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Dialogue: 0,0:00:00.67,0:00:05.97,Default,,0000,0000,0000,,If you're not good enough at Ultrasound, that's not an excuse to punish your patients with radiation.
Dialogue: 0,0:00:05.97,0:00:11.23,Default,,0000,0000,0000,,Get out there, ultrasound some hearts, lungs, IVCS and let us know how you feel about it.
Dialogue: 0,0:00:11.23,0:00:15.35,Default,,0000,0000,0000,,He got his wrist pain from over-aggressive high-fives.
Dialogue: 0,0:00:15.35,0:00:20.21,Default,,0000,0000,0000,,Hello Ultrasound Podcast listeners, welcome to the first Ultrasound Podcast Little Itty Bitty.
Dialogue: 0,0:00:20.21,0:00:23.70,Default,,0000,0000,0000,,We were going to call this something more cool, like an ultrasound podcast wee...
Dialogue: 0,0:00:23.70,0:00:30.01,Default,,0000,0000,0000,,But, we realized that Weingart has already trademarked 'Wee', and we had too many copyright suits out already.
Dialogue: 0,0:00:30.01,0:00:34.17,Default,,0000,0000,0000,,We've been trying to figure out how to better steal people's ideas without getting in trouble,
Dialogue: 0,0:00:34.17,0:00:38.10,Default,,0000,0000,0000,,We're calling this a Little Itty Bitty, not a Wee...but the idea is the same.
Dialogue: 0,0:00:38.10,0:00:42.39,Default,,0000,0000,0000,,Super short little episodes, that we think are important to talk about.
Dialogue: 0,0:00:42.39,0:00:47.32,Default,,0000,0000,0000,,That we're not really motivated enough to make a whole podcast.
Dialogue: 0,0:00:47.32,0:00:51.56,Default,,0000,0000,0000,,So, in honour of EMCRIT (who we plagiarized the idea from), we're going to take a suggestion from Scott.
Dialogue: 0,0:00:51.56,0:00:57.97,Default,,0000,0000,0000,,In his last episode, he mentioned us talking about confirming tube placement using ultrasound.
Dialogue: 0,0:00:57.97,0:01:02.59,Default,,0000,0000,0000,,We've already done one episode on the US guided cric.
Dialogue: 0,0:01:02.59,0:01:07.10,Default,,0000,0000,0000,,Keith Curtis described this method of using the US to identify the cricothyroid membrane.
Dialogue: 0,0:01:07.10,0:01:11.30,Default,,0000,0000,0000,,And get a tube in it more quickly in the obese patient than just by landmarks.
Dialogue: 0,0:01:11.30,0:01:21.95,Default,,0000,0000,0000,,This was published recently in Academic EM, but even before that, we got emails from you guys - the listeners - about 2 cases where using this, made a real difference.
Dialogue: 0,0:01:21.95,0:01:25.41,Default,,0000,0000,0000,,One was in a really bad burn patient with basically, no landmarks.
Dialogue: 0,0:01:25.41,0:01:28.66,Default,,0000,0000,0000,,And the other, was in a super-obese patient.
Dialogue: 0,0:01:28.66,0:01:34.73,Default,,0000,0000,0000,,We've got images from both of those cases and we hope to have the stories for you sometime in the near future.
Dialogue: 0,0:01:34.73,0:01:42.11,Default,,0000,0000,0000,,That's kinda old news, but I wanted to mention it because I am always happily surprised when I hear that you guys are actually doing this stuff.
Dialogue: 0,0:01:42.11,0:01:44.64,Default,,0000,0000,0000,,That we're teaching you about.
Dialogue: 0,0:01:44.64,0:01:46.21,Default,,0000,0000,0000,,You are all amazing.
Dialogue: 0,0:01:46.21,0:01:48.64,Default,,0000,0000,0000,,And make it fully worth it to make these podcasts.
Dialogue: 0,0:01:48.64,0:01:54.95,Default,,0000,0000,0000,,So, here it is Scott...a little itty bitty on tube placement confirmation via US.
Dialogue: 0,0:01:54.95,0:01:59.42,Default,,0000,0000,0000,,Now Scott mentioned looking at the lung for sliding to confirm mainstemmed intubation versus good placement.
Dialogue: 0,0:01:59.42,0:02:01.34,Default,,0000,0000,0000,,Which is a great thing to do.
Dialogue: 0,0:02:01.34,0:02:03.44,Default,,0000,0000,0000,,And here he is talking about it.
Dialogue: 0,0:02:03.44,0:02:06.66,Default,,0000,0000,0000,,SW: Ok, now we're going to think about checking tube depth.
Dialogue: 0,0:02:06.66,0:02:11.91,Default,,0000,0000,0000,,And that usually, in conventional EDs means an xray...and that's fine. You NEED an xray at some point post-intubation.
