Home Made IV Access Ultrasound Phantoms

home made IV access ultrasound phantom

We recently had the 3rd Tanzanian Conference on Emergency Medicine. Point of Care Ultrasound (PoCUS) training was one of the pre-conference workshops. Ultrasound-guided intravenous cannulation can be very challenging for many doctors in the emergency department.

Therefore, we had a station providing a real-time opportunity to practice IV access using our homemade ultrasound phantoms. And I shall share with you how we came up with this solution.

Ingredients

  • A plastic container (dimensions used here 8 x 5.5 x 5inches)
  • Long balloons
  • Assorted food colors
  • Gelatin
  • Metamucil (psyllium)
  • Powdered household detergent
  • Spoon, sieve, hand mixer, measuring cup, cooking pot and cooker
  • Filler syringes
  • Gloves
Ingredients for making the mixture
Ingredients for making the mixture
Food coloring dye
Food coloring dye
Equipment for making vessels
Equipment for making vessels

How to make your mixture

Take a cooking pot and fill it with 1200 mls of water (we used this as our molding device could accommodate this amount of mls) bring it to a boil (just as it begins to form tiny bubbles on the base add gelatin powder 8 tablespoons and stir with a hand mixer until it completely dissolves. Thereby add 2 tablespoons of Metamucil and 1 tablespoon of detergent and continue stirring with low flame until the mixture begins to thicken. At this point, you will also see foam that sits on top of the mix. Use a sieve to get the foam out. You can, at this point, add any colors that you would want. Let the mixture cool a little before pouring it into the container. As it cools, you will notice it becoming thicker.

How to set-up your mold/containers

You will need to make a hole on both ends on the container using a hand drill or a hot pointed knife. For this case, since we didn’t have a drill, we used a knife with a pointed tip – heated it up in a burner until it was hot enough and used it to make holes through the plastic container using a circular motion. It is important for the holes not to be too big but estimated to the caliber/ diameter of the long balloons since we need just enough space to pass the balloons across.

For our case, we made 4 holes, 2 on each end. But you can do more if you want. You can arrange balloons in superficial or deeper locations.

To setup the vessels using the long balloons, you will need half cup of water and red color dye. Mix just enough to make a mixture that looks like blood. This can be filled in the balloons with a syringe. Since the color dye can stain your fingers, it is important to use gloves just to prevent your fingers from staining.

Tip: To make an artery, you can fill the balloon much more so that there is minimal compressibility and for the vein, you can fill just enough and have room for compressibility. Don’t fill the balloons before passing it through the container; if you do this, the filled balloon won’t manage to fit into the holes. Once fixed, tie both ends to make knots that are big enough to cover the seal the holes made.
Before pouring the mixture into the container, spray it with some oil, or you can use a cloth dip it in oil and apply it on the inside of the container.

After that, pour your mixture in the container and let it cool. You can place it in the refrigerator and use it the next day. We left ours for 24 hrs prior use.

You can use silicone seals at the holes if you notice to have any leaks. Otherwise, if you don’t have this, you can use plastic food wrap to create a seal between the balloon knots and the container just so the mixture does not leak out until it has set.

Cooling in the refrigerator, note the plastic food wraps used as seal here and the knots
Cooling in the refrigerator, note the plastic food wraps used as seal here and the knots
6 hours after refrigeration
6 hours after refrigeration
Final product
Final product

And finally, the images that you will have on ultrasound.

Short axis/transvers view
Short axis/transvers view
Long/longitudinal axis view
Long/longitudinal axis view
TACEM - IV access workshop under US guidance
TACEM - IV access workshop under US guidance
Cite this article as: Masuma Ali Gulamhussein, "Home Made IV Access Ultrasound Phantoms," in International Emergency Medicine Education Project, November 18, 2019, https://iem-student.org/2019/11/18/home-made-iv-access-ultrasound-phantoms/, date accessed: December 12, 2019

Goals in Mechanical Ventilation: Concepts for the Students

Goals in Mechanical Ventilation: Concepts for the Students
Authors: Dr. Job Heriberto Rodríguez Guillén (@job_rdz), Dr. Sergio Edgar Zamora Gómez (@ezg_galeno)

Introduction

Mechanical ventilation (MV) is one of the cornerstones of life support in the emergency department. It provides time for establishing therapeutic management aimed at the triggering cause of injury until the patient improves physiologic balance (1). Therefore, MV can not be a unique and specific treatment for any disease by itself; but it has two general and fundamental goals: to support the injured lung and protect the healthy lung.

