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Advanced Emergency Nursing Blog from AENJ
The concepts, concerns, clinical practices, researches, and future of Advanced Emergency Nursing.
Sunday, January 31, 2016

​​I've been very fortunate in that my careers in emergency care have spanned many years, much of which was transitional and transformative so that I have lived (as the fortune cookie might say) "in interesting times.

There is in photojournalism, an apocryphal story of a prize-winning photo of a suicidal jumper snapped dramatically in mid-flight. The photographer is asked "How did you get that shot?" The reply was "It's nothing; just f/11, and be there."   To which, one might ascribe a translation:

  1. Be present, before or when events happen.
  2. Be alert to possibilities.
  3. Be pre-positioned anticipating events.
  4. Be suitably equipped, dialed-in, and ready to go.
  5. Make the decision (at what photographic-great Cartier-Bresson called "The Decisive Moment.")

This, in a sense, is an allegory to the realities of emergency care. Compare the possibilities of cardiac arrest resuscitation survival while in the Cardiac Cath Lab, the witnessed versus unwitnessed cardiac arrest in the ED, or the witnessed versus unwitnessed out-of-hospital cardiac arrest. There are no guarantees, only varying degrees of potential luck related to opportunity. 

My odyssey began as a younger brother who would frequently spend long periods reading my brother's "Handbook for Boys". I was able to witness (and be the patrol's practice mannequin for) the transition from Shafer's artificial respiration, the back and forth between Holger-Nielsen's and Sylvester's methods, and ultimately the "Rescue Breathing" of Peter Safar, James O. Elam, and Archer S. Gordon. This ultimately led me through Boy Scout first aid; American Red Cross first aid; teaching first aid; ambulance work in the pre-EMT era; teaching in an early EMT class; Paramedic; and nursing as an Emergency Nurse. 

My ambulance service was an early adopter: we were all certified in ACLS when few physicians and practically no nurses were. Have I seen changes? It's said that Sir William Osler remarked to always be sure to use a medication when it's new and still has the power to heal. The joke runs that we're so old that we remember when lidocaine worked. The first drug to go was the

  • aminophylline drip (bronchospasm);
  • then Hyperstat® Diazoxide (hypertensive emergency, but caused MIs and hypotension);
  • Isoproterenol drips for PEA (didn't work);
  • lidocaine drips for ventricular arrhythmias in favor of repeat bolus treatment;
  • Bretyllium came and went without being the hot number that it was expected to be;
  • Furosemide was a mainstay in Acute Pulmonary Edema, along with
  • Rotating Tourniquets (which was temporizing in decreasing preload);
  • Morphine didn't actually come until years later, so it wasn't treatment for CHF.
  • Valsalva's Maneuver could be used for PSVT after the IV (sometimes had to stop on-scene physicians) but one might innocently ask the patient to push himself upwards in the gurney. Adenosine eliminated doing Valsalva.
  • Dopamine was our only pressor.
  • Nitroprusside was not available.
  • I've had one "Precordial Thump" work, and one not: both were complete saves ("… and be there"). 

Our city was fairly compact with shorter transport times and each county devised its own drug list, so some drugs were not part of our drug bag. We believed in "priming the pump" first with a round of epinephrine and NAHCO3 before attempting defibrillation. We did uninterrupted cardiac compressions with interposed ventilations (this is trending again with an advanced airway in place to minimize interruptions). It took years to encounter "primary VF" (due to lack of 911 systems and late discovery/responses) but the switch to immediate shock had taken place: it was a clear very fine low voltage VF ("I've got a bad a feeling about this …"). No priming allowed: the shock converted to unresuscitable asystole and the patient died. One really only needed to know Sinus Rhythm, Atrial Fibrillation, and Asystole: there was rarely anything else. 

To paraphrase Lincoln Steffens, "I have watched the future come to be, and it's working."

       Sincerely,
 
              Tom Trimble, RN CEN
 
              All opinions are solely those of the author.
              Readers must verify validity to their own practice.


Friday, December 11, 2015

 

There is news [Gever] that the FDA has approved the sale of Naloxone, to consumers, as a nasal spray for rescue of opioid overdose. This follows the g-r-a-d-u-a-l introduction to police and non-EMS basic responders of naloxone for this purpose, and prescribing to family and friends of opioid abusers. California, for example, now permits pharmacists with a one-hour in-service training to prescribe such to the public.

