Ten Commandments of Airway Management

Slovis, C. M. (2005). Simple lessons to guide oxygenation & ventilation. JEMS.


Primary Care

10 commandments of primary care


Urgent Care

Deconstructing the Ten Commandments of Urgent Care Medicine



Vascular Emergency

The ‘Ten Commandments’ for European Society of Cardiology Guidelines on Aortic Diseases




The Ten Commandments of Good Psychiatry: Perspectives of a Fundamentalist Psychiatrist




Calming agitation with words, not drugs: 10 commandments for safety




Stress Aversion: 10 Commandments of Stress Avoidance for Working Moms




The 10 Commandments of Patient Engagement




Ten Commandments the Hearing Impaired Wish You Knew




The Ten Commandments of Communicating with People With Disabilities




The Ten Commandments Of Interacting With People With Mental Health Disabilities




Ten Commandments of Communicating about people with Intellectual Disabilities




Ten Commandments for Parents of Special Needs Children




10 Commandments of Good Parenting




10 Commandments of Dysfunctional Families


How they become that way


The 10 Commandments for Delivering Bad News


Workplace Human



Ten Commandments for the Care of Terminally Ill Patients




10 Commandments of Great Customer Service




10 Commandments for Hospitalists


An Oncologist’s view of patient needs when the patient is a caregiver.


10 Commandments for Nurses



Clinical Decision Support

The ten commandments of laboratory testing for emergency physicians

Lippi, G., Cervellin, G., & Plebani, M. (2014). The ten commandments of laboratory testing for emergency physicians. Clinical Chemistry and Laboratory Medicine, 52(2), 183-187.




Teaching in accident and emergency medicine: 10 commandments of accident and emergency radiology.

Touquet, R., Driscoll, P., & Nicholson, D. (1995). Teaching in accident and emergency medicine: 10 commandments of accident and emergency radiology. BMJ: British Medical Journal, 310(6980), 642.




“The Ten Commandments” for the Use of Iodinated Contrast Media




Ten Commandments to Reduce Cognitive Errors




Ten Commandments to Reduce Diagnostic Errors




Commandments to reduce cognitive and diagnostic errors


Blog adaptation of above two items.


Presentation ten most famous medical mistakes





Ten commandments for implementing clinical information systems




Ten Commandments for Effective Clinical Decision Support:

Making the Practice of Evidence-based Medicine a Reality



Risk Mgmt.

10 Commandments of Risk Management


(Camp Operations)


THE "20 Commandments" of EMTALA




Ten Commandments For Malpractice Depositions




The Top Ten Ways to Ensure Frustration, Miscommunication, and Poor Patient Care the Next Time You Provide (or Request) a Consult

[N.B. This is one of 15 articles in the same pdf relating to legal risks of consultations in the E.D.]


Patient Safety

Ten Patient Safety Commandments

A Health System’s view of patients helping their own safety.


The Ten Commandments of Emergency Care Research (p59 ff)


Mass Casualty

Management of Conventional Mass Casualty Incidents: Ten Commandments for Hospital Planning
Lynn, M., Gurr, D., Memon, A., & Kaliff, J. (2006). Management of conventional mass casualty incidents: ten commandments for hospital planning. Journal of burn care & research, 27(5), 649-658.



The 10 Commandments of Emergency Management (Opinion)



Psychosocial Response to Mass Casualty Terrorism: Guidelines for Physicians

(Not a Ten Commandments)



"Ten Commandments of Security and Law Enforcement" or "The Ten Deadly Sins."

Personal Security at Operational Level


The 10 Commandments of Preparedness

“Prepper” Philosophy


Ten Commandments of Emergency Preparedness Training

Trainer’s Tips for Training


Crisis and Critical Risk Communication

CDC guide for public messages & spokespersons


Crisis Management's 10 Critical Commandments


Explaining to the Public


Ten Commandments for using SMS in natural disasters

Text Alert Programs


Ten Commandments of security design



Top Ten Government Healthcare IT Security Commandments




Black Hat 2014: The 10 Commandments of Modern Cybersecurity




The ‘Ten Commandments’ of hospital design





The 10 Commandments For The OHS Person



The 10 Commandments of Safety for Supervisors


(Electrical Industry)


The 10 commandments of workplace safety



The Ten commandments of Safety Stop Taking Avoidable Risks - NOAA

(Detailed ppt for formal accident prevention program)


The 10 Commandments of Workplace Wellbeing Practitioners


Outdoor & Occupational


Ten Commandments of First Aid For Divers - First Aid for Diving Emergencies - Does the Diagnosis Matter?