Dialogue: 0,0:02:11.91,0:02:16.19,Default,,0000,0000,0000,,You could do an US too.
Dialogue: 0,0:02:16.19,0:02:21.99,Default,,0000,0000,0000,,One way to do it is to slowly advance the tube until the left sided lung sliding disappears. \N
Dialogue: 0,0:02:21.99,0:02:29.01,Default,,0000,0000,0000,,And at that point you pull back around 3cm-4cm. Then you 'll have a very nice tube position.
Dialogue: 0,0:02:29.01,0:02:34.02,Default,,0000,0000,0000,,Or you could actually look for the tube cuff in the trachea - it's a little harder.
Dialogue: 0,0:02:34.02,0:02:40.13,Default,,0000,0000,0000,,And these will hopefully all go up on the US podcast...Mike/Matt hopefully you're listening.
Dialogue: 0,0:02:40.13,0:02:43.18,Default,,0000,0000,0000,,So...what's Scott talking about here.
Dialogue: 0,0:02:43.18,0:02:47.84,Default,,0000,0000,0000,,He's talking about using the linear probe and evaluating the patient's chest for the presence of lung sliding.
Dialogue: 0,0:02:47.84,0:02:55.07,Default,,0000,0000,0000,,And the concept is that...if you are actually aerating the patient's lung, there's going to be lung sliding seen using that linear probe
Dialogue: 0,0:02:55.07,0:02:56.96,Default,,0000,0000,0000,,So, how do you do it?
Dialogue: 0,0:02:56.96,0:03:00.20,Default,,0000,0000,0000,,Well...you're going to use the linear probe, place it on the patient's chest.
Dialogue: 0,0:03:00.20,0:03:05.85,Default,,0000,0000,0000,,Usually, around the mid-clavicular line. (I usually use the mid-clavicular line on the right and the anterior axillary line on the left).
Dialogue: 0,0:03:05.85,0:03:09.47,Default,,0000,0000,0000,,But, it doesn't matter - as long as you see good lung tissue and can see the pleural line.
Dialogue: 0,0:03:09.47,0:03:11.54,Default,,0000,0000,0000,,You put the probe marker, typically towards the patient's head.
Dialogue: 0,0:03:11.54,0:03:18.98,Default,,0000,0000,0000,,And you'll sort of be in this sagital section, so you'll be looking between the rib spaces and you can see the rib shadows.
Dialogue: 0,0:03:18.98,0:03:22.08,Default,,0000,0000,0000,,And you'll get something that looks sorta like this.
Dialogue: 0,0:03:22.08,0:03:25.54,Default,,0000,0000,0000,,Rib shadow here, and rib shadow here.
Dialogue: 0,0:03:25.54,0:03:27.92,Default,,0000,0000,0000,,And then there's this bright white line between the rib shadows.
Dialogue: 0,0:03:27.92,0:03:29.22,Default,,0000,0000,0000,,It's your pleural line.
Dialogue: 0,0:03:29.22,0:03:31.32,Default,,0000,0000,0000,,Where the visceral and parietal pleura connect.
Dialogue: 0,0:03:31.32,0:03:33.54,Default,,0000,0000,0000,,When there sliding against one-another, we see this little shimmering occuring.
Dialogue: 0,0:03:33.54,0:03:39.61,Default,,0000,0000,0000,,We call this pleural sliding.
Dialogue: 0,0:03:39.61,0:03:43.07,Default,,0000,0000,0000,,Really, an easily visible thing, especially if the patient is breathing.
Dialogue: 0,0:03:43.07,0:03:45.80,Default,,0000,0000,0000,,And you'll typically see these when you bag the patient.
Dialogue: 0,0:03:45.80,0:03:50.70,Default,,0000,0000,0000,,If you're not bagging the patient, you're not going to see sliding.
Dialogue: 0,0:03:50.70,0:03:54.41,Default,,0000,0000,0000,,So, the technique is to try to find something that looks like this.
Dialogue: 0,0:03:54.41,0:03:59.68,Default,,0000,0000,0000,,This is an example of what you would see if you saw at pneumothorax or if you had say a right mainstem, and you're looking at the patient's left side.
Dialogue: 0,0:03:59.68,0:04:02.01,Default,,0000,0000,0000,,Where there is a rib shadow here, and a rib shadow here...
Dialogue: 0,0:04:02.01,0:04:06.56,Default,,0000,0000,0000,,and then, there's the pleural line, but there's no sliding along the pleural line.
Dialogue: 0,0:04:06.56,0:04:11.39,Default,,0000,0000,0000,,So I want you to do is, you'll want to look on both the right and left side.