Set your goals: Support and Protect

Support

MV supports the respiratory system; meanwhile, the primary disease becomes under control.

Example: A patient with acute respiratory distress syndrome (ARDS) due to pneumonia, where MV provides support to improve gas exchange and reduce work of breathing (WOB) meanwhile antibiotic treatment induces remission of the infectious disease.

Protect

MV is aimed to avoid complications not related to the primary disease. The patient-ventilator relationship becomes of benefit for the patient as his respiratory function is in the risk of injury because the primary disease does not allow him to breathe properly or because therapeutic interventions can reduce protective airway reflexes and lead to respiratory complications.

Example: Patients presenting neuromuscular diseases (Guillain-Barre syndrome), diseases affecting bulbar muscles (myasthenic crisis), decreased consciousness (stroke, poisoning) or severe traumatic brain injury, all these without lung injury at first but in high risk of pneumonitis and pneumonia due to aspiration of gastric content.

Goals of Mechanical Ventilation
Mechanical ventilation has two general and fundamental goals: to support the injured lung and protect the healthy lung.

Specific goals of mechanical ventilation

One of the specific objectives of MV is to promote the optimization of arterial blood gases levels and acid-base balance by providing oxygen and eliminating carbon dioxide (ventilation). MV can reduce the work of breathing by taking effort from respiratory muscles and maintaining the long-term respiratory support for patients with chronic diseases.

MV´s circle (2) begins by recognizing the patient´s need for mechanical ventilatory support. Intubation and ventilation decision making is an essential skill for emergency physicians. Consideration of the patient´s needs is the basis of this decision making. The main indications for intubation and mechanical ventilation are (3):

  1. Refractory hypoxemia
  2. Increased respiratory effort
  3. Apnea/hypopnea leading to inadequate ventilation (Hypercapnia)
  4. The inability for airway protection

The goals should be individualized and established according to the clinical situation that led the patient to required ventilatory support. Although standard criteria traditionally have been specified for the onset of MV (3), we must remember that indication for intubation and ventilation is an essential skill for every physician treating critical care patients and the key is just thinking about what the patient needs.

Standard criteria for starting mechanical ventilation
Acute Ventilatory Failure
pCO2 > 50 mmHg + pH < 7.30
Impending Ventilatory Failure
Maintains normal gasometric levels by increasing respiratory effort.
Severe Hypoxemia
pO2 < 60 mmHg + FiO2 > 50%

pCO2 and pO2 values at sea level

In general, we can encompass the specific objectives of MV in three fundamental principles that must be fulfilled in every patient by setting the goals according to the primary disease:

  1. Improve oxygenation (O2) and ventilation (CO2)
  2. Reduce respiratory effort
  3. Minimize ventilator-induced lung injury (VILI)

Conclusions

The goals of MV are established based on the primary disease that led the patient to need MV support, under the concept of protecting and supporting the lungs. Primum non nocere; lung-protective ventilation should be initiated in all patients who need it.

References and Further Reading

  1. Frank Lodeserto MD, “Simplifying Mechanical Ventilation – Part I: Types of Breaths”, REBEL EM blog, March 8, 2018. Available at: https://rebelem.com/simplifying-mechanical-ventilation-part/.
  2. Frank Lodeserto MD, “Simplifying Mechanical Ventilation – Part 2: Goals of Mechanical Ventilation & Factors Controlling Oxygenation and Ventilation”, REBEL EM blog, May 18, 2018. Available at: https://rebelem.com/simplifying-mechanical-ventilation-part-2-goals-of-mechanical-ventilation-factors-controlling-oxygenation-and-ventilation/.
  3. Scott Weingart. EMCrit Lecture – Dominating the Vent: Part I. EMCrit Blog. Published on May 24, 2010. Accessed on August 30th 2019. Available at [https://emcrit.org/emcrit/vent-part-1/ ].
Cite this article as: Job Guillen, "Goals in Mechanical Ventilation: Concepts for the Students," in International Emergency Medicine Education Project, September 2, 2019, https://iem-student.org/2019/09/02/goals-in-mechanical-ventilation-concepts-for-the-students/, date accessed: December 12, 2019

