1. Safe apnea time can be prolonged by preoxygenating patients using high-flow oxygen through a non-rebreather mask or positive pressure devices like CPAP. Positioning the patient at 20 degrees can add 90 seconds to the safe apnea time. 2. Evidence shows that backboards may cause more harm than benefit for patients with potential spinal injuries. Immobilization is important but backboards are not necessarily the best way to achieve it. 3. There have been multiple cases discussed of accidental poisonings, especially in children, from unusual sources like soy sauce, laundry pods, liquid nicotine, energy supplements and other substances. These cases provide important lessons about prevention.

1. Rounds December
1. Safe Apnea
2. Backboards
3. New Drug Overdoses

2. Preoxygenation and Prevention of
Desaturation During Emergency
Airway Management
• Based on the article by Scott Weingart and
Richard Levitan , Ann. Emerg. Med.
2012:59:165-175
• Patients requiring emergency airway
management are at great risk of hypoxemia..
You can minimize the risk of critical hypoxia
while securing a tracheal tube rapidly.

3. Peri Intubation Cardiac Arrest
Heffner,AC Resuscitation 2013

4. Safe Apnea
Duration of Apnea until O2 sat 88-90 %
Obese patients desaturate faster
Critically ill patients desaturate faster
A. Increased metabolic demands
B. Volume depletion
C. Shunting
D. Anemia
Remember that Pulse Oximetry lags by 30-60
seconds.

5. Oxyhemoglobin Dissociation Curve
Hypoxic below 60% High Risk Below 89%
• Weingart SD. AnnEmergMed 2013.

6. Safe Apnea Cont’d
• In a patient breathing room air before intubation,
desaturation will occur in 45-60 seconds. If , prior
to administering the paralytic, the patient’s lungs
are filled with O2, the time to desaturate will be a
lot longer…
• There are 3 goals: bring the O2 sat as close to
100% as possible, get rid of all the nitrogen and
fill those spaces with oxygen [78 % vs 21,
normally], maximize the O2 in the bloodstream .

7. How to give the O2
• A nonrebreather face mask will deliver only
60-70 % O2 when it is set at 15 LPM. If you
turn the flow rate up to 30-60 LPM you can
deliver 90 % FIO2. A tight seal must be
achieved to deliver more than ambient O2,
[21 % ] .
• A standard reservoir facemask with the
flow rate set as high as possible is the best
source of O2.

8. Concepts
• Risk stratification by O2 saturation
• Apneic Oxygenation [when the patient is not
breathing you are still oxygenating them]
• Preintubation CPAP in patients who remain
hypoxic, in spite of your efforts

9. Risk categorization, during
preoxygenation
• The Risk categories are based on a patient’s
response to high flow O2 with a nonrebreather
mask. Patients with an O2 sat of 96 % or greater
are at low risk of desaturation during intubation.
• Low Risk, SPO2 of 96-100 %, preoxygenate for 3
minutes with a nonrebreather mask with
maximal oxygen flow rate. One minute prior to
intubation use the non rebreather mask AND a
NASAL CANNULA at 15 LPM. During intubation
leave the nasal cannula in place

10. Risk Categorization Cont’d
• Moderate Risk , SPO2 of 91-95 %. High Risk,
hypoxic with an SPO2 of 90% or less while
receiving high flow O2
• For 3 minutes preoxygenation using CPAP or a
BVM with PEEP.
• One minute before intubating add a NASAL
CANNULA at 15 LPM, in addition to the CPAP or
BVM with PEEP
• During intubation continue the Nasal Cannula at
15 LPM

11. Improving Your Chances
• Positioning
• Preoxygenation and Denitrogenation
• Positive pressure Devices
• Passive Apneic Oxygenation

12. Positioning
• Put the head of the bed UP 20 degrees
• Why? When we are flat it is harder to take a
full breath and more of the posterior lung
becomes atelectatic. The diaphragms are
higher and the total lung volume is less. This
will increase the safe apnea time.
• THIS WILL ADD 90 SECONDS

13. Preoxygenation and Denitrogenation
When breathing room air 450 mls of O2 is present
in the lungs. When you replace the nitrogen with
O2 there is 3000 ml of O2 present in the lungs!
Oxygen consumption during apnea is 250ml/min. In
healthy patients the safe apnea time is 1 minute
with room air. You can prolong the safe apnea
period to 8 minutes!
THIS IS THE KEY

14. Positive Pressure Devices
• If unable to achieve O2 sat > 93% - 95% with
high FiO2
• CPAP / BiPAP
• BVM with a PEEP valve
• If patients are unable to achieve an O2 sat
> 95 % then they are likely to desaturate
during your intubation attempt. You must get
the alveoli open with positive pressure to
increase the O2 sat still higher.

15. Apneic Oxygenation
Why the nasal cannula? The O2 is under pressure and is
being forced into the lungs and across the alveoli during your
intubation. This will prolong the time it takes to desaturate .
You are keeping the patient alive longer. They will become
hypoxic more slowly.
The times to desaturation are 8 minutes in healthy adults
5 minutes in moderately ill adults and 2.7 minutes in obese
adults.
.
APNEIC OXYGENATION.

16. SUMMARY
• Position the patient at 20 Degrees
• Tight seal with Non rebreather
• Turn Flow rate to maximal
• Try to get O2 Sat to 100%
• Keep the O2 sat at 100% for 3 Minutes
• If Unable to get sat to 100%, Use CPAP
• Prior to Intubating, Use a NC at MAX FLOW

17. Backboards
• This is the talk given by Dr Christopher Colwell
at the ACEP meeting in 2014

18. SPINAL INJURIES

19. OUR CURRENT BELIEFS

20. WHY DO WE BELIEVE THIS ?

21. SPINE BOARDS

22. EVIDENCE OF HARM

23. MORE EVIDENCE

24. MORE EVIDENCE

25. STILL MORE

26. PENETRATING TRAUMA

27. PENETRATING TRAUMA

28. IMMOBILIZED

29. WHAT CAUSES INJURY?

30. SCOOPS

31. EXTRACTION TECHNIQUES

32. SPINE BOARDS :

33. Massive Overdose of Soy Sauce….

35. Pretty and Dangerous

36. Laundry Pods

37. MMWR 2012

40. Lessons From the laundry Room

42. Blue Baby

43. Suboxone Overdoses

44. Buprenorphine, Suboxone

45. MMWR 2013

47. Lessons, Again

48. Grunting Infant

49. Liquid Nicotine

50. MMWR 2014

53. Lessons

54. Poisoned with Lamusol

55. Levamisole

57. Lessons

58. Energized and Confused

59. Energy Supplements

61. Ohio Teenage Wrestler Died From a
Caffeine Overdose

63. Lessons

64. Not So Fast…