Dialogue: 0,0:04:11.39,0:04:18.68,Default,,0000,0000,0000,,And the first thing you'll do is basically push the tube down to the point where you'll only see sliding on the patient's right side.
Dialogue: 0,0:04:18.68,0:04:23.37,Default,,0000,0000,0000,,Here were looking at the patient's right side and you see sliding.
Dialogue: 0,0:04:23.40,0:04:26.54,Default,,0000,0000,0000,,But then we look at the left side and we don't see any sliding at all.
Dialogue: 0,0:04:26.54,0:04:28.32,Default,,0000,0000,0000,,That tells us that we're right mainstemmed.
Dialogue: 0,0:04:28.32,0:04:30.89,Default,,0000,0000,0000,,And then what Scott's saying is that you pull back until you see sliding on both sides.
Dialogue: 0,0:04:30.89,0:04:33.13,Default,,0000,0000,0000,,Like this...
Dialogue: 0,0:04:33.13,0:04:38.81,Default,,0000,0000,0000,,So now we're looking on the right side and we're seeing good sliding, and then again we're looking on the left side and we have good sliding.
Dialogue: 0,0:04:38.81,0:04:41.33,Default,,0000,0000,0000,,So we know that we are no longer right mainstemmed.
Dialogue: 0,0:04:41.33,0:04:46.51,Default,,0000,0000,0000,,And then Scott's saying you just pull back an additional 3cm, and that way you know you're in an adequate place.
Dialogue: 0,0:04:46.51,0:04:49.16,Default,,0000,0000,0000,,And this really makes sense.
Dialogue: 0,0:04:49.16,0:04:53.57,Default,,0000,0000,0000,,This is physiology, this is really basic ultrasound understanding.
Dialogue: 0,0:04:53.57,0:04:58.67,Default,,0000,0000,0000,,If we're aerating that lung, we're going to get sliding along that pleural line.
Dialogue: 0,0:04:58.67,0:05:01.53,Default,,0000,0000,0000,,This is a great tip, and really like the real-timeness of it.
Dialogue: 0,0:05:01.53,0:05:03.75,Default,,0000,0000,0000,,Yes...timeness is a word (at least in Kentucky).
Dialogue: 0,0:05:03.75,0:05:08.79,Default,,0000,0000,0000,,Personally, I use this more as confirmation, rather than real time visualization.
Dialogue: 0,0:05:08.79,0:05:13.51,Default,,0000,0000,0000,,I look at sliding while everyone else is auscultating after the intubation.
Dialogue: 0,0:05:13.51,0:05:22.02,Default,,0000,0000,0000,,Obviously if you're going to do this though, you should look prior to intubation while bagging as well, to make sure the absence of sliding you see is not a pneumo.
Dialogue: 0,0:05:22.02,0:05:26.81,Default,,0000,0000,0000,,And it only disappears after intubation, when you mainstem it and isolate that lung.
Dialogue: 0,0:05:26.81,0:05:34.12,Default,,0000,0000,0000,,If you continually back the tube up while looking for sliding to start again, until the whole thing is floating above the patient's head.
Dialogue: 0,0:05:34.12,0:05:36.44,Default,,0000,0000,0000,,Then it's probably a pneumo.
Dialogue: 0,0:05:36.44,0:05:39.26,Default,,0000,0000,0000,,Avoid this by looking prior to placement, while bagging.
Dialogue: 0,0:05:39.26,0:05:42.28,Default,,0000,0000,0000,,Now...did Weingart totally make this up?
Dialogue: 0,0:05:42.28,0:05:44.71,Default,,0000,0000,0000,,No, there's some pretty good evidence for using it.
Dialogue: 0,0:05:44.71,0:05:48.80,Default,,0000,0000,0000,,Just like any good ultrasound idea than anyone ever has, Blaivas has already studied it.
Dialogue: 0,0:05:48.80,0:05:56.30,Default,,0000,0000,0000,,In this study, he intubated a bunch of cadavers with a couple of other guys, and watched for lung sliding after the intubation.
Dialogue: 0,0:05:56.30,0:05:59.46,Default,,0000,0000,0000,,To confirm whether he was in the esophagus or trachea.
Dialogue: 0,0:05:59.46,0:06:02.61,Default,,0000,0000,0000,,And here are the results.
Dialogue: 0,0:06:02.61,0:06:04.70,Default,,0000,0000,0000,,Pretty awesome..
Dialogue: 0,0:06:04.70,0:06:09.34,Default,,0000,0000,0000,,There were two different operators, one was 95% sensitive and the other was 100%.
Dialogue: 0,0:06:09.34,0:06:12.80,Default,,0000,0000,0000,,And they were both 100% specific.
Dialogue: 0,0:06:12.80,0:06:15.50,Default,,0000,0000,0000,,For telling whether the tube went in the trachea or esophagus.