Pediatric Tube Sizes – Infographic

Pediatric tube sizes

Recently, Sam Ghali reminded us how important pediatric tube sizes, and how easy to calculate them. We think every medical students, interns and PGY1s should know this now. Here is his message on Twitter:

PEDIATRIC TUBE SIZES

CALCULATE  ENDOTRACHEAL TUBE (ETT) SIZE
[Age ÷ 4] + 4
There are many formulas to calculate the endotracheal tube size for kids. The given formula is one of the most common. Let’s think a six yo patient. Your ETT size is 6/4 = 1.5, and +4 = 5.5

NASOGASTRIC/OROGASTRIC TUBE OR FOLEY CATHETER SIZE
ETT x 2
NG/OG tubes and Foley catheters are measured as FRENCH. (Fr) If your ETT size is 5.5, then your NG/OG and Foley sizes will be 5.5 x 2 = 11 Fr.

HOW DEEP YOUR ETT  SHOULD BE
ETT x 3
If your calculated tube size is 5.5, your depth should be 5.5 x 3 = 16.5 cm. So, 16.5 cm mark should be seen at the level of central incisors.

CHEST TUBE SIZE
ETT x 4
If the same six yo patient needs a chest tube, your chest tube size is 5.5 x 4 = 22 Fr. By the way, this is mainly for trauma. Moreover, do not forget, smaller size tubes can work as same as big ones.

Cite this article as: iEM Education Project Team, "Pediatric Tube Sizes – Infographic," in International Emergency Medicine Education Project, July 24, 2019, https://iem-student.org/2019/07/24/pediatric-tube-sizes-infographic/, date accessed: December 12, 2019

Some Hints About Airway!

Some Hints About Airway!

Introduction

The airway is one of the most critical topics in the ER. Read everything about the airway; it is not a waste of time. Even if you have to spend one year just for airway, it is worth it. You will always be confident in dealing with whatever situation that might come to you. Although reading is essential, practicing and getting experience on airway issues is essential too. So, reading along with exposing many patients is a great combination to achieve good skills.

Build your own skills by reading then summarizing your own words. As long as it is correct and safe, the way accomplishing or securing the airway may not be important in many patients.

Here are some tips in airway management at the Emergency Department (ED)

I will mention some points that might help in the management of typical scenarios at the ED. They might look random, but trust me, it is the real deal.

  • Preparations

  • Attach the patient to monitor
  • Check the vitals,
  • Check saturation continuously,
  • Open IV lines (2x) and attach a bag of normal saline,
  • If the blood pressure is low use pressure cuff on the fluid’s bag,
  • If the patient maintains oxygenation don’t bag, just leave the mask on. Moreover, do not forget; bagging is not a safe procedure.
  • Your equipment’s; choose your tube size depending on the patient’s size, size of the laryngoscope
  • Make capnography ready
  • Call the respiratory therapist, if you don’t have one, you check the ventilation machine by yourself
  • Keep bougie on the side, and SUCTION! Doesn’t matter Yankuer or not anymore, as long as it takes away whatever is on your way. Don’t go too deep to avoid vomiting.
  • Raise the bed highest, keep the level of the patient up to your chest or even higher, the higher the better.
  • Have someone on your side in case you needed tracheal manipulation or pressure to facilitate the view.
  • Pay attention to hemodynamic parameters

  • Never intubate before knowing the blood pressure readings.
  • Never intubate with low blood pressure below 90 systolic.
  • Resuscitate then intubate.
  • Neutral hemodynamic resuscitation (some studies tried the use of paralytic agent alone, with local anesthetic on the glottis, the same idea as awake intubation, in case of hemodynamic instability to avoid the use of induction agents that might decrease hemodynamics). The risk of using multiple doses of an induction agent can cause hemodynamic instability.
  • However, if there is no contraindication, you can think of using ketamine to help boost the blood pressure.
  • Double the dose of your medication if the patient has low cardiac output. As with low cardiac output, the medication won’t reach fast; it might take longer than 4 min. There is no harm in increasing paralytic agents ONLY IF THE AIRWAY IS NOT DIFFICULT. Induction agents can be used as boluses also, but again be careful if the patient is unstable as it might worsen the condition.