 

This is altogether “a good thing.” In the 55 years since its discovery [Wikipedia], it has garnered a well-earned reputation as an unparalleled specific antidote or remarkable safety. Taken in the whole, for emergency use, undesired side-effects are few (most often none) requiring only observation, supportive care, and to ensure that the opioid level is below a toxic level before discharge with appropriate referral and education about supportive services to prevent relapse in the addiction.

 

It is so specific in its effects that its maker, “Endo Laboratories, a division of E.I. du Pont de Nemours,” during the 1970s advertised with the slogan: The response is the diagnosis.”

 

The truth is that this initiative is more than four decades late in arriving. Even in that era, some EMS personnel, whether rogue or liberally supervised depending on your viewpoint, felt able to give away doses of naloxone to the victim’s friends for potential use in an overdose by the persons present.

 

During the intervening years, little was done to move towards availability of naloxone outside of professional circles. Feelings and arguments were rife  that “junkies” couldn’t be trusted with it; that the therapeutic half-life is shorter than that of heroin upon which the victim would fall into greater harm if not medically supervised; that it should or should not be a routine part of  the “coma cocktail” by EMS or EDs; or even that ready availability of a rescue drug would "encourage" the abuse of heroin.

 

Of course, in the interval, the patent has expired upon this drug of singular use, which does not have a “mass” market to drive sales. Industry changes for “Big Pharma" haven't made it easy to market naloxone to the public [Drum] One might surmise that new profits from an old drug could come from extending availability and outreach. Development of intranasal application devices and auto-injectors now make it easier for laypersons to give the drug with minimal training.


 

Ironically, the most important life-saving care in opioid overdose arrives with the companion or first responder regardless of any equipment present: respiratory support with mouth-to-mouth artificial respiration (if the rescuer is willing to perform it).

Of course, the HIV scare, associated with shared needles, frightened the public into avoiding the most effective means of artificial respiration. The recent substitution of  “Hands-only CPR” being taught --largely because the public is unwilling to do direct oral contact-- has further deemphasized artificial respiration.

 

However, “Hands-only" is more appropriate for a “sudden-death” cardiac event (the heart stops first in an oxygenated body), whereas an hypoxic-anoxic state from respiratory arrest would benefit from artificial respiration –a different scenario entirely, wherein the body runs out of oxygen before the heart stops. But, mouth-to-mouth lacks the magical pizzazz of a miracle antidote in a special device. And, “if I just inject him, I don’t have to put my mouth on his!

 

Nonetheless, naloxone use by friends or bystanders is a good thing. It won’t save everyone by itself (respiratory support delayed ; too long; or aspiration has occurred; brain damage from prolonged hypoxia ensues; or the addict didn't set aside $75 for the antidote to be on hand "in case" . . . ) but naloxone will save some. Just have a CPR mask or filter, and the willing skill to support breathing, also.

 

How many more lives might have been saved in the last four to five decades?

 

 

Gever, John. Naloxone Nasal Spray OK'd for Sale. —FDA approves fast-acting reversal agent for opioid overdose. MedPageToday – Emergency Medicine. 11/19/2015. Accessed 11/19/2015.

 

Metropolitan Boston Emergency Medical Service Council, Inc. Nasal Narcan Education Program [PPT]] narcan.ppt” Accessed 11/19/2015.

 

No author. Narcotic antagonists —newest weapon against addiction. Links to original article  in Chemical & Engineering News, July 3, 1972 History of; antagonists compared; early strategy attempts to counter addiction; controversies.

 

Drum, Kevin. A Cheap and Easy Way to Treat Drug Overdoses. Mother Jones magazine’s motherjones.com blog & commentary. Tue Apr. 16, 2013 11:04 AM EDT.  .

 

 

 

Sincerely,
 
Tom Trimble, RN CEN
 
All opinions are solely those of the author.
Readers must verify validity to their own practice.

 

 

 

 


Saturday, November 7, 2015

 

In the first part of my career, I did ambulance work, before there was ACLS, and certainly no pain medicine. We had only first aid, oxygen, and CPR to offer. Even as a Paramedic, in the early days, there was no analgesia, sedative (except for seizures), or anesthetic, to provide. One was alone with an Ill or injured patient in the back of an ambulance throughout bumpy trips. Thoughtful driving might minimize the bumps but not eliminate all of them. One had to engage with the patient and talk them (and listen to them) into not noticing whatever else was going on.