Bush Survival 10 Commandments




10 Commandments of Avalanche Safety – Bruce Tremper




The Ten Commandments of Tractor Safety




The 10 Commandments of Event Safety



The Ten Commandments of Goal Setting



Ten Commandments for Implementing Change




The 10 Commandments of Steve Jobs [Infographic]




Quality Corner--Part 4: The 10 Commandments of Quality EMS



The Other Ten Commandments  10 Simple Steps to EMS Success



Fire Service

10 Commandments of Fire Safety




The Fire Department PIO Ten Commandments




10 Commandments Of Awesome Hot Chocolate




      Tom Trimble, RN CEN
All opinions are solely those of the author.

Friday, November 21, 2014

Unfortunately, most people learn most of what they think they know about firearms usage, ballistics, and gun handling from the entertainment industries. When stories are devised for entertainment, errors, or lies, are tolerated for “dramatic effect” and greater profits in a very competitive high-stakes industry with ever-evolving demands for yet more “cool” and bigger bang explosions. Truth, good sense, and science have nothing to do it with it.


True cowboys carried five rounds in their simple six-shooter for safety; the TV cowboys of our youth fired many more without reloading. The stunt man who is “shot” has a wired harness to yank him backwards off his feet. There’s no such thing as a handgun that is not detectable at the airport. Silencers don’t.  You can’t dance away from bullets as in Matrix, nor outrun an explosion.


All firearms-related events must be explained by laws of physics, mechanical and chemical engineering, and variables such as climatic effects and altitude, misadventure, human anatomy, physiology, and psychology. Very few conclusions can be drawn from the impressions of initial exam and treatment.


Because of skin elasticity, and wounding variables, it is not possible from wound appearance to judge the caliber of the missile. With measurements by thousandths of an inch, laboratory examination and measurement is more accurate.


Likewise the small hole is not necessarily the entry, nor is the large wound the exit. A contact wound may have gasses reflected backwards from a hard surface that blows the wound outwards. A round may dissipate its energy within the body and make only a small exit wound or none.


Projectiles do not travel in a straight line, neither in air nor through human tissue. The bullet may take an erratic path within the body as it meets different densities, or even be embolized. Be suspicious and thorough. Check for pulses and vascular insufficiency, or murmur. Sonography/radiography may help localize.


There is a vast difference in wounding effect between handguns and rifles or shotguns. There is no perfect weapon; and stopping a determined or drugged assailant may require many wounds; even wounds which will ultimately be fatal may not slow the aggression.


Wounding locations may not be what was initially perceived or stated due to movement during reaction time from detection of danger, response to assault, or delay in noting the ending of the fight. Natural psycho-physiological responses may alter perceptions during the life-threatening event.


It is critically important to document the physical findings in a plain-seeing, plain-speaking, non-judgmental manner that will not color or taint future investigations. In short, describe the simple appearance of wounds and findings, and the body’s response, without any forensic conclusions.


Avoid using wounding holes in clothing or tissue as the start of cutting with shears or incising tissue. Photograph whenever possible. Remember the confusion from JFK’s tracheotomy in the neck wound, and information recorded (or not recorded) in the chart.


Use paper bags, NOT plastic bags, for removed clothing, or to bag hands and feet, due to the “hot-house environment” created within the plastic that will degrade organic matter.

Call investigators and evidence technicians as soon as possible for best preservation and chain-of-custody evidence trail for all possible evidence. One must be prepared to state who had the evidence, when and for how long, and to whom and how it was transferred, at all times.


Recovered projectiles are preferably handled with gloved fingers, rather than toothed forceps that may alter evidentiary striations.


Accurate time entries are important to document.


It is not possible during acute resuscitation or at any time before a complete investigation, or even trial, to know who is innocent, guilty, or what occurred during the altercation. If you think your patient is the perpetrator, he may well be

an innocent, or even an off-duty or undercover officer. Do not compromise your care.


If there is active shooting around you, move, duck, get behind impenetrable cover, and leave by the safest way as soon as possible. Bullets, splinters, secondary missiles, do not discriminate or have a conscience; there is no self-destruct for a projectile in flight –it will not care whom it hits or discern if it was deserved or not. Police officers have poor hit probability, ricochets may occur, suppressive fire may be used (“keep ‘em pinned down”), or even ‘spray and pray.” Being a health care worker does not protect you from fire coming your way.


You are not safer in an area that is posted as a “gun-free zone.” Many potential, and defenseless, victims draw crazy “active killers.” 92% of recent events have occurred in such areas. Regardless, the number of such terror attacks is far less than public perception, is decreasing, and outnumbered by less obvious dangers.


