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M2E Too! Mellick's Multimedia EduBlog
The M2E Too! Blog by Larry Mellick, MD, presents important clinical pearls using multimedia.

By its name, M2E Too! acknowledges that it is one of many emergency medicine blogs, but we hope this will serve as a creative commons for emergency physicians.

Thursday, October 01, 2015

We received three consecutive pediatric trauma patients on backboards and in cervical collars during a recent shift in the pediatric ED. What was obvious with all three of these patients was their lack of a neutral cervical spine. Their airways simultaneously appeared to be partially compromised as large occiputs caused cervical flexion, their chins were pushed upward, and their mouths were forced closed as the cervical collars’ chin stabilizers were scrunched against their chest walls.


The heads of children are disproportionately large compared with their bodies. The cartoonist, Charles Schulz, captured the essence of this in Charlie Brown. When placed in a supine position, a child’s relatively large head causes forward flexion of the neck on the body. This forward flexion or supine kyphosis has been described in an article by Herzenberg et al. as a cause of anterior translation of the fractured cervical spine in pediatric trauma patients. (J Bone Joint Surg Am 1989;71[1]:15.) (The movement of the fractured cervical spines demonstrated in this article was dramatic.) This neck flexion also has the potential for compromising the airway. As is currently taught in most Pediatric Advanced Life Support (PALS) courses, the open airway is best accomplished by placing padding under the shoulders of these children.


Nypaver et al. studied neutral position and defined it in their study as using enough padding under the shoulders to bring the long axis of the cervical spine perpendicular to the transverse axis of the head. (Ann Emerg Med 1994;23[2]:208.) Placing padding under the shoulders of a supine child to align the tragus of the ear and the apex of the shoulder appears to maintain a neutral cervical spine. This is one relatively rare clinical setting where a single maneuver can simultaneously accomplish two potentially life-saving interventions. I discussed the association between an “open airway and neutral cervical spine” in a 1993 letter to the editor. (Pediatr Emerg Care 1993;9[2]:128.)


I’ve hoped for decades that the “open airway-neutral cervical spine” concept would catch on as teaching dogma. Unfortunately, based on my observations, it just doesn’t seem to be on the radar of most EMS training programs or if it is being consistently taught, the concept is rapidly forgotten by practicing paramedics and EMTs.


Click here to watch the video.


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Tuesday, September 01, 2015

Emergency medicine was a section in the department of surgery at the Medical College of Georgia until we became a department in 1996. The designation as an academic department occurred as part of my job negotiations when I was being recruited as the first academic chairman of emergency medicine.


But sometimes hard feelings and animosity lingers. I would like to say that relations with our surgical services were amiable and characterized by mutual respect in the years that followed, but in fact, hostility, open and hidden, was common. Consequently, to this day I still have a slight surge of adrenaline (fight, not flight) when certain surgeons enter the emergency department.


We in emergency medicine pride ourselves on being increasingly comfortable performing surgical and interventional procedures traditionally performed by other specialties, but without a doubt medicine remains an interdependent practice. In fact, if I were to be airlifted into an austere environment and had to select a second specialist to accompany me, I am pretty sure I would pick a general surgeon. Even now, there are patients and conditions when my surgical colleagues are a welcome sight. This month’s videos are examples of some of these clinical situations when I especially appreciate my surgical colleagues.



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Monday, August 03, 2015



When faced with a "can't intubate, can't oxygenate" crisis, the decision to move to a surgical airway must be made rapidly and deliberately. A surgical cricothyroidotomy is debatably the better approach in these situations, but a needle cricothyroidotomy may sometimes be indicated. It may be easier to perform in a very small child, for example, and although it is probably less than ideal in an adult, a rapid needle cricothyroidotomy may provide an oxygenation bridge that will prevent a critically hypoxic patient from arresting until a more definitive airway is secured.


Cricothyroidotomy with an over-the-needle catheter itself may be easy to perform, but the more technically and logistically difficult part of the procedure remains how to deliver oxygen through a 14G catheter. In the absence of a proper percutaneous transtracheal catheter oxygenation setup such as an Enk oxygen flow modulator or a Roy Rapid-O2 device, many different improvised setups have been described. These all have advantages and disadvantages, but the main disadvantage is that they involve putting together parts that were not designed to play nice with each other.


This video shows a novel setup that may be effective in providing percutaneous transtracheal catheter oxygenation. The system, consisting of large-bore suction tubing and a meconium aspirator, plus-or-minus zip ties, is connected to the oxygen regulator Christmas tree. A maximum flow rate can then be set at the oxygen regulator (typically 1 liter per minute per year of age to a maximum of 15 liters per minute,) with further regulation of flow and delivery of breaths by occlusion of the side port on the meconium aspirator. The large diameter of the exhalation port (the same side port on the meconium aspirator) should allow for adequate exhalation, although the limiting factor here will likely be the caliber of the catheter.


Improvised jet oxygenation device, version 1.


