Jun 16

Airway Management in Life Threatening COPD

NY Smog

Oxygen for COPD

The danger of hyperoxia to patients with COPD was recognized by Westlake in 1955. Westlake EK, Simpson T, Kaye M. Carbon dioxide narcosis in emphysema. The Quarterly journal of medicine. 24(94):155-73. 1955.

Knowledge translation, as ever, has been slow.  Hospital audits continue to show that these patients are treated with high flow oxygen, resulting in hypercarbia, acidosis and increased mortality. Aubier et al found that Hypoxia does not appear to decrease minute ventilation. They also found that the release of CO2 bound to Hemoglobin by the Haldane effect accounted for about 25% of the increase in PaCO2 in their COPD patients on high flow O2. Aubier M et al. Effects of the administration of O2 on ventilation and blood gases in patients with chronic obstructive pulmonary disease during acute respiratory failure. Am Rev Respir Dis.1980;122(5):747–754.

But the largest contribution to hypercarbia and acidosis in these patients is thought to be due to an oxygen induced reversal of a beneficial v/q mismatch. Robinson et al. The role of hypoventilation and ventilation-perfusion redistribution in oxygen-induced hypercapnia during acute exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2000;161(5):1524– 1529.

Non-invasive Ventilation

Brochard showed that NIV resulted in lower rates of intubation and shorter hospital stays for paitents with COPD exacerbation. And in 2001 Plant showed that long term survival was better as well. Brochard L, Mancebo J, Wysocki M, Lofaso F, Conti G, Rauss A, Simonneau G, Benito S, Gasparetto A, Lemaire F, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1995 Sep 28;333(13):817-22. 

Plant found that long term mortality was improved by NIV in copd. Plant PK, Owen JL, Elliott MW.  Non-invasive ventilation in acute exacerbations of chronic obstructive pulmonary disease: long term survival and predictors of in-hospital outcome. Thorax 2001;56:708-712.

GOLD and ATS/ERS Guidelines promote NIV as first line therapy in COPD exacerbation. GOLD Guidelines (goldcopd.it). Celli BR, MacNee W; ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004 Jun;23(6):932-46.

Del Sorbo L, et al. Extracorporeal Co2 removal in hypercapnic patients at risk of noninvasive ventilation failure: a matched cohort study with historical control. Crit Care Med. 2015 Jan;43(1):120-7.

PAP PAL was published by Rose on the satirical Gomerblog in 2015.

NIV failure results in higher mortality per Demoule. Demoule A, Girou E, Richard JC, Taille S, Brochard L (2006) Benefits and risks of success or failure of noninvasive ventilation. Intensive Care Med 32:1756– 1765. 


Scott Weingart’s concept of HOP killers as a mnemonic for predicted difficult physiology during intubation appear on his emcrit podcast in 2012 with subsequent appearances in his Laryngoscope as a murder weapon series.  emcrit.org.

In 2006 Baillard showed that NIV preoxygenates better than face mask. Baillard C, Fosse JP, Sebbane M, Chanques G, Vincent F, Courouble P, Cohen Y, Eledjam JJ, Adnet F, Jaber S. Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med. 2006 Jul 15;174(2):171-7.

Weingart’s 2016 paper is a great review of early ED vent management. Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016 Jun 8. pii: S0196-0644(16)30164-0.

Mosier’s review of mechanical ventilation is more comprehensive if you want to go deeper. Mosier JM, Hypes C, Joshi R, Whitmore S, Parthasarathy S, Cairns CB. Ventilator Strategies and Rescue Therapies for Management of Acute Respiratory Failure in the Emergency Department. Ann Emerg Med. 2015 Nov;66(5):529-41.

Jun 16



Edward Tufte – statistician and pioneer in the field of data visualization. Worth a look.

Garr Reynolds’ book Presentation Zen is required reading for the presentation enthusiast.

Nancy Duarte is a professional writer speaker and her design firm has prepared countless TED talks including Al Gore’s inconvenient truth. Tons of resources on her site.

The Teaching Course is an expensive introduction to cutting edge medical education – developed by Rob Rogers and Salim Rezaie. Scott Weingart has posted his lecture on presentation preparation mastery to vimeo.

The United States Military Academy offers this incredible pdf of a presentation on dynamic planning for counter insurgency in Afghanistan.

Ben Smith’s ultrasound of the week website hosts his clip deidentifier app, m-modify and a PMID citation generator. Not to mention highly educational weekly ultrasound cases.

iSKySoft offers an excellent commercial video and media conversion software.

Propanolol for stage fright: Effect of beta blockade and beta stimulation on stage fright. Brantigan CO, Brantigan TA, Joseph N. Am J Med. 1982 Jan;72(1):88-94. PMID: 6120650


Blyth meta-analysis that purported to lyse the dogma of standstill being associated with 100% mortality.

Bedside focused echocardiography as predictor of survival in cardiac arrest patients: a systematic review. Blyth L, Atkinson P, Gadd K, Lang E. Acad Emerg Med. 2012 Oct;19(10):1119-26. doi: 10.1111/j.1553-2712.2012.01456.x. Epub 2012 Oct 5. Review. Erratum in: Acad Emerg Med. 2015 Jul;22(7):892. PMID: 23039118

Tomruk paper from a group in Turkey that achieved ROSC in 55 patients with standstill. 45% of those with standstill were successfully resuscitated. No mention of survival to discharge, long term outcome, etc.