Dialogue: 0,0:06:15.50,0:06:20.38,Default,,0000,0000,0000,,Now Scott was talking about position, as to whether or not it was right mainstemmed or not...
Dialogue: 0,0:06:20.38,0:06:22.54,Default,,0000,0000,0000,,And they looked at that as well...
Dialogue: 0,0:06:22.54,0:06:24.15,Default,,0000,0000,0000,,It turns out it, that's not quite as good.
Dialogue: 0,0:06:24.15,0:06:28.26,Default,,0000,0000,0000,,As you can see here - their sensitivity was quite a bit lower...
Dialogue: 0,0:06:28.26,0:06:31.52,Default,,0000,0000,0000,,So not as good at telling if its in the esophagus or trachea.
Dialogue: 0,0:06:31.52,0:06:34.14,Default,,0000,0000,0000,,Here's another study, more recent from resuscitation...
Dialogue: 0,0:06:34.14,0:06:37.25,Default,,0000,0000,0000,,Where they had somewhat better results in trying to identify single-lung intubations.
Dialogue: 0,0:06:37.25,0:06:43.68,Default,,0000,0000,0000,,They looked at these patients bilaterally, at the mid-axillary line after intubation, and their accuracy was 88.7% for identifying single lung intubation.
Dialogue: 0,0:06:43.68,0:06:45.88,Default,,0000,0000,0000,,Pretty good.
Dialogue: 0,0:06:45.88,0:06:47.01,Default,,0000,0000,0000,,Not perfect.
Dialogue: 0,0:06:47.01,0:06:49.24,Default,,0000,0000,0000,,So it's hard to say this is a sure thing, like the trachea versus esophagus.
Dialogue: 0,0:06:49.24,0:06:50.87,Default,,0000,0000,0000,,But not bad.
Dialogue: 0,0:06:50.87,0:06:55.22,Default,,0000,0000,0000,,And the had less than 10 total patients they got single lung intubated.
Dialogue: 0,0:06:55.22,0:06:59.44,Default,,0000,0000,0000,,So, I'm not sure what to make of the 88%.
Dialogue: 0,0:06:59.44,0:07:02.46,Default,,0000,0000,0000,,But it's something for you to think about.
Dialogue: 0,0:07:02.46,0:07:08.10,Default,,0000,0000,0000,,And just to be clear about what doesn't work, you can't use diaphragm movement, like this study tried.
Dialogue: 0,0:07:08.10,0:07:13.32,Default,,0000,0000,0000,,Specificity for mainstem intubation was 50% in this study.
Dialogue: 0,0:07:13.32,0:07:14.46,Default,,0000,0000,0000,,So don't do this.
Dialogue: 0,0:07:14.46,0:07:17.41,Default,,0000,0000,0000,,They did comment that it was 8minutes quicker than xray.
Dialogue: 0,0:07:17.41,0:07:18.58,Default,,0000,0000,0000,,But it was wrong.
Dialogue: 0,0:07:18.58,0:07:24.89,Default,,0000,0000,0000,,Sliding is better, like in the Blaivas study, but still not great for mainstem or not.
Dialogue: 0,0:07:24.89,0:07:30.31,Default,,0000,0000,0000,,So, this really hasn't been confirmed and shown that we're good enough at telling if it was mainstemmed or not.
Dialogue: 0,0:07:30.31,0:07:38.34,Default,,0000,0000,0000,,But I couldn't find anyone who's actually done the real time (watching the sliding) while advancing - that Weingart proposed.
Dialogue: 0,0:07:38.34,0:07:39.59,Default,,0000,0000,0000,,That would be really cool to see.
Dialogue: 0,0:07:39.59,0:07:43.42,Default,,0000,0000,0000,,These were static measures that I just showed you the studies for.
Dialogue: 0,0:07:43.42,0:07:47.33,Default,,0000,0000,0000,,A dynamic measure like that, may actually be useful and really good.
Dialogue: 0,0:07:47.33,0:07:50.55,Default,,0000,0000,0000,,I think someone should actually study this Weingart method.
Dialogue: 0,0:07:50.55,0:07:54.03,Default,,0000,0000,0000,,So I had also mentioned viewing the balloon in the cords.
Dialogue: 0,0:07:54.03,0:07:56.67,Default,,0000,0000,0000,,This looks like this - and is also useful.
Dialogue: 0,0:07:56.67,0:08:03.22,Default,,0000,0000,0000,,But if you are confirming after intubation, I think that good lung sliding while bagging the tube is much easier.
Dialogue: 0,0:08:03.22,0:08:07.53,Default,,0000,0000,0000,,And we've got great evidence for that, to tell whether or not it is in the esophagus or trachea.
Dialogue: 0,0:08:07.53,0:08:14.00,Default,,0000,0000,0000,,What is super useful and fun, is real time visualization of the tube placement.
