FINGER: A Novel Approach to Teaching Simple Thoracostomy.

For decades, most prehospital clinicians have only been armed with needle thoracostomy to treat a tension pneumothorax, which has a significant failure rate. Following recent changes by the US military, more ground and air transport agencies are adopting simple thoracostomy, also commonly referred to as finger thoracostomy, as a successful alternative. However, surgical procedures performed by prehospital clinicians remain uncommon, intimidating, and challenging. Therefore, it is imperative to adopt a training strategy that is comprehensive, concise, and memorable to best reduce cognitive load on clinicians while in a high-acuity, low-frequency situation. We suggest the following mnemonic to aid in learning and retention of the key procedural steps: FINGER (Find landmarks; Inject lidocaine/pain medicine; No infection allowed; Generous incision; Enter pleural space; Reach in with finger, sweep, reassess). This teaching aid may help develop and maintain competence in the simple thoracostomy procedure, leading to successful treatment of both a tension pneumothorax and hemothorax.

The Case for Bougie Use on Every Intubation.

Despite its value in emergency airway management, the endotracheal tube introducer, commonly known as the bougie, has traditionally been a point of disagreement between providers. It is typically viewed as a "rescue" device and not a primary airway tool. However, its value as a primary device during plan A has recently been recognized. Two studies have shown increased first-pass success using a bougie on the initial attempt. Additionally, bougie use on every intubation increases provider comfort with the device so that, on a truly difficult intubation, the skills and mechanics are instilled. In the out-of-hospital and critical care transport settings, intubation is often inherently more difficult because of varying environments. For these reasons, the bougie should be integrated into the first intubation attempt in emergent intubation.

Emergency Reflex Action Drills and the Problem with Stress.

Clinicians involved in the care of critically ill patients are often exposed to demanding and stressful situations that require immediate action. Evidence suggests that human performance can be significantly diminished when multiple stressors and stimuli are present. Humans have developed conscious and unconscious methods of dealing with this type of cognitive overload in various high-risk occupations, but these coping methods have not necessarily been structured and adapted to the provision of emergency medical care. Emergency reflex action drills (ERADs) are derived from available evidence in specific domains (e.g., airway management) and develop automaticity of critical skills which engender quick, effective, and reproducible performance with minimal cognitive load. These are pre-planned, practiced responses to specific, high-demand and time-sensitive situations. This article outlines the psychological, cognitive, and behavioral effects of stress that affect performance and necessitate development of ERADs. It also reviews the scientific underpinnings behind how humans have adapted cognitive behavioral techniques to manage under high-stress situations. Finally, this article recommends the adoption of these cognitive tactics via ERADs to enhance clinical practice and provides an example in the context of airway management.

Randomized Controlled Trial of Point-of-Care Ultrasound Education for the Recognition of Tension Pneumothorax by Paramedics in Prehospital Simulation.

OBJECTIVE: The primary goal of this study was to determine if ultrasound (US) use after brief point-of-care ultrasound (POCUS) training on cardiac and lung exams would result in more paramedics correctly identifying a tension pneumothorax (TPTX) during a simulation scenario. METHODS: A randomized controlled, simulation-based trial of POCUS lung exam education investigating the ability of paramedics to correctly diagnose TPTX was performed. The US intervention group received a 30-minute cardiac and lung POCUS lecture followed by hands-on US training. The control group did not receive any POCUS training. Both groups participated in two scenarios: right unilateral TPTX and undifferentiated shock (no TPTX). In both scenarios, the patient continued to be hypoxemic after verified intubation with pulse oximetry of 86%-88% and hypotensive with a blood pressure of 70/50. Sirens were played at 65 decibels to mimic prehospital transport conditions. A simulation educator stated aloud the time diagnoses were made and procedures performed, which were recorded by the study investigator. Paramedics completed a pre-survey and post-survey. RESULTS: Thirty paramedics were randomized to the control group; 30 paramedics were randomized to the US intervention group. Most paramedics had not received prior US training, had not previously performed a POCUS exam, and were uncomfortable with POCUS. Point-of-care US use was significantly higher in the US intervention group for both simulation cases (P <.001). A higher percentage of paramedics in the US intervention group arrived at the correct diagnosis (77%) for the TPTX case as compared to the control group (57%), although this difference was not significantly different (P = 0.1). There was no difference in the correct diagnosis between the control and US intervention groups for the undifferentiated shock case. On the post-survey, more paramedics in the US intervention group were comfortable with POCUS for evaluation of the lung and comfortable decompressing TPTX using POCUS (P <.001). Paramedics reported POCUS was within their scope of practice. CONCLUSIONS: Despite being novice POCUS users, the paramedics were more likely to correctly diagnose TPTX during simulation after a brief POCUS educational intervention. However, this difference was not statistically significant. Paramedics were comfortable using POCUS and felt its use improved their TPTX diagnostic skills.

The High-Risk Airway.

The high-risk airway is a common presentation and a frequent cause of anxiety for emergency physicians. Preparation and planning are essential to ensure that these challenging situations are managed successfully. Difficult airways typically present as either physiologic or anatomic, each type requiring a specialized approach. Primary physiologic considerations are oxygenation, hemodynamics, and acid-base, whereas anatomic difficulty is overcome using proper positioning and skilled laryngoscopy to ensure success. It is essential to be comfortable performing alternative techniques to address varying presentations. Ultimately, competence in airway management hinges on consistent training, deliberate practice, and a dedication to excellence.

Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine.

Endotracheal intubation (ETI) is a high-risk procedure commonly performed in emergency medicine, critical care, and the prehospital setting. Traditional rapid sequence intubation (RSI), the simultaneous administration of an induction agent and muscle relaxant, is more likely to harm patients who do not allow appropriate preparation and preoxygenation, have concerning airway anatomy, or severe hypoxia, acidemia, or hypotension. Ketamine, a dissociative anesthetic, can be used to facilitate two alternatives to RSI to augment airway safety in these scenarios: delayed sequence intubation - the use of ketamine to allow airway preparation and preoxygenation in the agitated patient; and ketamine-only breathing intubation, in which ketamine is used without a paralytic to facilitate ETI as the patient continues to breathe spontaneously. Ketamine may also provide hemodynamic benefits during standard RSI and is a valuable agent for post-intubation analgesia and sedation. When RSI is not an optimal airway management strategy, ketamine's unique pharmacology can be harnessed to facilitate alternative approaches that may increase patient safety.