Assessment of cardiac ultrasonography in predicting outcome in adult cardiac arrest. Tomruk O, Erdur B, Cetin G, Ergin A, Avcil M, Kapci M. J Int Med Res. 2012;40(2):804-9. PMID: 22613446

Bocka definition of echocardiac cardiac activity: Electromechanical dissociation in human beings: an echocardiographic evaluation. Bocka JJ, Overton DT, Hauser A. Ann Emerg Med. 1988 May;17(5):450-2. PMID: 3364823

Turning Technologies remote polling system

The R Project for statistical computing. https://www.r-project.org/

Krippendorff, K. (2011). Computing Krippendorff’s Alpha-Reliability. Retrieved from http://repository.upenn.edu/asc_papers/43

Hayes A, Krippendorff K. Answering the Call for a Standard Reliability Measure for Coding Data. Communication Methods and Measures. 2007;1(1):77-89.

Reason Study: ppt from CAEP presentation

Ultrasound podcast on REASON study.



Unluer et al compared bedside ultrasound and radiology ultrasound to clinical course and surgical findings.  174 patients. Bedside and radiology ultrasound were found to have similar test characteristics and both exceeded plain film radiography.

Ultrasonography by emergency medicine and radiology residents for the diagnosis of small bowel obstruction. Unlüer EE, Yava?i O, Ero?lu O, Yilmaz C, Akarca FK. Eur J Emerg Med. 2010 Oct;17(5):260-4. doi: 10.1097/MEJ.0b013e328336c736. PMID: 20216422

Jang et al found that bedside ultrasound outperformed plain films using ct as gold standard in 76 patients.

Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Jang TB, Schindler D, Kaji AH. Emerg Med J. 2011 Aug;28(8):676-8. doi: 10.1136/emj.2010.095729. Epub 2010 Aug 22. PMID: 20732861



This radiology study meta-analysis of 630 ultrasound patients and 684 ct patients found US test characteristics to be non-inferior to CT.

Graded compression ultrasonography and computed tomography in acute colonic diverticulitis: meta-analysis of test accuracy. Laméris W, van Randen A, Bipat S, Bossuyt PM, Boermeester MA, Stoker J. Eur Radiol. 2008 Nov;18(11):2498-511. PMID: 18523784


Fox compared bedside ultrasound in 126 patients to either path report for those that underwent appendectomy or telephone follow up if they didn’t. They achieved excellent  specificity 90% – but mediocre sensitivity – only 65%. This is one way we use very commonly use ultrasound, though – as a rule in only modality.

Prospective evaluation of emergency physician performed bedside ultrasound to detect acute appendicitis. Fox JC, Solley M, Anderson CL, Zlidenny A, Lahham S, Maasumi K. Eur J Emerg Med. 2008 Apr;15(2):80-5. doi: 10.1097/MEJ.0b013e328270361a. PMID: 18446069

Jim Tsung’s 2014 study found 100% sensitivity with a strict technique – their protocol required the appendix to be fully visualized from tip to cecum in long view and then transversely throughout the same course. This resulted in a higher number of equivocal studies, but no false negative laparotomies.  Having no false negative laparotomies builds real trust with your pediatric surgeons.

The effect of point-of-care ultrasonography on emergency department length of stay and computed tomography utilization in children with suspected appendicitis. Elikashvili I, Tay ET, Tsung JW. Acad Emerg Med. 2014 Feb;21(2):163-70. doi: 10.1111/acem.12319. PMID: 24673672



Summers and Fox found test characteristics in BUS noninferior to RUS.

A prospective evaluation of emergency department bedside ultrasonography for the detection of acute cholecystitis. Summers SM, Scruggs W, Menchine MD, Lahham S, Anderson C, Amr O, Lotfipour S, Cusick SS, Fox JC. Ann Emerg Med. 2010 Aug;56(2):114-22. doi: 10.1016/j.annemergmed.2010.01.014. PMID: 20138397

Villar’s and Fox’s study – looked at data from a prior study comparing gallstones along vs. stones + secondary signs for the diagnosis of cholecystitis with Radiology ultrasound or pathology report as the gold standard. They found that absence of gallstones ruled out cholecystitsi with a sensitivity of 100%..

Studies like these make my life so easy.

The Absence of Gallstones on Point-of-Care Ultrasound Rules Out Acute Cholecystitis. Villar J, Summers SM, Menchine MD, Fox JC, Wang R. J Emerg Med. 2015 Oct;49(4):475-80. doi: 10.1016/j.jemermed.2015.04.037. Epub 2015 Jul 7. PMID: 26162764

Dec 12

Drink Up

Black Coffee in a Black Cup by Ted ThompsonAssociation of Coffee Drinking with Total and Cause-Specific Mortality

May 12

RUSH in Arrest


This morning I gave grand rounds on the use of ultrasound in cardiac arrest at my home base of the mount sinai hospital in new york city.  More info at sinaiem.us.

Oct 11

Probe before Scalpel

The tides have shifted.  The days of poking a finger into a mass, declaring it a fluctuant abscess and opening it are over.  With point of care ultrasound widely available, it makes sense to scan the area you are planning to cut into.  You never know what you may find.

This week, in the Journal of Ultrasound in Medicine, Blaivas and Adhikari published their case series of Unexpected Findings on Point-of-Care Superficial Ultrasound Imaging Before Incision and Drainage.  They recorded a total of six cases.  A wrist mass clinically consistent with abscess found to contain arterial flow on ultrasound that was ultimately diagnosed as a liposarcoma.  A couple of cases where upper extremity abscesses were unroofed rather than incised due to proximity to vascular structures.  An abdominal wall abscess that turned out to be an incarcerated hernia.  A femoral artery pseudoaneurysm, and a solid mass thought to be an atypical bartholin’s cyst eventually diagnosed as labial cancer

These six cases are a clarion call.

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