Here is a great video summarizing hemodynamic issues in airway management

  • Intubation and beyond

  • Use direct laryngoscopy first, use the old school equipment to keep your skills fresh, but keep the video laryngoscope ready on the side. Some experts recommends using video laryngoscope blade for direct laryngoscope and if you need, just look to the screen.
  • Still failed multiple trials with the laryngoscope? Consider difficult airway. One of the recommendations is to “leave the tube in the esophagus and insert another tube; the other opening is definitely the trachea.” By the way, there are tools to understand the difficulty of the airway, so know and use it.
iEM-infographic-pearls-airway - Assessing Airway Difficulty
  • Rapid Sequence Intubation (RSI) and Delayed RSI: Delayed RSI used mainly in the ICU, and many authors hate this term. However, there is no harm if the patient is maintaining oxygenation, you can give a sedative and look before proceeding to RSI. Just don’t call this approach “RSI.”
  • Rocuronium or Succinylcholine; both will paralyze the patient; it is not about which one is better; it depends on the type of airway you are dealing with. If it is a difficult airway, you do not want to use rocuronium and end up bagging the patient for one hour. Using a short-acting agent is a smart move.
  • However, if it is easy, use it as it would help in paralyzing the patient for an hour, but doesn’t mean the patient is fine, do not forget analgesia/sedation!
  • The tube is in, yay! Good for you, but your work is not done yet. All of us been through the situation where we jump into the airway, insert the tube and leave. This is not a skill lab; it is a real patient. The patient is not moving does not mean he is fine, you paralyzed him but he can still feel. Insert the tube, attach capnography, bag, auscultate, make sure of the level of the tube’s depth, order x-ray STAT then start analgesia/sedation infusion! No matter how naive you are or had a blackout, use midazolam and fentanyl! However, please learn other options too, because different patients may require different agents.
  • Propofol infusion, the bright side of Propofol is its analgesic and sedative effect, although it has a high risk of causing hypotension.
  • The dilemma of which medication to use, as for induction or paralyzing. No one can tell you that one medication is better than the other. Read everything about each medication, understand it, then you make your own mixture.

As long as you keep reading, and updating your knowledge, with of course practice and exposure to different type of situations, you will always know how to deal with every situation.

Further Reading

Cite this article as: AlHanouv AlQahtani, "Some Hints About Airway!," in International Emergency Medicine Education Project, July 17, 2019, https://iem-student.org/2019/07/17/some-hints-about-airway/, date accessed: December 12, 2019

Laceration Repair: A Rural Encounter

The word “emergency” carries some connotation with it. A lack of time to act, a situation that demands speed, a sense of acuity. Medicine on the other hand is related to healing, soothing and improving, a slow and gentle process. I sometimes wonder if the name of the specialty (Emergency Medicine) is an oxymoron.

Etymology aside, this specialty of medicine has meant at least two different things to me at two different settings. I have worked as an intern at Patan Hospital, a tertiary care center and as an in-charge of emergency services of Beltar Primary Healthcare Center (PHC), a government establishment in rural Nepal. I intend to describe my perspective and illustrate what different experiences of emergency medicine in different settings has to offer. I hope in doing so, I’ll be able to illustrate some of my workarounds that make the difference less overwhelming.

I have been posted at Beltar PHC, Nepal for the past 18 months. The center has been running primary emergency services. Initial stabilization and proper referral are two major ways Beltar PHC helps to save lives. The nearest city where cases are referred to are Dharan (50.5 km away) and Biratnagar (92 km away). Emergency personnel includes one doctor on call, one paramedic, two sisters for delivery and one office assistant. Laboratory and X-ray services are not available apart from office hours. Emergency investigations available include ECG, UPT and Obstetric USG. The government freely supplies medical equipment and a limited number of medicines.

Entrance to Emergency Services at Beltar PHC
Former Emergency Setup at Beltar PHC
Former Emergency Setup at Beltar PHC

A 27-year-old male

A 27-year-old male with a cut injury on his right forearm was brought to the PHC. It was a quiet day at the Emergency Department (ED) and most of the cases were OPD cases that did not make it on time.

One-way ED helps people here, albeit not an ideal way, is to act as a rescue for patients who travel long distances to get to the OPD if they do not make it on time.