The Eddie Eagle GunSafe® Program, an effective and suitable safety program for young children, is provided by the National Rifle Association, It only promotes safety, not gun use.


Discussion of safety issues have led to safety rules for firearms in different forms  for many years. The most durable and concise modern expression is the Four Rules of Gun Safety by Col. Jeff Cooper, a USMC officer, academician, firearms trainer and expert. Any accidental or negligent shooting is a violation of one or more of these rules.


1. All guns are always loaded. Even if they are not, treat them as if they are.

2. Never let the muzzle cover anything you are not willing to destroy. (For those who insist that this particular gun is unloaded, see Rule 1.)

3. Keep your finger off the trigger till your sights are on the target. This is the Golden Rule. Its violation is directly responsible for about 60 percent of inadvertent discharges.

4. Identify your target, and what is behind it. Never shoot at anything that you have not positively identified,


The Eddie Eagle GunSafe® Program, an effective and suitable safety program for young children, is provided by the National Rifle Association, It only promotes safety, not gun use.


Simple Ballistics
Duke Orthopaedics presents Wheeless' Textbook of Orthopaedics: Gun Shot Wounds
Simple Reviews
Prehospital Care  Blog of medical and trauma care by Orthopaedic Surgeons in an austere environment in association with Society of Military Orthopedic Surgeons

Norouzpour, A., Khoshdel, A. R., Modaghegh, M. H., & Kazemzadeh, G. H. (2013). Prehospital Management of Gunshot Patients at Major Trauma Care Centers: Exploring the Gaps in Patient Care. Trauma Monthly, 18(2), 62.

PMID: 24350154 [PubMed] PMCID: PMC3860682

Tactical Combat Casualty Care (ppt)

Dan S. Mosely, Maj USA MC FS  20 Jun 05

Treatment Reviews

Bruner, D., Gustafson, C. G., & Visintainer, C. (2011). Ballistic injuries in the emergency department. Emergency medicine practice, 13(12), 1-30.

PMID 22232864 EB Medicine: Full text

Motamedi, M. H. K., Ebrahimi, A., & Shams, A. (2013). Current trends in the management of maxillofacial gunshot injuries: a critical review. Annals of Oral & Maxillofacial Surgery, 1(1), 8.

Rohit Shahani, MD, MS, MCh  & Jan David Galla, MD, PhD Penetrating Chest Trauma Treatment & Management  Medscape Updated: Dec 13, 2013

Dicpinigaitis, P. A., Koval, K. J., Tejwani, N. C., & Egol, K. A. (2006). Gunshot wounds to the extremities. BULLETIN-HOSPITAL FOR JOINT DISEASES NEW YORK, 64(3/4), 139.

de Barros Filho, T. E. P., Cristante, A. F., Marcon, R. M., Ono, A., & Bilhar, R. (2014). Gunshot injuries in the spine. Spinal cord. Spinal Cord (2014) 52, 504–510; doi:10.1038/sc.2014.56; published online 29 April 2014

Evolution of Care and Survival

In Medical Triumph, Homicides Fall Despite Soaring Gun Violence

By Gary Fields and Cameron McWhirter.  The Wall Street Journal Updated Dec. 8, 2012 12:12 a.m. ET

Hostile Fire Environments

Murphy’s Law of Combat Operations 
[includes coarse military humor]

Firearms in the Entertainment Industry
Horman, GS. 10 Movie Myths Dispelled “American Rifleman July 16, 2012

Pappalardo, Joe Anatomy of the Perfect (Undead) Headshot  Popular Mechanics website ©2014 Hearst Communication, Inc.

Seymour, Mike The Art of Wire Removal 10/27/07
{How stuntmen’s wires are removed from the image that you see on screen.}
Gun Safety
Gun Control Controversy

GunFacts.Info website 119 pp pdf

Lott, John R. New CPRC Report: Errors in Bloomberg’s latest report on Mass Shootings October 2, 2014 Crime Prevention Research Center

Lott, John R., Jr .Report from the Crime Prevention Research Center

The Myths about Mass Public Shootings: Analysis

October 9, 2014 Revised 36pp pdf

The Facts about Mass Shootings  It’s time to address mental health and gun-free zones. By John Fund. National Review Online December 16, 2012 4:00 PM


      Tom Trimble, RN CEN
All opinions are solely those of the author.

About the Author

Tom Trimble
Tom Trimble, RN CEN is the Online Editor of AENJ.