Dialogue: 0,0:08:14.00,0:08:15.12,Default,,0000,0000,0000,,This is really cool.
Dialogue: 0,0:08:15.12,0:08:21.90,Default,,0000,0000,0000,,Now, like many others of you out there, I primarily use the glidescope, and have my residents use it as well.
Dialogue: 0,0:08:21.90,0:08:25.62,Default,,0000,0000,0000,,As you've got higher success rates, and less cranking on the person.
Dialogue: 0,0:08:25.62,0:08:26.82,Default,,0000,0000,0000,,i.e. better care...
Dialogue: 0,0:08:26.82,0:08:29.55,Default,,0000,0000,0000,,It's how I would want myself, or my family intubated.
Dialogue: 0,0:08:29.55,0:08:36.56,Default,,0000,0000,0000,,And when we use the video laryngoscope, I can watch, exactly what's going on, on the video - in real time.
Dialogue: 0,0:08:36.56,0:08:43.68,Default,,0000,0000,0000,,However, residents and new trainees need to be able to use the normal blade.
Dialogue: 0,0:08:43.68,0:08:47.42,Default,,0000,0000,0000,,So for newer intubators, I will have them try direct laryngoscopy first with glidescope next to us - ready as needed.
Dialogue: 0,0:08:47.42,0:08:56.39,Default,,0000,0000,0000,,And this use to be a somewhat nerve-wracking experience, as they are new users and I can't really see what is happening.
Dialogue: 0,0:08:56.39,0:09:03.20,Default,,0000,0000,0000,,It always amazed me how of then they could definitely see the cords if I asked, but it ended up in the goose somehow.
Dialogue: 0,0:09:03.20,0:09:08.76,Default,,0000,0000,0000,,Now I know I could have them use the glidescope as a direct laryngoscope, and only look at the screen myself.
Dialogue: 0,0:09:08.76,0:09:14.12,Default,,0000,0000,0000,,But I think they should get comfortable with actual steel.
Dialogue: 0,0:09:14.12,0:09:18.10,Default,,0000,0000,0000,,It definitely makes me less comfortable though when I am teaching them this way.
Dialogue: 0,0:09:18.10,0:09:20.33,Default,,0000,0000,0000,,Since I can't see what's going on.
Dialogue: 0,0:09:20.33,0:09:23.37,Default,,0000,0000,0000,,But super nerve-wracking no more!
Dialogue: 0,0:09:23.37,0:09:27.48,Default,,0000,0000,0000,,Now I just quietly, relaxed, place the probe on the neck.
Dialogue: 0,0:09:27.48,0:09:32.08,Default,,0000,0000,0000,,And get this picture of the trachea, and the esophagus.
Dialogue: 0,0:09:32.08,0:09:35.36,Default,,0000,0000,0000,,Then I ask them, "what do you see?"
Dialogue: 0,0:09:35.36,0:09:37.57,Default,,0000,0000,0000,,ughhhh......I think I see the cord, I'm passing through the cord.
Dialogue: 0,0:09:37.57,0:09:48.21,Default,,0000,0000,0000,,And then I say "Hold on there tiger! - I just saw it pass through the esophagus, why don't you pull back and try again." (in a pretty condescending voice).
Dialogue: 0,0:09:48.21,0:09:50.20,Default,,0000,0000,0000,,So then they pull back just a bit, and try again.
Dialogue: 0,0:09:50.20,0:09:55.00,Default,,0000,0000,0000,,And then I see this.
Dialogue: 0,0:09:55.00,0:09:55.90,Default,,0000,0000,0000,,The espophagus, the trachea.
Dialogue: 0,0:09:55.90,0:10:01.11,Default,,0000,0000,0000,,And as the tube passes through the trachea, I see it light up. Just like that.
Dialogue: 0,0:10:01.11,0:10:05.12,Default,,0000,0000,0000,,And then I know it was definitely through the cords.
Dialogue: 0,0:10:05.12,0:10:10.86,Default,,0000,0000,0000,,They ask me "How do the lungs sound?", and I say "Don't worry about it, I trust ya"...and then I walk away.
Dialogue: 0,0:10:10.86,0:10:12.60,Default,,0000,0000,0000,,Not really...I wish I was that cool.
Dialogue: 0,0:10:12.60,0:10:15.24,Default,,0000,0000,0000,,I'm actually still sweating it, and waiting for the CO2 monitor to turn yellow.
Dialogue: 0,0:10:15.24,0:10:16.71,Default,,0000,0000,0000,,Listening to both side, and looking for sliding.
Dialogue: 0,0:10:16.71,0:10:20.14,Default,,0000,0000,0000,,But I'm trying to do it all while looking somewhat cool.
