Pre-intubation Optimization of the Neurocritical Care Patient

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Image Credit: Wikimedia

Author: Tim Montrief, MD MPH
Jackson Memorial Health System/University of Miami
AAEM/RSA Publications and Social Media Committee Member

The catastrophic neurologic emergency remains one of the most challenging presentations managed by emergency physicians. Stress, diagnostic uncertainty, and time-sensitive nature lead to challenging management decisions. Likewise, the intubation of the neurocritical care patient provides many challenges, and requires a modified technique to avoid the harmful consequences of intubation, including an exaggerated reflex sympathetic response to laryngoscopy, hypotension due to induction agents, and exacerbation of elevated intracranial pressure (ICP). Additionally, maximizing first past success and minimizing hypoxia is especially important in patients with central nervous system (CNS) pathology, in particular, unsecured aneurysmal subarachnoid hemorrhage (SAH), traumatic brain injury (TBI), and stroke. Optimization of the neurocritical care patient is of upmost importance, and many of the techniques are familiar to the emergency physician. For instance, apneic oxygenation via a nasal cannula on the patient at 15 L/min maximizes oxygenation prior to intubation. Additionally, one may raise the head of the bed, which decreases ICP and has a ben­eficial effect on oxygenation. While ninety degrees is the ideal angle, elevation of the head of bed to thirty degrees is also an option. Finally, if faced with an agitated, combative patient, delayed sequence intubation (read more about it here) may be an option to optimize preoxygenation.

ECMO in the Adult ED

Image Source: Joint Base San Antonio

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Author: Tim Montrief, MD, MPH
Emergency Medicine Resident, PGY-2
Jackson Memorial Hospital

Extra Corporeal Membrane Oxygenation (ECMO), more accurately known as Extracorporeal Life Support (ECLS) is a type of prolonged mechanical cardiopulmonary support that began in the 1970s. Its technology, indications, and usage have rapidly evolved over the last two decades; it has now become an essential tool in the care of critically ill adults and children refractory to conventional management who have potentially reversible causes of respiratory/cardiac failure. With the development of ECMO programs across the nation, this technology is making its way to an emergency department (ED) near you.

The Cruelty of Depression

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Author: Becky Lee, MS4
University of Maryland School of Medicine
AAEM RSA Wellness Committee

In the middle of a hot August day, excited chatter echoed inside the dome of the columned, 200-year-old medical school building. It was our first day of medical school, and my classmates and I were eager to get started on our long-held dreams of becoming doctors. The next few days of orientation were a blur of information and optimism, all leading up to the first day of anatomy lab, where we paused in solemn silence to thank the donors and their families. I let this feeling sink in – the feeling that I was exactly where I was supposed to be. I had no idea that the next few months would be my darkest days of medical school. By the time winter break loomed around the corner, I couldn’t sleep, I no longer felt like eating, and I stopped talking to my friends and family. I stopped running and reading. In fact, I stopped going outside altogether. I spent most of my time in bed, staring at the ceiling, wondering if things would ever get better, and questioning how I ended up here. Sometimes, the thought occurred to me that I wouldn’t mind if I didn’t wake up the next day.