The Bougie POD

Awwww yisss, airway stuff!

I’d like to start this POD off by talking about the study that got everyone buzzing about the bougie this summer, published last June in JAMA by Driver et al. at Hennepin:

Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation, A Randomized Clinical Trial

Numbers and outcomes:

• They randomized 757 patients: 381 to a bougie-first approach, 376 to a traditional styletted ETT-first approach

• Population was >18, undergoing intubation with a Macintosh (standard geometry) blade (direct or video, how much the intubator looked at the screen was at the teams discretion)

• 380 patients had at least one difficult airway feature

• Success on 1st attempt was 98% in bougie-first group vs 87% in ETT+stylet group, P=0.0001, NNT=9

• Success on 1st attempt in patients with difficult airway features was 96% in bougie-first group vs 82% in ETT+stylet group, P<0.0001, NNT=7

Let’s just state what that last NNT means in words to let it sink in: You have use a bougie on 7 patients with difficult airway features in order to prevent one first-pass failure.

Furthermore, the bougie held its own among every stratification, e.g.:

• Obese patients: (96% vs 75%)

• Patients that needed cervical in-line stabilization: (100% vs 78%,)

• Patients with poor views (Cormack-Lehane grades 2 to 4): (97% vs 60%)

A few other noteworthy things:

• The duration of the first pass was about the same between bougie and ETT groups,

• The total time of intubation was far longer in the ETT group, owing to more often needing multiple attempts passes

• No difference in complication rate or direct airway trauma

Bottom line: This is extremely compelling evidence that first pass success is improved with use of a bougie.

We massively underutilize the bougie. Let’s improve our first pass success and use it more often.

I would especially consider using a bougie as first pass if you’re a less-experienced intubator or you’re starting to learn DL. Furthermore, even if you want to be old school and use it “only as a backup/rescue device”, heaven help you if you actually have to use it as such and have never practiced using it.

For anyone that may not be 100% familiar…

How to use a bougie:

• get a view

• pass your bougie through the cords, the coudé tip helps guide it anteriorly where it needs to go

• you know you’re in the trachea because it stops around the carina (be gentle, airway perforations are sub-optimal), you can also theoretically feel the subtle clicking of the tracheal rings as it slides down the trachea

• your assistant slides the tube over the back end of the bougie and then stabilizes the back of the bougie while you railroad the tube over it and through the cords

• keep retracting the tongue with the laryngoscope while you do this to facilitate passage

• you may encounter some resistance when it reaches the arytenoids; twisting the tube solves this problem

• you can definitely do all this by yourself too, it’s just a little trickier to maneuver all the moving parts

The bougies used in the Hennepin study were 70 cm gum elastic (blue) bougies, the same ones we stock in our ED. These as well as slightly shorter 60cm bougies are stocked in most departments you might work in. Thanks to Reuben we also now stock the purple malleable bougies! These excellent devices and will save you when you run into weird geometry and can even be used with hyperangulated laryngoscopes but this is a little harder. When I use them as a regular bougie, I’ll usually give them a slight coudé tip and mild anterior bend like that of the ETT and revise if necessary. The stopper can be taken off or used to pre-load the tube.

Superficial Cervical Plexus Block POD

That’s right. Time to talk about my favorite nerve block.

The SCPB

This block is 

quick

and

easy

.

It makes

IJ central lines

painless procedures

.

It also provides excellent analgesia for

clavicle fractures

,

ear lobe lacerations

,

blind subclavian lines

, or

anything within this quadrilateral

:

How to do it

Find the

posterior aspect of the sternocleidomastoid (SCM) muscle

.

Position the probe half way down the SCM as you measure it from mastoid process to clavicle.

About at the level of the superior aspect of the thyroid cartilage, also about where the EJ crosses over the sternocleidomastoid.

The fascial plane under the posterior aspect of the sternocleidomastoid muscle is your target.

Like other

plane blocks

 you are not targeting any one nerve in particular. By infiltrating this tissue plane, you get the superficial plexus as it peeks out from behind the SCM at this level:

Inject 5-10 cc of local anesthetic.

Ensure it is spreading in the plane like this.

Safety:

• As with all ultrasound guided nerve blocks, visualize your needle tip always, especially prior to injection.

• When you begin injecting, inject one mL only to ensure you see it spreading in the fascial plane. Then inject the rest.

• Withdraw before you inject if there is even a slight possibility you are close to a vessel

• Throw some color on your site to ensure you identify any vessels.

• In general this is a very well tolerated and forgiving block.

• The incidence of phrenic nerve involvement is extremely low with SCPB, far lower than with the interscalene block. Phrenic nerve involvement will be avoided if ensure you don’t go too deep - a few cm, or about half way down the deep edge of the SCM. Going deeper than this results in a deep cervical plexus block which will result in some motor and sensory blockade of the arm.

• Horner’s syndrome is a rare and self-limiting complication.

• The amount of local anesthetic used in this block is nowhere near close to toxic levels, so local anesthetic systemic toxicity will not occur as long as you manage to avoid the IJ and carotid.

Tips and troubleshooting

• For a central line, you can set up, gown, drape, and set up your ultrasound like usual, then use the 5 cc lidocaine which come in the central line kit for your block. Place the block first, then flush your line/lay out your equipment, and your patient will likely be completely numb by the time you’re ready to start your line placement.