Dialogue: 0,0:10:20.14,0:10:22.47,Default,,0000,0000,0000,,I definitely have a reputation to look after.
Dialogue: 0,0:10:22.47,0:10:25.19,Default,,0000,0000,0000,,And again, I'm not totally making this up.
Dialogue: 0,0:10:25.19,0:10:27.42,Default,,0000,0000,0000,,It's been studied a fair amount.
Dialogue: 0,0:10:27.42,0:10:34.25,Default,,0000,0000,0000,,In this study, they had EM doctors watch the neck sonographically during real intubation in the OR with elective surgery.
Dialogue: 0,0:10:34.25,0:10:37.15,Default,,0000,0000,0000,,And these guys were pretty awesome.
Dialogue: 0,0:10:37.15,0:10:44.35,Default,,0000,0000,0000,,But is it true that you could do this in the ED (Not in elective intubation)?
Dialogue: 0,0:10:44.35,0:10:49.85,Default,,0000,0000,0000,,Well, this other group studied this in the tracheo-rapid US exam or TRUE study.
Dialogue: 0,0:10:49.85,0:10:52.13,Default,,0000,0000,0000,,And they too were awesome.
Dialogue: 0,0:10:52.13,0:10:58.46,Default,,0000,0000,0000,,Prospective, real ED intubations, 98.2% accuracy!
Dialogue: 0,0:10:58.46,0:11:03.30,Default,,0000,0000,0000,,So, what doesn't work for looking at the neck for tube placement?
Dialogue: 0,0:11:03.30,0:11:06.86,Default,,0000,0000,0000,,Well, you can't really look after the fact.
Dialogue: 0,0:11:06.86,0:11:15.59,Default,,0000,0000,0000,,You can, and you may see a nice picture, but when you use the static method, you may see what you think is a tube in the trachea.
Dialogue: 0,0:11:15.59,0:11:22.34,Default,,0000,0000,0000,,But what this study found, was that the sensitivity fell to 51% (From 97%) in the same intubations.
Dialogue: 0,0:11:22.34,0:11:25.67,Default,,0000,0000,0000,,When compared to the dynamic view.
Dialogue: 0,0:11:25.67,0:11:27.36,Default,,0000,0000,0000,,Watching it in real time.
Dialogue: 0,0:11:27.36,0:11:30.71,Default,,0000,0000,0000,,You have to watch it while it's happening, not afterwards.
Dialogue: 0,0:11:30.71,0:11:35.48,Default,,0000,0000,0000,,And if you're feeling really frisky....you don't have to do these things in isolation, you can combo-them up.
Dialogue: 0,0:11:35.48,0:11:38.84,Default,,0000,0000,0000,,Watch the neck, watch for sliding bilaterally.
Dialogue: 0,0:11:38.84,0:11:44.30,Default,,0000,0000,0000,,It's all information you can put together in your overall assessment.
Dialogue: 0,0:11:44.30,0:11:49.04,Default,,0000,0000,0000,,So, a real quick how-to and logistic discussion.
Dialogue: 0,0:11:49.04,0:11:52.09,Default,,0000,0000,0000,,First, it's at the suprasternal notch.
Dialogue: 0,0:11:52.09,0:11:56.10,Default,,0000,0000,0000,,Much lower than what you're probably expecting.
Dialogue: 0,0:11:56.10,0:12:00.04,Default,,0000,0000,0000,,Not at the cricothyroid membrane, but lower to get this view.
Dialogue: 0,0:12:00.04,0:12:05.33,Default,,0000,0000,0000,,I prefer the curvilinear probe, with the depth adjusted as shallow as it could go.
Dialogue: 0,0:12:05.33,0:12:09.06,Default,,0000,0000,0000,,And as you can see I have the probe here on Mike's neck, midline.
Dialogue: 0,0:12:09.06,0:12:13.68,Default,,0000,0000,0000,,And you can't really see the esophagus because it is hidden behind the trachea.
Dialogue: 0,0:12:13.68,0:12:17.49,Default,,0000,0000,0000,,Mike's swallowing here, but you don't really see it because it is behind the air-filled trachea.
Dialogue: 0,0:12:17.49,0:12:22.03,Default,,0000,0000,0000,,However, if you move the probe to the side, kind of oblique.
Dialogue: 0,0:12:22.03,0:12:24.81,Default,,0000,0000,0000,,Just as you see on Mike's neck here.
Dialogue: 0,0:12:24.81,0:12:27.49,Default,,0000,0000,0000,,You can definitely see the esophagus, right beside the trachea.
Dialogue: 0,0:12:27.49,0:12:32.96,Default,,0000,0000,0000,,And as he swallows, I think he was drinking a skinny sugar-free banana latte with extra whip cream.
