Prevention of desaturation during intubations

A great article in this month's Annals of Emergency Medicine from Scott Weingart and Richard Levitan: "Preoxygenation and Prevention of Desaturation During Emergency Airway Management."

Recommendations for improving oxygenation and preventing desaturation during ED intubations:

1.  Preoxygenate patient using standard reservoir facemask with highest possible flow rate of O2, head-up position, when possible.

2.  If possible, preoxygenate for 3 minutes or have patient take 8 maximal inhalation/exhalation breaths.

3.  For patients who cannot achieve saturations > 93-95% with high FiO2, consider preoxygenation with PEEP, including CPAP masks, noninvasive positive-pressure ventilation, or PEEP valves on a bag-valve-mask device.  

4.  Provide passive oxygenation during RSI (using high-flow O2 via nasal cannula after sedatives and paralytics given) to increase duration of safe apnea in ED tracheal intubations.

6.  Ventilate hypoxemic patients during onset phase of muscle relaxants in RSI prior to tracheal intubation.  For fully oxygenated patients at low risk for desaturation, ventilation is not required during the onset phase of muscle relaxants.

7.  Position patients to maximize upper airway patency using ear to sternal notch positioning.


References:
1.  Weingart, S and Levitan, R.  Preoxygenation and Prevention of Desaturation During Emergency Airway Management.  Annals of Emergency Medicine 2012;59:165-75.

Normal ESR values by age

Rule for correcting erythrocyte sedimentation rate (ESR) by age:

Men:  Age in years  /  2
Women:  Age in years + 10  /  2


References:
1.  Miller A, Green M, Robinson D.  Simple rule for calculating normal erythrocyte sedimentation rate.  BMJ 1983; 286:266.  

What are the top causes of small bowel obstruction?

Upright abdominal film showing multiple air-fluid levels.

Most common causes of small bowel obstruction in adults:

#1.  Adhesions after abdominal surgery (60%)
#2.  Malignancy (20%)
#3.  Hernia (10%)
#4.  Inflammatory bowel disease (5%)

Intussusception is the most common cause of small bowel obstruction in children.

References:  
1.  Nobie, BA.  Small-Bowel Obstruction.  Emedicine.  Available at http://emedicine.medscape.com/article/774140-overview#aw2aab6b2b3.  Accessed March 3, 2012.