The paramedics just arrived with a new patient to the resuscitation room. You find an altered patient actively vomiting bloody vomitus and food particles. You prepare for a difficult airway. You prepare 2 Yankauer suction catheters, but you are still worried that the food particles may clog up the catheters. Is there a better alternative?
Up to 44% of emergent intubations are complicated by blood, vomit, or food particles in the airway. It has been shown that contaminated airways may lead to multiple intubation attempts and are associated with poor outcomes, such as peri-intubation cardiac arrest [1, 2].
The Yankauer suction catheter is the most commonly available tool in the Emergency Department to remove foreign particles, but performs poorly when compared to larger-bore catheters . The Yankauer was made initially for surgical field management, with small holes at the tip to gently remove (or become clogged with) debris without damaging tissue. Some standard Yankauer designs have a built-in safety vent hole on the shaft, which if unoccluded, renders the device virtually useless . This protective equipment design does not offer maximum help during emergent large-volume regurgitation dirty airway management.
Alternatively, there is the DuCanto suction catheter. It is a specialized and more expensive large-bore version of the Yankauer; however, it is not as readily available and more expensive .
Trick of the Trade: Use a large-bore endotracheal tube as a rigid suction catheter
A large-bore, such as a size 10.0, endotracheal tube can serve as a rigid suction catheter. Note the diameter sizes of the Yankauer, DuCanto, and 10.0 endotracheal tube below.
- Materials needed
- Size 10.0 endotracheal tube (or the largest size you have)
- Suction tubing and canister
- Making the device
- Insert the rubber end of the suction tubing over the plastic endotracheal tube adaptor
- Attach suction tubing to the canister
- Turn suction on
Video Demonstration: Yankauer vs Large-Bore Endotracheal Tube
Editorial Note: If the rigidity of the catheter is less important, you can also insert the soft suction tubing directly into the airway to remove contents.
Read other Tricks of the Trade posts on ALiEM.
- Nikolla DA, Heslin A, King B, Carlson JN. Comparison of suction rates between a standard Yankauer and make-shift large bore suction catheters using a meconium aspirator and various sized endotracheal tubes. J Clin Anesth. 2021 Sep;72:110262. doi: 10.1016/j.jclinane.2021.110262. PMID 33839435
- Hasegawa K, Shigemitsu K, Hagiwara Y, et al. Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med. 2012;60(6):749-754.e2. doi:10.1016/j.annemergmed.2012.04.005. PMID 22542734
- Andreae MC, Cox RD, Shy BD, et al. 319 Yankauer Outperformed by Alternative Suction Devices in Evacuation of Simulated Emesis.” Ann Emerg Med. 68(4), S123 [research abstract] doi: 10.1016/j.annemergmed.2016.08.335
You’re seeing a patient returning to the ED after a recent diagnostic paracentesis. The patient is complaining of persistent peritoneal fluid leakage. They’ve tried putting pressure with no success. You tried applying a medical adhesive glue and noticed it was unsuccessful, based on the patient’s gown continuing to get wet with ascites fluid. Now what?
Trick of the Trade: Pressure Gauze and Transparent Film Dressing
The medical adhesive glue trick was proposed in the Trick of the Trade 1.0 version by Dr. Borloz and Dr. Lin in November 2012.
|Gauze 2″ x 2″||1-2|
|Transparent Film Dressing (Tegaderm) 2.5″ x 2.75″||3-4|
Consider combining both this trick of the trade and the adhesive glue technique. Hat tip to Dr. Christian Rose [Twitter @RoseLikeTheFlwr] for this idea.
Interested in other Tricks of the Trade posts?
Read the series of Tricks of the Trade posts.
Treatment of digoxin toxicity can be quite complex and generally involves the use of digoxin immune Fab (DigiFab®) for symptomatic patients. The dosing of DigiFab can vary depending on the amount ingested, serum concentration, and/or suspected chronicity of toxicity. Alternatively, for an acute ingested of an unknown amount where the serum concentration is not available, it is recommended that 10 vials of DigiFab be administered empirically. This antidote is expensive (~$5,000 per vial) and not always readily available in every hospital. Given the complicated dosing and cost, alternative dosing strategies are being explored.
Researchers from Australia first proposed an initial 2-vial DigiFab dose for acute digoxin poisoning in a 2014 review article . They followed this up with a pharmacokinetic study supporting the simplified dosing scheme . Based on their early data, the Australian poison center recommendations were revised to instead use small doses of DigiFab (2 vials at a time) with repeat doses as needed to achieve clinical effect. This allowed them to prospectively study this new dosing strategy in 21 cases of digoxin toxicity . Most patients required less than would have been administered following traditional dosing calculations. Patients receiving the lower-dosing scheme did have a rebound in free digoxin levels >2 ng/mL at a median time of 18 hours in patients with normal renal function and 103 hours in patients with an acute kidney injury. Most patients received 2 vials of DigiFab initially and a median of 4 vials total after receiving additional doses based on persistent or recurrent symptoms. Overall, patients required significantly less antidote with similar clinical outcomes. Importantly, there are limitations with the data to date, highlighted in a letter-to-the-editor with a subsequent response from the original authors [4, 5]. This titration approach should only be considered with input from a toxicologist and still requires the same level of monitoring.
|Characteristics and Savings|
|Amount of digoxin ingested*||13 mg (9.5-25 mg)|
|Initial potassium*||5 mEq/L (4.5-5.4 mEq/L)|
|Fatalities due to digoxin toxicity||0|
|Estimated vials saved^||223-356 vials|
|Estimated cost savings^†||$1.1-1.8 million|
* Median (IQR)
Following administration of DigiFab, avoid measurement of the total digoxin concentration as this measures both free drug and drug bound to DigiFab, which will cause the result to be falsely elevated . Additionally, extracorporeal treatments are not recommended for the removal of digoxin or the digoxin-Fab complex, regardless of the clinical context .
