13 02, 2017

Trick of the Trade: Rapid Insertion of Orogastric Tube


We have all been in the situation: an intubated patient needs an orogastric (OG) tube and no one has been able to place it successfully. Unfortunately, we typically find out about this situation after several failed attempts, when the patient is bleeding and/or the anatomy is distorted. It may coil in the mouth or esophagus. Here I present a novel technique to rapidly place an OG tube within seconds.

23 11, 2016

PV Card: LVAD Complications


Patients with left ventricular assist devices (LVAD) often cause much anxiety amongst providers in the emergency department. This is understandable with all of the hardware, diminished or absent peripheral pulses at baseline, and potential for complications. To add to the already helpful reviews about LVADs at REBELEM and emDocs, this is a PV card set providing a methodical approach to troubleshooting LVAD complications, including a reproduction of an algorithm for managing the LVAD patient with altered mental status from EMCrit.1–3

12 09, 2016

AIR Series: Procedures Module (2016)

Welcome to the Procedures Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index the ALiEM AIR Team is proud to present the highest quality procedure content. Below we have listed our selection of the 13 highest quality blog posts within the past 12 months (as of June 2016) related to procedure emergencies, curated and approved for residency training by the AIR Series Board. More specifically in this module, we identified 3 AIRs and 10 Honorable Mentions. We recommend programs give 4 hours (about 20 minutes per article) of III credit for this module.


20 07, 2016

Trick of the Trade: Tibial Intraosseous Line Stabilization in an Agitated Patient

Intraosseous needle - image from Dr. Rob CooneyWith the advent of commercial intraosseous (IO) needles for vascular access, administering IV medications for patients in extremis has been made much easier. Securing the IO needle to the patient’s tibia, femur, or humerus, however, is a different story. After successful patient resuscitation, these needles often tenuously secured through creative uses of sterile gauze, trimmed paper cups, bag valve masks, and/or just tape. Stabilization of tibial IO lines can be difficult in a sedated, intubated patient. This can be even more difficult in an agitated, moving patient.


5 07, 2016

AIR-Pro Series: Critical Care (part 2) Module

Welcome to the Critical Care (Part 2) Block!

Below we have listed our selection of the highest quality posts related to 4 advanced level questions on critical care topics posed, curated, and approved for senior residents by the AIR-Pro Series Board. The blogs relate to the following questions:

  1. Advanced ventilatory management
  2. Submassive pulmonary embolism management
  3. Hypotensive intubation
  4. End of life discussion

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR-Pro stamp of approval will only be given to posts scoring above a strict scoring cut-off of ≥28 points (out of 35 total), based on our AIR-Pro scoring instrument, which is slightly different from our original AIR Series scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR-Pro Board members as worthwhile, accurate, unbiased and useful to senior residents. Only the posts with the AIR-Pro stamp of approval will be part of the quiz needed to obtain III credit. To decrease the repetitive nature of posts relating to these advanced concepts, we did not always include every post found that met the score of ≥28 points.

Take the quiz at ALiEMU
ALiEMU AIR-Pro Critical Care (Part 2) block quiz

Interested in taking the quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a one-time login account if you haven’t already.

Highlighted AIR-Pro posts

Article Title Author Date Link Title
Taking ownership of the ventilator Evan Miller & Maxim Dzeba April 21, 2016 EM Docs: Ventilator management AIR-PRO
Mechanical ventilation in ARDS: 2014 update Matthew Hoffman May 12, 2014 PulmCCM: Mechanical Ventilation AIR-PRO
Thrombolysis for submassive pulmonary embolism Chris Nickson Jan 7, 2016 LITFL: Thrombolysis for submassive PE AIR-PRO
Controversies of thrombolytics for pulmonary embolism Brit Long May 28, 2016 EM Docs: Controversies in thrombolytics AIR-PRO
How to intubate a patient with hypotension Scott Weingart Aug 5, 2013 EM Crit: Hemodynamic kills AIR-PRO
Intubating the critically ill patient Zach Radwine Jan 6, 2014 EM Docs: Intubating the critically ill AIR-PRO
DNR means do not treat… and other end of life care myths Ashley Shreves Aug 2014 EP Monthly: DNR means do not treat AIR-PRO
Dominating the vent: Part 1 Scott Weingart May 24, 2010 EM Crit: Dominating the vent (1) Honorable Mention
Dominating the vent: Part 2 Scott Weingart June 1, 2010 EM Crit: Dominating the vent (2) Honorable Mention
Pulmonary embolism treatment options Scott Weingart & Oren Friedman July 14, 2014 EM Crit: Pulmonary Embolism Honorable Mention
Critical care palliation Scott Weingart & Ashley Shreves Feb 18, 2013 EM Crit: Critical care palliation Honorable Mention

If you have any questions or comments, please contact us!

16 05, 2016

Trick of the Trade: Pre-Charge the Defibrillator

Pre-Charge the Defibrillator CPRIn cardiac arrest care it is well accepted that time to defibrillation is closely correlated with survival and outcome.1 There has also been a lot of focus over the years on limiting interruptions in chest compressions during CPR. In fact, this concept has become a major focus of the current AHA Guidelines. Why? Because we know interruptions are bad.2,3 One particular aspect of CPR that has gotten a lot of attention in this regard is the peri-shock period. It has been well established that longer pre- and peri-shock pauses are independently associated with decreased chance of survival.4,5 Can we do better to shock sooner and minimize these pauses?


3 05, 2016

Trick of the Trade: Securing the intraosseous needle


So much attention is appropriately focused on the anatomy and technique for intraosseous needle placement. In contrast, very little attention is paid to securing the needle. Often this involves a make-shift setup which involves gauze, wraps, and/or tape. This becomes especially important in the prehospital setting where these can be easily dislodged. The following trick stems from a Twitter discussion in 2015 amongst prehospital providers, lamenting this fact.