The patient had a clean wound, about 5 cm long with smooth edges. We washed the wound using tap water; a practice equally efficacious to using saline but way more affordable for a rural setup. To suture the wound, we made our equipment ready. A long suture thread was cut from a nylon thread roll sterilized in betadine, some gauze pieces prepared by our office assistant that had been autoclaved and stored in an old dressing drum were taken out.

Suture materials at Beltar PHC
Dressing Drums at Beltar PHC

The thread was inserted into a needle, probably too big (turns out what needle size to use and when was a dilemma of privilege). Sometimes, we use needles that come with 2 ml syringes instead; they are sharper for skin penetration than the big suture needles our government freely supplies. The wound was sutured and the patient discharged.

That night I reflected on how things would have been subtly but significantly different at Patan Hospital. A sterilized suture set, autoclaved, packed and ready to use along with a ready to use surgical suture would be available. The procedure would have taken place in a more private space and not where visitors had the opportunity to peak in through our foldable privacy screen. Maybe the patient would have had to wait longer to get attention but the difference would not have been much, considering the time it takes to prepare every instrument here.

Each minor aspect of this difference deserves to be heard, talked about and their solution sought for. I plan to write about each of these as a series of article that follows. Proper resource allocation is a time and economy intensive goal; nevertheless the ultimate one. Maybe small workarounds are what we need during the period of transition, especially for places like Beltar.

Laceration repair is a common procedure in every emergency department. Setting differs and with it the availability of resources. Nevertheless, the core principles that govern patient care and the science behind it remains the same. While we wait for more convenient and sophisticated solutions, which all patients deserve, here are some points to remember regarding laceration repair that can help provide an acceptable standard of care even in resource-limited settings.

  • While working in rural, one should be well aware of its limitations. Some lacerations that require surgical consultation and need to be referred include (1):
    • Deep wounds of the hand or foot
    • Full-thickness lacerations of the eyelid, lip, or ear
    • Lacerations involving nerves, arteries, bones, or joints
    • Penetrating wounds of unknown depth
    • Severe crush injuries
    • Severely contaminated wounds requiring drainage
  • Non-contaminated wounds can be successfully closed up to 18 hours post-injury while clean head wounds can be repaired up to 24 hours after injury (2).

  • Drinkable tap water can be used for wound irrigation instead of sterile saline. At least 50 to 100 ml of irrigation solution per 1 cm of wound length is needed at a pressure of 5 to 8 psi for optimal dilution of wound’s bacterial load. The wound can be put under running water or can be irrigated using a 19-gauge needle with a 35 ml syringe (3).

  • Local hair should be clipped, not shaved, to prevent wound contamination(4).

  • Strict sterile techniques are unnecessary to be followed during laceration repairs. The instruments touching wound (sutures, needles, etc.) should be sterile, but everything else only needs to be clean(1). Clean non-sterile examination gloves can be used instead of sterile gloves during wound repair(5).
  • Local anesthesia with lidocaine 1% or bupivacaine 0.25% is appropriate for small wounds while large wounds occurring on limbs may require a regional block (1). Epinephrine should not be used in anatomic areas with end arterioles, such as fingers, toes, nose, penis, and earlobes.
  • Maximum doses of local anesthetic are as follow (6):
    • Lidocaine (without epinephrine): 3 – 5 mg/kg
    • Lidocaine (with epinephrine): 7 mg/kg
    • Bupivacaine (without epinephrine): 1 – 2 mg/kg
    • Bupivacaine (with epinephrine): 3 mg/kg
  • The suture used for skin repair include non-absorbable sutures (nylon and polypropylene) while absorbable sutures (polyglactin, polyglycolic) is used to close deep lacerations. For skin closure, silk sutures are no longer used because of skin abscess formation, their poor tensile strength and high tissue reactivity. In general, a 3–0 or 4–0 suture is appropriate on the trunk, 4–0 or 5–0 on the extremities and scalp, and 5–0 or 6–0 on the face (6).
    • Sterilization of sutures can be done by complete immersion in povidone-iodine 10% solution for 10 minutes followed by rinsing in sterile saline/water. Sutures that can be sterilized or re-sterilized include monofilament sutures (Prolene or Nylon) and coated sutures (Vicryl, Ethibond) (7).