 

In my opinion, hypnosis is a little-understood but potentially valuable technique for the emergency department. In essence, it is a means of establishing rapport and conveying ideas, understandings, and possibilities, which might be useful for the patient. The patient isn't actually "asleep" as is so often thought, but is a willing participant who interacts knowingly for the benefits to be obtained.

 

In a sense, whenever a nurse or mother soothes a child, or analgesia is given with the suggestion of its benefit ("verbal endorphin enhancement"), or a patient is led by suggested imaginings ("guided imagery") to gain further benefit, then the principles of hypnosis have been used regardless of how it is called or the methods used. In truth, a so-called "trance" state does not need to exist for useful work to be done.

 

What is useful is for the practitioner to be able to establish a rapport, and to express what the patient might wish to use in a form that is meaningful from the patient's own needs, perceptions, and desires. "Why, yes, that's what we try to do with any patient!" ─Yes, of course, you do; that is good care and practice.

 

What is valuable is that training in hypnotherapy provides us with a way of making such a consistent practice of expressing things in a manner consistent with the patient's needs and desires so that it we use it effectively all the time. Why is this important? Remember that it is impossible to shout at a person to "Relax!" and have him do so. Everything must come from within. Redirection must create what is desired. If the patient is distracted, we suggest a focus. If the patient is focused elsewhere, we provide a distraction. Literally, focus is distraction; and, distraction is focus.

 

When a patient is in crisis, the world contracts to primal needs and perceptions seeking a control of self and immediate surroundings. This can make him spontaneously receptive to useful suggestion, and he will cling to it as a drowning man will cling to a floating object. This reinforcement helps him redraw his area of control; each slight physical improvement noted to him will reinforce his belief in his survival. When a patient is so adrift, give me a clinician who will lean in and talk directly to his ear with suggestions, encouragement, anticipatory guidance through what will come, and talks him through to confidence and success!

 

Is this hypnosis? Where's the swinging watch or spiral disc? Why is there no droning of "You are getting slee-e-e-py!"? Isn't this just good care? Yes; it is taking advantage of spontaneous natural receptivity to exchange meanings, understandings, and feelings. Yes; it is good care. And, it's using a hypnotherapeutic means to gain benefit for the patient. Studying hypnotherapy helps us make better use of these skills.

 

Why isn't hypnosis used more in emergency departments? I think that it's a number of things.

  • The ED is a bright, noisy, distracting, barely controlled environment with many interruptions. This is difficult to modify.
  • There is a common perception that hypnosis is a rare skill unsuited to the ED, and a feeling of wanting reliable scientific means to achieve effects. "There's no time for hypnosis. Propofol is my hypnosis."
  • No one wants to look weird, or to be using "alternative medicine" methods of dubious reliability. It seems odd to suggest hypnosis; so, in effect, we do what parts of it that we can, and call it something else as a euphemism.
  • It's difficult to have a cohesive team approach. Everyone works different shifts and may have different "styles" of practice; consultants may not be in on the scheme. It's not uncommon for a colleague to pipe up "Hey, you're making me sleepy!"
  • Calling in a "Child Life Specialist" may, in fact, be the only time that we admit we need non-pharmaceutical distraction, suggestion, and focus, to aid in the procedure. And, we don't even realize it as such.
  • When we say to a colleague, "Say, you did a great job in talking that patient down!" … we are saying that "You did a nice job in establishing rapport and communicating ideas, possibilities, and understandings."

 

Well, then, what to do?

  • Find a continuing education course in hypnotherapy.
  • Read any of the books by or about Milton H. Erickson, M.D. (an amazing and gifted American psychiatrist who pioneered modern methods of hypnosis); such books are often in medical or academic libraries, many are online with digital samples.
  • Contact your psychiatry service or Child Life for local suggestions.
  • Remember that your interactions with the patient needn't be a ritual or simulation of a "stage hypnosis" presentation. All that is necessary is to recognize when rapport is occurring, enhance it when possible, and frame the desired responses in terms that would be perceived and framed by the patient's own needs.
  • With patients in crisis (e.g., respiratory failure, awake intubation, etc.), a team clinician with these skills should engage the patient continuously, mouth to ear, until the patient is comfortable and stable.  

 

 

*Iserson, K. V. (2014). An hypnotic suggestion: review of hypnosis for clinical emergency care. The Journal of emergency medicine, 46(4), 588-596. http://dx.doi.org/10.1016/j.jemermed.2013.09.024 PMID: 24472351

 

*"New Definition: Hypnosis". Society of Psychological Hypnosis Division 30 – American Psychological Association as cited in Wikipedia.