Dialogue: 0,0:12:32.96,0:12:36.47,Default,,0000,0000,0000,,It's super easy to see that esophagus slide out.
Dialogue: 0,0:12:36.47,0:12:40.33,Default,,0000,0000,0000,,Just like you can see it light up as you passed the air filled tube through it.
Dialogue: 0,0:12:40.33,0:12:44.83,Default,,0000,0000,0000,,Hopefully not, but if you're resident or someone else did.
Dialogue: 0,0:12:44.83,0:12:47.60,Default,,0000,0000,0000,,If you're showing a video it's always the resident, it's not you.
Dialogue: 0,0:12:47.60,0:12:51.39,Default,,0000,0000,0000,,Now, you probably want a protocol, right?
Dialogue: 0,0:12:51.39,0:12:54.72,Default,,0000,0000,0000,,Well, too bad.
Dialogue: 0,0:12:54.72,0:12:56.34,Default,,0000,0000,0000,,I'm not interested in giving you a protocol for this.
Dialogue: 0,0:12:56.34,0:12:59.75,Default,,0000,0000,0000,,What I want is to give you mad skillz.
Dialogue: 0,0:12:59.75,0:13:05.88,Default,,0000,0000,0000,,Take all this, practice on yourself, you're going to be amazed at how easy it is to see the esophagus and trachea.
Dialogue: 0,0:13:05.88,0:13:08.39,Default,,0000,0000,0000,,Practice on some cadavers.
Dialogue: 0,0:13:08.39,0:13:11.29,Default,,0000,0000,0000,,And try it out in some non-emergent conditions first.
Dialogue: 0,0:13:11.29,0:13:14.28,Default,,0000,0000,0000,,Then go for it.
Dialogue: 0,0:13:14.28,0:13:17.08,Default,,0000,0000,0000,,Use what you need, when you need it.
Dialogue: 0,0:13:17.08,0:13:19.61,Default,,0000,0000,0000,,Obviously this does not replace capnography, xray, and other means of confirmation.
Dialogue: 0,0:13:19.61,0:13:22.66,Default,,0000,0000,0000,,But it's one more piece of data in real time.
Dialogue: 0,0:13:22.66,0:13:24.77,Default,,0000,0000,0000,,Sometimes, very helpful.\N
Dialogue: 0,0:13:24.77,0:13:32.60,Default,,0000,0000,0000,,Sometimes knowing 30s sooner than you would with capnography is really important for a sick, desating patient.
Dialogue: 0,0:13:32.60,0:13:34.78,Default,,0000,0000,0000,,So, I like it!
Dialogue: 0,0:13:34.78,0:13:37.02,Default,,0000,0000,0000,,And I think Mikey likes it too.
Dialogue: 0,0:13:37.02,0:13:38.22,Default,,0000,0000,0000,,Right Mike?
Dialogue: 0,0:13:38.22,0:13:41.48,Default,,0000,0000,0000,,Mike: I couldn't agree more Matt, this is really interesting stuff.
Dialogue: 0,0:13:41.48,0:13:46.03,Default,,0000,0000,0000,,And I think the most interesting aspect of this is using the dynamic US.
Dialogue: 0,0:13:46.03,0:13:52.82,Default,,0000,0000,0000,,To really ensure that the resident or whoever the provider is, really has the tube in the right place.
Dialogue: 0,0:13:52.82,0:13:58.92,Default,,0000,0000,0000,,Because, I think it is ridiculously easy to tell whether it is going into the esophagus or trachea.
Dialogue: 0,0:13:58.92,0:14:03.63,Default,,0000,0000,0000,,As far as what Scott's talking about - using US for placement of the tube.
Dialogue: 0,0:14:03.63,0:14:07.38,Default,,0000,0000,0000,,And determining whether you've got a right or left mainstem.
Dialogue: 0,0:14:07.38,0:14:11.29,Default,,0000,0000,0000,,I think that's really interest, and their isn't a lot of research on that.
Dialogue: 0,0:14:11.29,0:14:15.12,Default,,0000,0000,0000,,But I did find a case series.
Dialogue: 0,0:14:15.12,0:14:17.24,Default,,0000,0000,0000,,Reported by none other than Mike Blaivas.
Dialogue: 0,0:14:17.24,0:14:23.69,Default,,0000,0000,0000,,Looking at POCUS for sonographic detection of ETT mainstem intubation.
Dialogue: 0,0:14:23.69,0:14:30.66,Default,,0000,0000,0000,,This is really interesting because, these were just unusual cases, where they found the ETT went into the left mainstem.
Dialogue: 0,0:14:30.66,0:14:36.06,Default,,0000,0000,0000,,Basically lost lung sliding on the right when they looked with US after intubation.
Dialogue: 0,0:14:36.06,0:14:38.92,Default,,0000,0000,0000,,And they looked because they had decreased breath sounds on the right side.