Timing of Suture Removal (6)

Wound Location Time of Removal (Days)
Face
3 - 5
Scalp
7 - 10
Arms
7 - 10
Trunk
10 - 14
Legs
10 - 14
Hands or Feet
10 - 14
Palms or Soles
14 - 21

Tetanus Prophylaxis (8)

Wound Previous Vaccine Tetanus Vaccine
Clean Wound
Previous vaccine ≥3 doses - The last dose within 10 years
No Need
Previous vaccine ≥3 doses - The last dose more than 10 years
Yes
Previous vaccine ≥3 doses - NOT RECEIVED
Yes
Contaminated Wound
Previous vaccine ≥3 doses - The last dose within 5 years
No
Previous vaccine ≥3 doses - The last dose more than 5 years
Yes
Previous vaccine ≥3 doses - NOT RECEIVED
Yes + TIG

Factors that may increase chances of wound infection (9)

  • wound contamination,
  • laceration > 5 cm,
  • laceration located on the lower extremities,
  • diabetes mellitus

Antibiotics

  • Prophylactic systemic antibiotics are not necessary for healthy patients with clean, non-infected, non-bite wounds(10). 
  • Prophylactic antibiotic use is recommended for (11): 
    • human bite wounds 
    • deep puncture wounds
    • wounds involving the palms and fingers
  • Topical antibiotic ointments decrease the infection rate in minor contaminated wounds. 

References and Further Reading

  1. Forsch RT. Essentials of Skin Laceration Repair. Am Fam Physician. 2008 Oct 15;78(8):945-95
  2. Berk WA, Osbourne DD, Taylor DD. Evaluation of the ‘golden period’ for wound repair: 204 cases from a third world emergency department. Ann Emerg Med. 1988;17(5):496–500.
  3. Wheeler CB, Rodeheaver GT, Thacker JG, Edgerton MT, Edilich RF. Side-effects of high pressure irrigation. Surg Gynecol Obstet. 1976;143(5):775–778./ Moscati RM, Reardon RF, Lerner EB, Mayrose J. Wound irrigation with tap water. Acad Emerg Med. 1998;5(11):1076–1080.
  4. Howell JM, Morgan JA. Scalp laceration repair without prior hair removal. Am J Emerg Med. 1988;6(1):7–10.
  5. Perelman VS, Francis GJ, Rutledge T, Foote J, Martino F, Dranitsaris G. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial. Ann Emerg Med. 2004;43(3):362–370.
  6. Forsch RT, Little SH, Williams C. Laceration Repair: A Practical Approach. Am Fam Physician. 2017 May 15;95(10):628-636.
  7. Cox I. Guidelines for Re-Sterilising Sutures. Community Eye Health. 2004;17(50): 30.
  8. Kretsinger K, Broder KR, Cortese MM, et al. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55(RR-17):1–37.
  9. Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: what are the risks for infection and has the ‘golden period’ of laceration care disappeared? Emerg Med J. 2014;31(2):96–100.
  10. Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies. Am J Emerg Med. 1995;13(4):396–400.
  11. Worster B, Zawora MQ, Hsieh C. Common Questions About Wound Care. Am Fam Physician. 2015 Jan 15;91(2):86-92.
Cite this article as: Carmina Shrestha, "Laceration Repair: A Rural Encounter," in International Emergency Medicine Education Project, June 21, 2019, https://iem-student.org/2019/06/21/laceration-repair-a-rural-encounter/, date accessed: December 12, 2019

Airway Tips by Manrique Umana

Dr. Manrique Umana from Costa Rica presented a fantastic lecture during the 30th Emergency Medicine Conference of Mexican Society in Cancun/Mexico. Every emergency physician should know the airway tips he gave in the talk. Moreover, medical students and interns should also be aware of these clues. Therefore, we asked him to summarize his speech for iEM. You will find English and Spanish version of the summary on the below videos. Enjoy!

Airway Tips

This video includes a summary of “physiologically difficult airway” presentation given by Dr. Manrique Umana from Costa Rica.

Consejos de la vía aérea

Este video incluye un resumen de la presentación de la “vía aérea fisiológicamente difícil” realizada por el Dr. Manrique Umana de Costa Rica.