 

*Deltito, J. A. (1984). Hypnosis in the treatment of acute pain in the emergency department setting. Postgraduate medical journal, 60(702), 263-266. PMCID: PMC2417820.

 

Anbar, R. D. (2002). Hypnosis in pediatrics: applications at a pediatric pulmonary center. BMC pediatrics, 2(1), 11. [PDF]

 

*Bierman, S. F. (1989). Hypnosis in the emergency department. The American journal of emergency medicine, 7(2), 238-242. http://dx.doi.org/10.1016/0735-6757(89)90145-9. PMID: 2920089.

 

Hopayian, K. (1984). A brief technique of hypnoanasthesia for children in a casualty department. Anaesthesia, 39(11), 1139-1141. PMID: 6507833.

 

O'Donnell, J., Maurice, S., & Beattie, T. (2002). Emergency analgesia in the paediatric population. Part III Non-pharmacological measures of pain relief and anxiolysis. Emergency medicine journal: EMJ, 19(3), 195. [PDF] PMID: 11971825.

 

Ehrlich, Steven D., NMD. Hypnotherapy.  University of Maryland Medical Center. Medical Reference Guide, Complementary and Alternative Medicine Guide. Last reviewed on 9/19/2013.

 

Wobst, A. H. (2007). Hypnosis and surgery: past, present, and future. Anesthesia & Analgesia, 104(5), 1199-1208. [PDF]

 

Marmer, M. J. (1956). The role of hypnosis in anesthesiology. Journal of the American Medical Association, 162(5), 441-443.

 

Stewart, J. H. (2005, April). Hypnosis in contemporary medicine. In Mayo Clinic Proceedings (Vol. 80, No. 4, pp. 511-524). Elsevier. [PDF]

 
 
     Sincerely,
 
           Tom Trimble, RN CEN
 
         
All opinions are solely those of the author.
           Readers must verify validity to their own practice.
 
 

Friday, October 2, 2015


All the world’s a stage,
And all the men and women merely players;
They have their exits and their entrances,
And one man in his time plays many parts,
His acts being seven ages. At first the infant,
Mewling and puking in the nurse’s arms;
And then the whining schoolboy, with his satchel
And shining morning face, creeping like snail
Unwillingly to school. And then the lover,
Sighing like furnace, with a woeful ballad
Made to his mistress’ eyebrow. Then a soldier,
Full of strange oaths, and bearded like the pard,
Jealous in honor, sudden and quick in quarrel,
Seeking the bubble reputation
Even in the cannon’s mouth. And then the justice,
In fair round belly with good capon lined,
With eyes severe and beard of formal cut,
Full of wise saws and modern instances;
And so he plays his part. The sixth age shifts
Into the lean and slippered pantaloon,
With spectacles on nose and pouch on side;
His youthful hose, well saved, a world too wide
For his shrunk shank; and his big manly voice,
Turning again toward childish treble, pipes
And whistles in his sound. Last scene of all,
That ends this strange eventful history,
Is second childishness and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything.

William Shakespeare’s
As You Like It Act II, Scene vii.

 

Recently, a nurse [Leonard] wrote of her father’s illness and learning to cope with changing roles and attaining empowerment as a nurse-advocate in her father’s care. It has been reposted widely.

 

Her story speaks to many of us as we ourselves age and retire; face the aging and end of life problems of our parents; reevaluate our roles as “good child” and and a “good subordinate” healthcare worker; and be able to speak up as needed. Her story has the advantage of having time to evolve and is still ongoing.

 

A large number of “older” nurses are now retiring, or withdrawing in hours of work, or from bedside care. I call this part of a “Broken-Down Baby Boomer Syndrome.” We are old, and if our parents still live, they are very old. The formerly up-and-coming younger professionals are hitting midlife stride but are developing their own aches and pains as their parents, no longer young, retire or become older and sicker. The youngest professionals are working, playing, starting families, and struggling with a completely different economy. Those second jobs will take a toll on their physique and psyche. More nurses yet will need to be recruited and educated to replace those leaving and to serve a population that will be 25% geriatric.

 

It is very off-putting to have one’s soundly reasoned professional advice to a parent be ignored, dismissed, or thought to be insulting the parent’s competence. One is the whippersnapper child, presumptuous, and even “planning to put me in an old-folks home.” Other divisive influences might exploit such contretemps to gain a foothold of control and misuse the trust that is given.