I requested FOAM community feedback on Twitter, YouTube, and Google+, and the PHARM Podcast comments section has helped improve on the concept, with a few notable changes. The use of zip ties to secure the tubing to the regulator and to the aspirator is likely unnecessary. (Thank you, ‏@ketaminh, @TBayEDguy, and ‏@MikeSteuerwald.) The system coming apart under excessive pressure may provide an extra layer of safety over providing too much pressure to the patient.


The other major change came at the suggestion of Scott Weingart, MD (@emcrit), who, like many others, was concerned about the feasibility of putting together the homemade ETT to male Luer lock adapter. His brilliant solution is to use a male Luer lock to Christmas tree adapter, which is commercially available and designed for this very purpose (Multipurpose Tubing Adapter, Cook Medical; Attach a cut-off ETT to the Christmas tree end and screw the Luer lock end into the catheter. The meconium aspirator can then be connected to the ETT adapter, as shown in the video and oxygen can be delivered by occluding the port of the meconium aspirator as described.

The multipurpose tubing adapter from Cook Medical is a male Luer lock to a universal taper. (


The advantages of this setup is that all parts are stock, and nothing has to be manufactured; it just has to be put together in the right order. Another advantage of the multipurpose tubing adapter is that, like the meconium aspirator, it has several uses because it can be used for draining fluid after paracentesis or thoracentesis and for irrigating through a chest tube as may be needed in the severely hypothermic patient.


My recommendations, still being studied and revised, are:

1. Put the kit together ahead of time. Suction tubing, a meconium aspirator, a male Luer multipurpose tubing adapter, ETT, and an old-fashioned nonsafety 14G catheter are required. The zip ties are optional.

2. Have a backup plan. The methods previously described do work. A 7.0 mm ETT adapter will fit directly into the barrel of a 3 ml syringe, which has a male Luer lock tip. I would avoid the 3 mm ETT adapter directly into the catheter method as well as the three-way stopcock method unless that's all you have.

3. High flows may not be needed. 1 LPM per year of age to a maximum of 15 LPM is probably adequate and a safe starting point. Alternatively, 15 LPM is probably safe on everyone.

4. Using a BVM is inadequate and will not work because you cannot generate enough pressure or flow. Get or put together a proper PTJV setup that allows for adequate flow and exhalation.




Injection cap from a pediatric double-lumen central line kit, trimmed as shown.




The trimmed injection cap fits snugly inside a 7.5mm ETT adapter.



A better solution is to use a multipurpose tubing adapter from Cook Medical connected to a cut-off ETT.




There’s a long story behind the birth of this setup. Back in the late 1990s and early 2000s, in the early stages of the Internet, and before blogs or FOAM, there were Usenet newsgroups. A popular Usenet newsgroup among paramedics and a few EMS physicians was misc.emerg-services. There, a motley group of providers with strong opinions and a passion for learning gathered to discuss cases and prehospital care. It was a discussion on that newsgroup that made me question what I had always been taught and had taught others that using an adult BVM to ventilate through a 3 mm ETT adapter straight into the 14G catheter hub or through a 6.5 mm ETT fit into the barrel of a 3 ml syringe Luer-locked to the catheter or hooking O2 tubing to a three-way stopcock would be effective.


Through trial and error, I practiced all these methods ahead of time and found them clunky and ineffective. I then started to play with all the equipment available and see what fit well with what, trying to find equipment that was designed to fit each other. I needed something that would hook up to tubing of some sort that had a ventilation hole and would fit a 15 mm port. Of course, the answer was the meconium aspirator. I played with the setup and was happy about how easy it was to put together and how easy it was to deliver flow.


The one problem was that the system came apart at very high flows. The answer to that was the zip ties. (Our ETT holders at the time came with small zip ties, so they were already available in our airway bags.) The only weakness remaining was the connection between the meconium aspirator and the 14G catheter. I could not find anything that went from a 15 mm port (ET adapter) to a Luer lock. Finally, I decided to make my own, finally arriving to the IV port cap to ETT adapter solution described in the video. This is the setup I've had with me for years. I am thankful to Scott Weingart for his elegant improvement to the setup and to the rest of the FOAM community for their comments and contributions.


Detailed Comments from #FOAMed

Minh Le Cong, MBBS (‏@ketaminh), of the PHARM Podcast and, commented that the zip ties were probably unnecessary, at least in pediatrics, because the flows and pressures needed are not that high. Generally, 1 LPM per year of life (maximum: 15 LPM) is an adequate starting point. Mike Steuerwald, MD (‏@MikeSteuerwald), made similar comments. This thought was also echoed by Yen Chow, MD (‏@TBayEDguy), who tested the setup without zip ties and was satisfied that they were redundant. He also tested using a needle-free cap, and was able to get good flows through it. (


Dr. Le Cong also liked the versatility of the meconium aspirator, where it not only can be used for this PTJV setup, but also for the suction-as-you-go setup that Dr. Mellick did a video on before. ( He also introduced me to the Roy Rapid-O2, and it is the ideal setup, according to the Royal Children's Hospital Melbourne Anaesthesia (‏@RCHAnaesthesia). ( Unfortunately, it is unavailable in the United States, but Dr. Le Cong was gracious enough to provide me with a sample at SMACC. This setup is very similar to the Roy device, with some minor differences.