Cite this article as: iEM Education Project Team, "Airway Tips by Manrique Umana," in International Emergency Medicine Education Project, March 22, 2019, https://iem-student.org/2019/03/22/airway-tips-by-manrique-umana/, date accessed: December 12, 2019

Bat Sign

Dear students/interns, learn ultrasonographic anatomy and clinical ultrasound basics to improve your decision making processes.

bat2

The bat sign is critical for correct identification of the pleural line. Always begin lung ultrasound by identifying the bat sign before proceeding to look for artifacts and pathologies.

This sign is formed when scanning across 2 ribs with the intervening intercostal space.

The wings are formed by the 2 ribs, casting an acoustic shadow. The body is the first continuous horizontal hyperechoic line that starts below one rib and extends all the way to the other. (see above video) The body is the pleural line, i.e., parietal pleural. Normally, the pleural line is opposed to and hence indistinguishable from the lung line (formed by the visceral pleura).

To learn more about it, read chapter below.

Read "Blue Protocol" Chapter

Corner stitch

Need a chest tube or not?

420 - right pneumothorax1

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

From experts to our students! – Splinting

From experts to our students! – eFAST

Selected Procedures

17 of recommended procedures by SAEM/ IFEM  are uploaded to the Website! with curated #FOAMed resources.

Intraosseous (IO) Line/Access

by Keith A. Raymond Introduction Peripheral Intravenous (IV) cannulation is a nursing skill. Few countries throughout the world require physicians to perform this procedure on

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Splinting and Casting

by Joseph Pinero, Timothy Snow, Suzanne Bentley Case Presentation 1 65-year-old female with a history of hypertension and diabetes presenting with right wrist pain and

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Urinary Catheter Placement

by Gul Pamukcu Gunaydin Case Presentation A 75-year-old male patient was admitted to the emergency department with difficulty voiding. He had this complaint for over

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Reduction of Common Fractures and Dislocations

by Dejvid Ahmetović and Gregor Prosen Introduction Most of the orthopedic injuries can be predicted considering the chief complaint, the age of the patient and

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Rapid Sequence Intubation (RSI)

by Qais Abuagla Introduction Airway management is one of the most important skills for an Emergency Department practitioner to master because failure to secure an

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Procedural Sedation and Analgesia

by Nik Rahman Introduction When working in the emergency room, one often finds himself in a situation where painful diagnostic or therapeutic procedures are needed

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Nasogastric Tube Placement

by Sara Nikolić and Gregor Prosen Introduction Nasogastric (NG) tube placement is one of the most common procedures performed in intensive care settings, the emergency

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Lumbar Puncture

by Khuloud Alqaran Case Presentation A16-year-old male, without a known case of any medical illness, presented to the ED accompanied by his mother. His chief

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Pericardiocentesis

by David Wald and Lindsay Davis Case Presentation A 52-year-old female with a history of metastatic breast cancer presents to the emergency department with a

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Emergency Delivery

by David F. Toro, Diana V. Yepes, Ryan H. Holzhauer Case Presentation As you begin the morning of your next weekend day shift in a

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Intravenous (IV) Line Access

by Keith A. Raymond Introduction Peripheral Intravenous (IV) cannulation is a nursing skill. Few countries throughout the world require physicians to perform this procedure on

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Gastric Lavage and Activated Charcoal Application

Gastric Lavage and Activated Charcoal Application chapter written by Elif Dilek Cakal from Turkey is just uploaded to the Website! Read Chapter

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Cardiac Monitoring

by Stacey Chamberlain Case Presentation A 44-year-old male patient with a history of hypertension and end-stage renal disease on hemodialysis presents with shortness of breath after

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Basics of Bleeding Control

by Ana Spehonja and Gregor Prosen Types of wounds Contusion (Contusio): It is a result of minor forces, usually over clothes on 90°angle. Capillaries beneath

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Arthrocentesis

by Tanju Tasyurek Introduction Arthrocentesis is an acknowledged, useful procedure to puncture and aspiration of a joint. It is usually performed both as a diagnostic and

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Arterial Blood Gas (ABG) Sampling

by Matija Ambroz and Gregor Prosen Case Presentation A 23 years old pregnant woman was admitted with a history of polyuria, dysuria, fever, and thirst.

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Automated External Defibrillator (AED) Use

by Mehmet Ali Aslaner Introduction AED is a portable electronic device that produced to detect and treat the life-threatening cardiac arrhythmias such as like ventricular fibrillation

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