Download PERCUTANEOUS TRANSTRACHEAL VENTILATION WITHOUT A

CORRESPONDENCE
507
PERCUTANEOUS TRANSTRACHEAL VENTILATION
WITHOUT A JET VENTILATOR
To the Editor:—Airway management is a priority in the resuscitation of the critically ill. In most cases, this can be achieved by
basic or advanced airway procedures. In a minority, however,
these procedures fail and a surgical intervention will be required to
secure the airway.1 The 3 principal methods of obtaining a surgical
airway in the emergency setting are surgical cricothyroidotomy,
needle cricothyroidotomy, or cricothyroidotomy using commercial
equipment.1,2 Of these methods, needle cricothyroidotomy provides the simplest, fastest, and safest access.2,3 Theoretical and
practical aspects of the technique are described in various emergency textbooks and taught on a variety of resuscitation courses,
including advanced cardiac life support (ACLS), advanced trauma
life support (ATLS), and advanced pediatric life support (APLS).
Although needle cricothyroidotomy can be easily performed, many
physicians are not familiar in connecting the transtracheal catheter
to an oxygen source and the way to ventilate the patient with a jet
ventilator (also known as jet insufflator). Moreover, a jet ventilator
is often unavailable to EMS. We described an easy-to-use method
of transtracheal ventilation and oxygen delivery in the emergency
setting when a jet ventilator is not available.
Classically, equipment for needle cricothyroidotomy consists of
high-pressure noncollapsible oxygen tubing, a 13- or 14-gauge
needle catheter, an oxygen source with a flow at 10-15 L/min, and
a manual jet ventilator/insufflator device.4,5 We describe an alternative method of transtracheal ventilation and oxygen delivery for
needle cricothyroidotomy in which the equipment is readily accessible, simple to assemble, and easy to use.
FIGURE 1. Preprepared equipment for needle cricothyroidotomy and their assembly for transtracheal ventilation.
EQUIPMENT
See Figure 1.
1. An oxygen source with a flow at 10-15 L/min.
2. A commercial bag-valve-mask device (AMBU bag), which
includes noncollapsible oxygen tubing and a reservoir bag
(mask not included).
3. A large-bore over-the-needle intravenous catheter (14
gauge ⫻ 2-in).
4. A 3-mL plastic syringe.
5. An endotracheal tube (7.5 mm inner diameter).
Although rarely performed, needle cricothyroidotomy is a
potentially life-saving procedure. The range of adapted equipment at present used for needle cricothyroidotomy is diverse.
We describe and demonstrate a method of transtracheal ventilation and oxygen delivery for needle cricothyroidotomy that is
easily accessible, simple to assemble, easy to use, and readily
available in every emergency setting.
CHEE-FAH CHONG, MD
TZONG-LUEN WANG, MD, PHD
HANG CHANG, MD, PHD
Emergency Department
Shin Kong Wu Ho-Su Memorial Hospital
Taipei, Taiwan, R.O.C.
ASSEMBLY OF EQUIPMENT
See Figure 2.
1. Connect the cricothyroidotomy catheter to a 3-mL syringe
barrel (with its plunger and needle removed).
2. Connect the 3-mL syringe barrel to a 7.5-mm inner diameter endotracheal tube adapter (test in advance that the
3-mL syringe barrel will fit tightly into a 7.5-mm inner
diameter endotracheal tube adapter).
3. Connect the endotracheal tube adapter to a bag-valve-mask
device (with its valve locked and oxygen tubing connected to
an oxygen source with a flow at 10-15 L/min).
4. Manual ventilation at a rate of 1-second compression
with 4-second relaxation is appropriate (guided with chest
rise).
© 2003 Elsevier Inc. All rights reserved.
0735-6757/03/2106-0016$30.00/0
doi:10.1016/S0735-6757(03)00166-9
References
1. Baskett PJF, Bossaert L, Carli P, et al: Guidelines for the advanced management of the airway and ventilation during resuscitation.
A statement by the Airway and Ventilation Management Working
Group of the European Resuscitation Council 1996;31:201-230.
2. Leibovici D, Gofrit B, Shemer ON, et al: Prehospital cricothyroidotomy by physicians. Am J Emerg Med 1997;15:337-339
3. Benumof JL, Scheller MS: Importance of transtracheal jet ventilation in the management of the difficult airway. Anesthesiology
1989;71:769-778
4. Petty WC: Establish the airway: use percutaneous high-pressure transtracheal jet ventilation in an emergency. AANA J 1993;61:
349-352
5. Morley D, Thorpe CM: Apparatus for emergency transtracheal
ventilation. Anaesth Intensive Care 1997;25:675-678
This document is for personal use only
AMERICAN JOURNAL OF EMERGENCY MEDICINE ■ Volume 21, Number 6 ■ October 2003
508
FIGURE 2.