Dialogue: 0,0:14:38.92,0:14:43.81,Default,,0000,0000,0000,,And what they ended up doing in most of these cases was pulling the tube back 2-3cm.
Dialogue: 0,0:14:43.81,0:14:47.69,Default,,0000,0000,0000,,So you should check it out, it's in the Journal of US.
Dialogue: 0,0:14:47.69,0:14:51.40,Default,,0000,0000,0000,,And pretty cool stuff.
Dialogue: 0,0:14:51.40,0:14:53.76,Default,,0000,0000,0000,,Matt: I've got 2 important pieces of new for you.
Dialogue: 0,0:14:53.76,0:14:58.23,Default,,0000,0000,0000,,1) If you've made it this far we've got bonus clip for you from Casey Parker at broomedocs.com.
Dialogue: 0,0:14:58.23,0:15:03.37,Default,,0000,0000,0000,,2) You can quit emailing me about finding a replacement for Mike because I found him.
Dialogue: 0,0:15:03.37,0:15:06.75,Default,,0000,0000,0000,,You already know that Casey is brilliant, from reading posts on his broomedocs blog.
Dialogue: 0,0:15:06.75,0:15:12.30,Default,,0000,0000,0000,,2 days ago he sent me this clip from the chapter he's writing for Introduction to Bedside US Volume 2.
Dialogue: 0,0:15:12.30,0:15:16.32,Default,,0000,0000,0000,,On the Secondary US Survey in Trauma.
Dialogue: 0,0:15:16.32,0:15:18.55,Default,,0000,0000,0000,,It's related to this topic, so I wanted to throw it in here.
Dialogue: 0,0:15:18.55,0:15:22.72,Default,,0000,0000,0000,,Now the stethoscope can still be a very useful tool in this process.
Dialogue: 0,0:15:22.72,0:15:24.97,Default,,0000,0000,0000,,He's brilliant, hilarious and Australian.
Dialogue: 0,0:15:24.97,0:15:32.31,Default,,0000,0000,0000,,You're in a busy trauma and your resident's just intubated the patient.
Dialogue: 0,0:15:32.31,0:15:36.35,Default,,0000,0000,0000,,And the sats are really staying in the low 90s.
Dialogue: 0,0:15:36.35,0:15:39.82,Default,,0000,0000,0000,,Pressure alarm on the ventilator is going off.
Dialogue: 0,0:15:39.82,0:15:42.55,Default,,0000,0000,0000,,You realize that something's not quite right.
Dialogue: 0,0:15:42.55,0:15:46.48,Default,,0000,0000,0000,,So you pick up your linear probe and place it on the left chest wall.
Dialogue: 0,0:15:46.48,0:15:49.83,Default,,0000,0000,0000,,And you look at what's going on there.
Dialogue: 0,0:15:49.83,0:15:53.75,Default,,0000,0000,0000,,At first glance, it looks like normal lung sliding.
Dialogue: 0,0:15:53.75,0:15:58.90,Default,,0000,0000,0000,,But if you look closely, and listen to the sats monitor in the background.
Dialogue: 0,0:15:58.90,0:16:03.32,Default,,0000,0000,0000,,Beep.Beep.Beep.Beep.Beep.Beep.Beep.
Dialogue: 0,0:16:03.32,0:16:07.69,Default,,0000,0000,0000,,You'll notice these movements are time exactly with the cardiac pulsations.
Dialogue: 0,0:16:07.69,0:16:09.70,Default,,0000,0000,0000,,This is the lung pulse-sign.
Dialogue: 0,0:16:09.70,0:16:14.23,Default,,0000,0000,0000,,Of a normally expanded, but non-ventilated lung.
Dialogue: 0,0:16:14.23,0:16:19.55,Default,,0000,0000,0000,,Most likely a right mainstem bronchus.
Dialogue: 0,0:16:19.55,0:16:23.49,Default,,0000,0000,0000,,And you'll want to pull that tube back, so you can once again ventilate that lung.
Dialogue: 0,0:16:23.49,0:16:29.01,Default,,0000,0000,0000,,At this point, you should leave the probe on the chest wall, while you withdraw the tube.
Dialogue: 0,0:16:29.01,0:16:33.81,Default,,0000,0000,0000,,And you can confirm sliding once you've pulled the tube back past the carina.
Dialogue: 0,0:16:33.81,0:16:37.29,Default,,0000,0000,0000,,I usually get my stethoscope at this point.
Dialogue: 0,0:16:37.29,0:16:39.31,Default,,0000,0000,0000,,And use it to strangle the resident.
Dialogue: 0,0:16:39.31,0:16:43.12,Default,,0000,0000,0000,,That way everyone learns something from the experience.