Gavin Doolan, MBBS (‏@anaestricks), suggested that the #14G catheter may be too large in an neonate/infant, and that a #16G may be adequate on those patients. It was also suggested that the new safety catheters that we all use nowadays are not ideal for this procedure and that traditional non-safety catheters be stocked with the kit for this purpose.


Dr. Steuerwald, from the blog Taming the SRU, also posted a link to their ideas:, and was the one to suggest that 1 LPM per year of life (maximum of 15 LPM) is an adequate starting point and that 15 LPM may be fine for everyone. (J Trauma 1989;29[6]:774; Paediatr Anaesth 2009;29[5]:458; Paediatr Anaesth 2014;24[2]:208.)


Watch Dr. Solis demonstrate his innovative needle cricothyrotomy technique.


Dr. Solis is an emergency physician with the Huntsville Hospital System in Hunstville, AL, and an occasional assistant professor at Georgia Regents University, where he works with Larry Mellick, MD, who shot the video. Dr. Mellick is a professor of emergency medicine and pediatrics at Georgia Regents University in Augusta, the former chairman of emergency medicine at Georgia Regents Health System, and a professor of emergency medicine and pediatrics at Georgia Regents Medical Center and Children’s Hospital of Georgia.


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Wednesday, July 01, 2015

Ketamine is a fascinating drug with multiple potential applications in the emergency department, but emergency physicians should consider this phencyclidine-like dissociative agent for pain management.


Pain, as we know, has complex mechanisms and pathways. Peripheral and central sensitization of pain pathways are recognized as part of the process of chronic and subacute pain syndromes. The NMDA receptor is central to the sensation of pain, and ketamine’s ability to centrally block the NMDA receptor is widely recognized and accepted as the mechanism for pain relief.


Ketamine is rapidly distributed into the brain and other highly perfused tissues. Multiple reports in the literature describe the successful use of ketamine for refractory chronic pain. One report indicated that half of patients treated with subanesthetic doses of ketamine had up to three weeks of relief. (Pain Med 2012;13[2]:263.)


Now, there is growing interest among emergency physicians in the use of low-dose ketamine infusions for a wide variety of pain syndromes and etiologies. (Ann Emerg Med 2015 March 26; Low-dose ketamine is increasingly being used in our emergency department. Slow infusions over 20 minutes of these low doses (0.25 mg/kg) avoids the dysphoria that sometimes occurs with ketamine.


Thankfully, intravenous lorazepam rapidly resolves these complaints when the side effects occasionally occur. These videos demonstrate three patients with very different but severe chronic pain syndromes who responded nicely to slow infusions of low-dose ketamine.


Click here to watch low-dose ketamine infusions for cancer pain.


Click here to watch low-dose ketamine infusions for peripheral neuropathy pain.


Click here to watch low-dose ketamine infusions for sickle cell pain.



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Monday, June 01, 2015

Targeted or targetoid rashes are one specific rash presentation that is commonly seen and occurs with at least three conditions. Other conditions have target-like lesions, but by far the most common are acute annular urticaria or urticaria multiforme, erythema multiforme, and serum sickness-like rashes (SSLR).


Unlike true serum sickness, SSLR is not a type III reaction, and frank arthritis, hypocomplementemia, vasculitis, and nephropathy are not typically seen. These rashes have significant overlap in presentation and appearance, and they are frequently confused for each other. Nevertheless, it is possible to tease out unique characteristics that allow the clinician to differentiate among the three conditions.


The classic skin lesion of erythema multiforme is a target or iris lesion characterized by concentric erythematous rings separated by rings of near-normal color. The lesion size may range from 2 mm to 20 mm. The other conditions have lesions that appear similar and present as annular and polycyclic wheals with central clearing or ecchymotic or purpuric centers.


We were able to capture in the videos below visual images and historical accounts of two different patients presenting with targetoid lesions that were most consistent with urticaria multiforme and serum sickness-like conditions.


Click here to watch Dr. Mellick diagnose targetoid rashes on arms and legs.


Click here to watch Dr. Mellick diagnose the urticarial multiforme rash.


Dr. Mellick is a professor of emergency medicine and pediatrics at Georgia Regents University in Augusta, the former chairman of emergency medicine at Georgia Regents Health System, and a professor of emergency medicine and pediatrics at Georgia Regents Medical Center and Children’s Hospital of Georgia.



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About the Author

Larry Mellick, MD
Dr. Mellick is a professor of emergency medicine and pediatrics at Georgia Regents University in Augusta, the former chairman of emergency medicine at Georgia Regents Health System, and a professor of emergency medicine and pediatrics at Georgia Regents Medical Center and Children’s Hospital of Georgia.