Demonstration of transtracheal ventilation on a manikin via preassembled needle cricothyroidotomy equipment.
SCREENING FOR ANTICHOLINERGIC ABUSE IN PATIENTS
WITH CHRONIC MENTAL ILLNESS
To the Editor:—Over the course of the past decade, the abuse of
anticholinergic drugs among psychiatric patients has received increased attention in the clinical setting and medical literature.1-3
Our clinical experience in the urban setting of Jacksonville, Florida
correlates with recent studies that suggest abuse of these agents
among psychiatric patients is increasing.4 Because many of those
with chronic mental illnesses are evaluated in the ED on a daily
basis, providers who care for this population should be aware of
the possibility that anticholinergic misuse and abuse might be the
cause of, or might contribute to, the patient’s presenting complaint.
Anticholinergic and antihistaminic agents, such as benztropine
mesylate (Cogentin), trihexyphenidy (Artane), and diphenhydramine (Benadryl), are routinely used in psychiatry to treat the
extrapyramidal side effects of antipsychotic medications. In very
high doses these agents will produce perceptual abnormalities
(e.g., visual hallucinations) and mood-altering states (e.g., euphoria).5 However, in toxic ranges these same agents have the potential to produce life-threatening arrhythmias (e.g., supraventricular
tachycardias), severe heart blocks, and myocardial contractility
depression, which require emergent medical attention.6 Anticholinergic-induced delirium, hyperthermia, and seizures are also potential consequences of toxicity and not uncommon reasons for ED
evaluations. Following chronic use, tolerance and withdrawal
symptoms are likely sequelae.
According to a recent study of psychiatric patients who abused
anticholinergic medications, the most common reason given for
their misuse was “to get high,” followed by wanting to achieve an
“energized” effect and warding off feelings of depression.4 Trihexyphenidyl, the most stimulating of the anticholinergic agents,
was cited by the study’s patients as their preferred drug of choice.
There are a number of reasons why anticholinergic abuse is not
identified in the ED and other clinical settings. First, mental status
changes and affective changes of the patient are often attributed to
the underlying psychiatric disorder rather than the psychoactive
effects of the anticholinergic agent. Second, these are not drugs
that are identified with routine urine or serum toxicology testing.
© 2003 Elsevier Inc. All rights reserved.
0735-6757/03/2106-0017$30.00/0
doi:10.1016/S0735-6757(03)00167-0
Third, unless the ED physician suspects anticholinergic abuse, the
patient is seldom directly questioned about the possible misuse of
these agents and likely will not voluntarily offer the information
without prompting.
Although drug screening is widely used in busy ED’s to detect
substance abuse, psychiatric patients who are misusing anticholinergic agents will likely only be identified if the physician performs
a careful history that specifically addresses this issue.7 Unfortunately, this is a form of substance abuse the detection of which
rests almost entirely on the physician’s suspicion and the patient’s
reported history. It has been my experience that individuals with
chronic mental illnesses who abuse anticholinergics seldom spontaneously offer the information but are surprisingly forthcoming
regarding amounts, frequency, and duration when specifically
asked. Hence, in light of the reality that anticholinergic abuse
among chronic mentally ill patients appears to be on the rise, those
who treat psychiatric patients in the ED should remain alert to the
identification of this potentially life-threatening form of substance
abuse in a highly vulnerable population.
RICHARD C. CHRISTENSEN, MD, MA
Community Psychiatry Program
University of Florida College of Medicine
Jacksonville, FL
References
1. Zemishlaney Z, Aizenberg D, Weiner Z, et al: Trihexyphenidyl
(Artane) abuse in schizophrenic patients. Int Clin Psychopharmacol
1996;11:199-202
2. Dooris B, Reid C: Feigning dystonia to feed an unusual drug
addiction. J Accid Emerg Med 2000;17:311
3. Barsoum A, Kolivakis TT, Margolese HC, et al: Diphenhydramine (Unisom), a central anticholinergic and antihistaminic: abuse
with massive ingestion in a patient with schizophrenia. Can J Psychiatry 2000;45:846-847
4. Buhrich N, Weller A, Kevans P: Misuse of anticholinergic drugs
by people with serious mental illness. Psychiatr Serv 2000;51:928929
5. Christensen RC: Misdiagnosis of anticholinergic delirium as
schizophrenic psychosis. Am J Emerg Med 1995;13:117-118
6. Clark, F, Vance MV: Massive diphenhydramine poisoning resulting in wide complex tachycardia: successful treatment with sodium bicarbonate. Vet Hum Toxicol 1991;32:200
7. Perrone J, De Roos F, Jayaraman S, et al: Drug screening
versus history in detection of substance use in ED psychiatric
patients. Am J Emerg Med 2001;19:49-51
This document is for personal use only