• The other option is to place your block while you’re doing your pre-scan. This way you can use 5-10 cc, but you have to get it out of the Pyxis. Just clean the probe and the skin with a chlorhexidine swab and use sterile gel.

• If it’s your first time doing a block, consider doing it as a 2 person block. Use some IV extender tubing and have another provider operate the syringe for you. I like slightly longer tubing than typical IV tubing, e.g. the one below. At Maimo, you can find it in the stock room between North and South sides, top shelf straight ahead when you first walk in.

• Can't visualize your needle? Make sure your ultrasound probe is directly above it and in-line with it. Next, make sure it is as close to parallel to the surface of the probe/perpendicular to the ultrasound beams as possible. If you are approaching a 45 degree angle, your needle will be close to invisible. At close to a 0 degree angle, it will shine like a laser beam.

• You can use the 27 gauge needles to make it more comfortable but they are a little harder to see.

Further reading and references:

http://highlandultrasound.com/superficial-cervical-plexus-block/

 - Highland crushes nerve block education with their website and their SCPB page is no exception

https://www.ultrasoundpodcast.com/2015/03/superficial-cervical-plexus-block-with-bedsidesono-trust-us-this-is-really-awesome-foamed/

 - Mike and Matt of ultrasound podcast also did an amazing episode on this where many of the images in this tutorial are from

https://www.nysora.com/cervical-plexus-block

 -

Another good resource

Crashing Asthmatic POD

We treat asthma on a daily basis, especially in the peds ED. But what if duonebs x3, steroids, and mag isn’t doing the trick?

THE CRASHING ASTHMATIC

• Nebulized epinephrine may help.

• If no improvement, start dosing IM epi as if it were anaphylaxis: 0.5 mg (0.01 mg/kg) q 10 min, or start a drip at 5 mcg/min and titrate to effect.

• Keep going with continuous albuterol nebs.

• If pharmacy isn’t around to make an epi drip, consider a “dirty” epi drip: 1 mg epi (an entire vial of code cart epi) added to 1 L NS or LR, start at 2 drops per second and titrate up.

• Alternatively, terbutaline IV can be started: 10 mcg/kg bolus over 10 min and then drip starting at 0.4 mcg/kg/min and titrate up. Terbutaline is a systemic beta agonist. Perhaps they’re so tight that the albuterol you’re nebulizing is not getting where it needs to go due to profound bronchoconstriction. The main adverse effect is here is vasodilation-related hypotension.

By this point, your intubation stuff should be ready and the patient should be in resus.

They also will be having insensible losses so should get as 20 cc/kg IVF bolus.

Still getting worse.

Now this gets interesting.

We are really trying to avoid intubating any asthmatic because of historically poor outcomes with intubation, but sometimes it is unavoidable.

Next step is to try BiPAP. BiPAP could also be started simultaneously with epi. If they can’t tolerate BiPAP, consider ketamine to help them tolerate BiPAP. Ketamine can be dosed numerous ways. If sub-dissociative dosing is pursued, you risk them freaking out. If dissociative dosing, there’s a higher risk of laryngospasm. But consider this, they’re on the brink of getting intubated anyway. If your last-ditch-effort-ketamine gives them laryngospasm, that might be your cue to push a paralytic.

Ketamine and BiPAP has failed.

Time to intubate. Preoxygenate as much as possible. Use the largest ETT possible. First pass success is key. Induce with ketamine 2 mg/kg if they’re not already in the K-Hole. Roc or Sux.

Now they’re intubated

• They have OBSTRUCTIVE LUNG PHYSIOLOGY. It will take them way longer than usual to exhale. Thus:

• Low respiratory rate! 8 breaths/min

• Lung protective tidal volume: 7 cc/kg ideal body weight

• Minimal PEEP: 0 (ZEEP) - 2 cc H2O

• High inspiratory flow rate: 90 LPM or I:E 1:5

• FiO2 100%

• The ventilator will alarm due to high PEAK pressures. This is OK. Have the respiratory therapist fix it to raise the alarm threshold. The high peak pressures are a consequence of their tight bronchioles.

• If running into issues with ventilator dyssynchrony, consider paralyzing with cisatracuium

• Relative hypoxia (sat mid 80s, goal >90%) and hypercarbia (goal >7.15) is OK

• Aggressive airway suctioning

• If they begin crashing, disconnect from vent and push on chest to ensure breath stacking is not the issue; rule out pneumothorax; rule out displaced/clogged/kinked ETT

Still doing poorly

• Call the ECMO team for VV ECMO

• Anesthesia to set up inhaled anesthetics! e.g. desflurane, sevoflurane. Not tons of evidence, but in case series' and anecdotally, this works really well.

• Fun fact, CO2 can be dialyzed out of someone rather than ventilated out of someone. However, you need to be in a center where ECMO is also done, because it’s basically putting a piece of the ECMO circuit into a CVVHD circuit. Yes. Blew my mind too.

See Reuben’s algorithm on this at https://emupdates.com/when-the-patient-cant-breathe-and-you-cant-think-the-emergency-departement-life-threatening-asthma-flowsheet/