 

When the parent gives excuses, rationalizations, or even confabulates explanations, one really wants to believe those, and hardly think to question and investigate whether such is so. “Trust, but verify.”

 

With the parent’s provider, one might be thought to be only the “driver” for the appointment and not a natural ally with a common patient. (What, challenge my judgement?) When there are multiple specialist providers that can be too many blind men examining the fabled elephant and having different findings; polypharmacy is often a result. The unifying thoughts of the gate-keeping primary provider may be ignored by the elder who may respect the specialist more.

 

When there are different perceptions as to medical needs, one must try to depersonalize the family relationship briefly to ask oneself “If this were my patient, what would be the right thing to do?” As you owe a patient the kindness that you would show a parent, so must you also owe your parent the same professional advice that you would give your patient. Explaining and exploring the proposed action as the most reasonable step to return to status ante quo may be the most helpful approach.

 

Some degree of cooperation and shared understanding by the parent is required, as Powers of Attorney for Health Care Decisions are valid only during the incapacity of the parent and there is often a long and debatable period as to how much relative capacity actually exists in legal terms. A General Power of Attorney would be needed to manage finances and property. —Mom or Dad may seem to close relatives to be neglectful of responsibilities or “not doing well” yet still may have sufficient faculties to pass an interview to determine capacity (in the legal sense) and be bluffing their way along. Subtle signs may be noticed only by family but the law requires “hard” signs of grave disability to understand or manage affairs and plan for meeting basic needs.

 

If one can achieve some agreements beforehand to any serious illnesses, some problems can be forestalled. Be aware of friends and confidants who might be a willing ally. On touchy matters, such as a mental status evaluation, circumspection in supporting the recommendations of care agencies may be needed lest one be thought too ardent in changing status.

 

I learned from my mother that one must plan ahead for infirmities and old age just as much as planning for the events of today. There are no easy answers or predictable solutions for all possibilities, but trust and planning help.

 

Leonard, Julie, BSN, RN. “From our readers: When your parent is the patient.” American Nurse Today website. American Nurses Association (ANA), August 2015 Vol. 10 No. 8.

 

Sincerely,

 

Tom Trimble, RN CEN

 

All opinions are solely those of the author.

Readers must verify validity to their own practice.

 

#30#

 


Monday, September 14, 2015

 

 

Preface: In January 2015, this blog provided resources for Emergencies of the Third Trimester, however, we did not separately discuss airway management in third trimester pregnancy.

 

What:   When a third-trimester pregnant woman is stopped in your ED, one cannot help having concern for things that might go wrong. She’s there because your hospital is under-resourced, has injury or illness not thought related to gravidity, is too “sick” to make it to OB Labor/Delivery, or you’re trying to get OR to open. In rural Critical Access Hospitals, or austere conditions, you may be all that is available.

While one first thinks of problems with the pregnancy or the fetus, the woman may be there for reasons that may impact her life or that of her child: e.g., a motor vehicle collision may inflict injuries; especially as the seat belt may not have been worn due to poor fit (riding above the pelvis) or discomfort over the gravid uterus, thus she may have been at greater risk than other passengers. The greatest risk to the child is the risk to the mother.

 

Why:  Why did Rapid Sequence Induction by anaesthetists develop? Because of the grave concerns of airway management, difficult airway, and aspiration common to third-trimester pregnancy. 

Present obstetric anesthesia practice fosters awake delivery ± regional anesthesia whenever possible to avoid intubation; but when intubation is clearly needed, it is best performed with aspiration precautions, RSI, and a cuffed tube.

When difficulty occurs, second generation supraglottic airways may be used for rescue, especially one that favors conduit intubation through the SGA; concurrent ventilation with a bronchoscopy swivel adapter during fiberoptic guidance is ideal.

 

When: The patient needs airway control for resuscitation of mother or child, emergent surgery for maternal or fetal indications; block cannot be effected or would be unsafe. The concept of post-mortem caesarian delivery is being supplanted by ante-mortem resuscitative uterine extraction to save both mother and child.

 

What’s different about late-gravidity airways? – What to do about it?

  1. Increasing maternal weight, even morbid obesity, impairs stomach-emptying, and a diaphragm raised by baby’s presence, thus each partuitent is essentially a “full-stomach” patient. Further, there may also have been recurring esophageal reflux irritating the vocal cords.

  2. These reasons also decrease functional reserve capacity (FVC) of the lungs, and inhibit diaphragmatic excursion, especially if supine: patients can desaturate very quickly. Use the NODESAT technique. Monitor oximetry and capnography.