- In select cases of acute digoxin poisoning, patients may safely receive 2 vials of DigiFab with repeat doses as necessary based on symptoms. If considering this treatment approach, it is recommended to consult with a toxicologist and/or pharmacist.
- Total serum digoxin levels can be falsely elevated following the administration of DigiFab.
Want to learn more about EM Pharmacology?
- Chan BSH, Buckley NA. Digoxin-specific antibody fragments in the treatment of digoxin toxicity. Clin Toxicol (Phila). 2014;52(8):824-836. doi: 10.3109/15563650.2014.943907. PMID: 25089630.
- Bracken LM, Chan BSH, Buckley NA. Physiologically based pharmacokinetic modelling of acute digoxin toxicity and the effect of digoxin-specific antibody fragments. Clin Toxicol (Phila). 2019;57(2):117-124. doi: 10.1080/15563650.2018.1503288. PMID: 30306803.
- Chan BS, Isbister GK, Chiew A, Isoardi K, Buckley NA. Clinical experience with titrating doses of digoxin antibodies in acute digoxin poisoning. (ATOM-6). Clin Toxicol (Phila). Published online August 23, 2021:1-7. doi: 10.1080/15563650.2021.1968422. PMID: 34424803.
- Mahonski S, Howland MA, Su MK. Comment on: clinical experience with titrating doses of digoxin antibodies in acute digoxin poisoning. Clinical Toxicology. 2021;0(0):1-2. doi: 10.1080/15563650.2021.1994986. PMID: 34709957
- Chan BS, Buckle NA. Authors’ reply to comment on: clinical experience with titrating doses of digoxin antibodies in acute digoxin poisoning. Clin Toxicol (Phila). Published online December 14, 2021:1. doi: 10.1080/15563650.2021.2013497. PMID: 34904491.
- DigiFab®. Package insert. BTG International Inc; 2017.
- Mowry JB, Burdmann EA, Anseeuw K, et al. Extracorporeal treatment for digoxin poisoning: systematic review and recommendations from the EXTRIP Workgroup. Clin Toxicol (Phila). 2016;54(2):103-114. doi: 10.3109/15563650.2015.1118488. PMID: 26795743.
In medical training there is a lack of simulation based activities including procedural labs. Suturing is a critical skill for trainees to master in the emergency department. However, supervised practice is needed prior to suturing a real patient for the first time. This innovation allows early trainees to master suturing while on shift, using easy to find materials, which increases procedural competency and confidence. This activity allows the teacher to assess and correct the trainees procedural skills prior to attempting to suture a real patient.
Name of innovation
- This Do-It-Yourself Suture Kit Station incorporates easy to find materials available in every emergency department, allowing early trainees to master suturing prior to suturing real patients.
- Medical students and early trainees who need suture practice
General group size
- One-on-one student training is ideal, but can have multiple students who can practice using multiple suturing stations
- If teacher unable to instruct while on shift, trainees can be shown a suture training video and practice alongside the video
- Blue chuck pad
- Paper/cloth tape
- Suture material
- Suture kit
More detailed description of the activity and how it was run
- Make the DIY Suture Kit Station (see above video):
- Place a thick chuck pad on a flat sturdy surface.
- Apply cloth tape to the entire surface of the chuck, and tape over the chuck. This is now the suturing pad.
- Use a scalpel to make an incision to the pad.
- Use the back blunt end of the scalpel to ‘fluff’ up incision edges to make laceration.
- Use a laceration repair kit and suture to close the laceration.
- Instruct the trainee on proper suturing technique on the suture station (or show a suture training video)
- Have the trainee continue practicing until adequate comfort and proficiency level is achieved
- Suture real patient!
Lessons learned, especially with regard to increasing resident and program buy in
- Procedural skills require much repetition to gain proficiency. This is best done with video tutorials, supervision, and deliberate practice.
- Practicing in a simulated environment greatly improves skill and confidence in real clinical practice.
Educational theory behind the innovation including specifics/styles of teaching involved
- Simulation practice increases procedural competency.
- Practicing on shift allows trainees to reach the number of repetitions required to gain mastery in suturing, Routt  showed that the number of repetitions required to gain proficiency was 41 times.
- Competency in suturing is required even when cases are low. Wongkietachorn et al. demonstrated that tutoring suturing improves the trainees’ skillset. A practice suture kit helps improve retention for real-life scenarios .
- This DIY suture pad station technique is easily available and inexpensive.
- To improve suturing techniques and enhance skill retention, medical students and early trainees need to learn with guided supervision on simulated task trainers.
- Routt E, Mansouri Y, de Moll EH, Bernstein DM, Bernardo SG, Levitt J. Teaching the Simple Suture to Medical Students for Long-term Retention of Skill. JAMA Dermatol. 2015 Jul;151(7):761-5. doi: 10.1001/jamadermatol.2015.118. PMID: 25785695.
- Wongkietkachorn A, Rhunsiri P, Boonyawong P, Lawanprasert A, Tantiphlachiva K. Tutoring Trainees to Suture: An Alternative Method for Learning How to Suture and a Way to Compensate for a Lack of Suturing Cases. J Surg Educ. 2016 May-Jun;73(3):524-8. doi: 10.1016/j.jsurg.2015.12.004. Epub 2016 Feb 20. PMID: 26907573.