What is the optimal position to intubate an obese patient?

click image to enlarge

Source

Image source: http://bentollenaar.com/_MM_Book/Ch.43.htm

Mattu, A.  Emedhome.com.  EMCast.  January 2012.

Is this right IJ central line correctly placed as noted on chest x-ray?

Blue dot marks tip of IJ.   Contrast adjusted to maximize clarity of IJ and tracheobronchial angle.  Click on image to enlarge.

IJ should be pulled back 1-2 cm.  Ideal location is at the superior vena cava/atrial junction which is located  3-5 cm below the tracheobronchial angle, a distance which is reproducible in patients despite gender and body habitus. 


Source

Emedhome.com.  Clinical Pearls: "Proper Position of a Central Line."  7 April 2010.

Marcucci, L. Avoiding Common ICU Errors.  "Place the Tip of a Central Venous Catheter at the Junction of the Superior Vena Cava and Atrium"  Lippincott Williams & Wilkins.  2007.

Here's a great primer on reading ED CTs

http://radiology.cornfeld.org/ED/

Granted, you're not the radiologist but knowing a bit about how to pick up emergency pathology on CTs ordered in the department can come in handy.   The link leads to a repository of relevant cases with thorough explanations and high quality annotated images.  Be sure to read the instructions before embarking as it will help you to best navigate the site.

Hat tip to ER Jedi.

How do you perform a cricothyrotomy? Here are videos of my favored techniques.

There are a bunch of devices and associated techniques to perform a cric.  Below I have posted videos of my favorite technique to perform a standard cric and needle cric.  These are my preferred methods because they can be performed with items lying around any standard ED and don't rely on having any special equipment (ie jet ventilator, etc ...) - which often seems to go missing when needed most.

Bougie-Aided Standard Cric (hat tip to EMCrit)




Needle Cricothyrotomy




Source

Video, Bougie Aided Standard Cricothyrotomy: http://www.youtube.com/watch?v=wVQFJR7qmrQ&feature=player_embedded

Video, Needle Cricothyrotomy: http://www.youtube.com/watch?v=Fq5YCpYTYUY

At what age does the surgical airway technique of choice transition from needle cricothyrotomy to standard (percutaneous or open) cricothyrotomy?

10 years old.   Standard cric should be avoided in children less than 10 years old.


Source

Marx: Rosen's Emergency Medicine, 7th ed.

When placing a central line, a question that occasionally arises is whether you are in the artery or vein? Here's a video compliments of Dr. Weingart of the EMCrit Blog on a novel technique to help figure it out before you dilate the vessel.

Are you in the Artery or the Vein? from Scott from EMCrit on Vimeo.

Source

http://emcrit.org/central-lines/

What is the best approach for elbow arthrocentesis?

Lateral.

1. Prep. Anesthetize.
2. Flex elbow 45 degrees.
3. Pronate hand.
4. Identify depression between the lateral epicondyle of the humerus, the radial head and the tip of the olecranon process of the ulna.
5. Insert needle perpendicular to skin. Aspirate.
   

Source

Reichman, E and Simon, R. Emergency Medicine Procedures

Image source: http://emedicine.medscape.com/article/79975-treatment

Quick! What are you going to do?!? .... You can't intubate or ventilate this 7 year old kid.

If you can't intubate or ventilate a child despite attempting several airway techniques ie LMA, boogie, glide scope, etc ... there's always the handy, but rarely used, cricothyrotomy.

In children, pediatric needle cric kits exist out there but unless you're at a hospital that sees lots of sick children, the likelihood that they're stocked and easily accessible is about nil.

But not to despair, the majority of physicians can quickly assemble a "make shift" system from the following items found in most EDs.

• 14 gauge IV catheter
• 3 cc syringe
• 7.0 endotracheal tube adapter

Procedure:

1. Prep crichothyroid membrane
2. Attach 3 cc syringe 1/2 filled with saline to the 14 gauge angiocath
   
3. Puncture cricothyroid membrane with needle directed at 45 degree angle caudally while pulling back on the syringe's plunger
   
4. Stop advancing the angiocath once bubbles are noted in the syringe
5. Remove syringe and needle, leaving plastic IV catheter in trachea
   
6. Remove plunger from 3 cc syringe. Empty water. Attach syringe to IV catheter.
   
7. Attach 7.0 endotracheal tube adapter to 3 cc syringe.
8. Bag ventilate.
   

Source

Roberts: Clinical Procedures in Emergency Medicine, 5th ed.

Walls, R. Manual of Emergency Airway Management.

What is M mode ultrasound? What is it good for?

In M mode, a "single beam" of ultrasound provides a one dimensional image tracked over time. It has a high sampling frequency (up to 1000 pulses per second) and is useful in assessing rates such as fetal cardiac activity.




Source

Cosby, K. MD and Kendall, J. MD. "Practical Guide to Emergency Ultrasound"

Image source: College of Veterinary Medicine, the University of Tennessee. http://www.vet.utk.edu