  3. The weight of the fetus upon the aorta and IVC, especially when supine, embarrasses return circulation, contributes to shock, and O2 delivery to the fetus may be sluggish. If the patient cannot be managed with a leftward tilt of the body and bolstered there, then Manual Displacement of the Gravid Uterus (leftward) is mandatory.

  4. Due to weight gain and fluid retention, tissues of the upper airway may be edematous, engorged, and friable, impairing laryngoscopy and intubation, also making manual upper airway manipulations and BVM ventilation more difficult. Obesity/Morbid Obesity increases the risks. Be prepared with a bougie or ventilating introducer such as the Frova Catheter, and with smaller-than-expected endotracheal tubes.

  5. As above, especially in short-necked women and obesity, the chest contours may be raised, and breasts enlarged, to the extent that your customary laryngoscope handle may not fit between the airway and the chest wall.

    –“Ramp” the patient to a 30° angle with the “ear hole” level with the manubrium/sternum, and face parallel to the ceiling. This helps all of the above, improves visualization of the glottis, improves FRC, improves oxygenation/ventilation, and minimizes regurgitation/aspiration.

    –Use a short or stubby handle, if available. If not, then de-mount the blade; insert in mouth sideways; rotate to correct A-P orientation; remount handle.

    –If you have difficulty visualizing your approach to the glottis while in the ramped position, consider:

    A) Using a footstool or standing on the end of the gurney to attain a superior altitude.

    B) Having an assistant who is facing “do the heavy lifting” taking over the laryngoscope handle while you look and direct.

    C) Lowering the bed, but not the head of the bed, and facing the patient yourself (or kneeling/straddling alongside on the bed surface), use your right hand to hold the inverted laryngoscope (like an Ice-Axe or Tomahawk) to perform laryngoscopy and manipulate the tube with your left hand.

    –A videolaryngoscope may be of great assistance.

    –If you foresee great difficulty, be fully set-up with a second-generation supraglottic airway (ideally, able to be a conduit for an endotracheal tube) and cricothyrotomy kit ready to go.

    –Don’t remain fixated on intubation. Oxygenation is primary. Ventilation is next. Neither requires an endotracheal tube. Call for help before, or upon first difficulty, not afterwards. More damage to the airway occurs with each attempt. Successful simplicity trumps a precarious triumph over adversity that results in a damaged airway or mother or child.

 

 

Kodali, B. S., Chandrasekhar, S., Bulich, L. N., Topulos, G. P., & Datta, S. (2008). Airway Changes during Labor and Delivery. Anesthesiology, 108(3), 357-362. [Free]

 

Isono, S. (2008). Mallampati classification, an estimate of upper airway anatomical balance, can change rapidly during labor. Anesthesiology, 108(3), 347. [Free]

 

Mrinalini Balki, M.B.B.S., M.D., Mary Ellen Cooke, M.D., F.R.C.P.C., Susan Dunington, M.A., R.R.T., F.C.S.R.T., Aliya Salman, M.D., F.R.C.P.C., Eric Goldszmidt, M.D., F.R.C.P.C.; Unanticipated Difficult Airway in Obstetric Patients: Development of a New Algorithm for Formative Assessment in High-fidelity Simulation. Anesthesiology 2012;117(4):883-897.

Figure 1. Algorithm for unanticipated difficult airway in obstetric patients. Ibid.

 

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

 

Geoff Jara-Almonte, MD and Hilary Fairbrother, MD  // Editor: Alex Koyfman, MD Resuscitation of the Pregnant Trauma Patient – Pearls and Pitfalls www.emdocs.net 2/6/2015

 

Cabrera, Daniel, M.D. A new mindset: from perimortem cesarean to resuscitative hysterotomy. EMBlog Mayo Clinic. Tue, Aug 25, 2015.

 

Weingart, Scott, MD. Use of the bougie for intubation.  YouTube. 6/2010.

Llobell, Francisca, MD PhD. Frova intubating catheter+ Jet rescue in mannequin. YouTube. May 24, 2014. 

Weingart, S. D., & Levitan, R. M. (2012). Preoxygenation and prevention of desaturation during emergency airway management. Annals of emergency medicine, 59(3), 165-175. [PDF]

Sincerely,
 
Tom Trimble, RN CEN
 
All opinions are solely those of the author.
Readers must verify validity to their own practice.

#30#

 

 

About the Author

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