Paraspinous Cervical Block for Headache

Previously we have discussed the use of propofol for migraine headache (part 1, part 2).  In this post, we’ll look at another headache treatment that can be added to your armamentarium, the paraspinous cervical block.

There are many standard cocktails for headache management in the ED, but unfortunately, many of these require an IV, fluids, and multiple medications.  This requires a significant amount of nursing time and often ties up a precious bed in the ED.  What if we could perform an injection at the bedside and send the patient home 10-15 minutes later?  Wouldn’t that be awesome?

DuhSilly

The majority of literature on the paraspinous cervical block has been published by Larry Mellick, an Emergency Physician in Georgia, and his twin brother, Gary Mellick.  According to them, this can be used for all types of headache, from tension type/migraine headaches, to orofacial/dental pain, to meningitis.  The meningitis part is self-report by Larry, not anything that has been studied.

Tim McCormick and Stuart Swadron have previously written on the subject over at EPMonthly, please read their short article now and then come back here.  It will only take about a minute, I promise.

So how do I perform this?

It’s actually very easy.  The steps are listed here, and below are videos from Larry Mellick and Al Sacchetti on how to perform the technique.

1)Landmark the C7 spinous process, which is usually the most prominent one.

2)Mark a point 1 inch lateral to the spinous process on each side, basically in the belly of the trapezius muscle overlying the transverse process.

3)Clean the area with alcohol swab.

4)Raise a wheal using lidocaine.

5)With patient in a sitting position and head held upright, insert a 25 gauge, 1.5 inch needle angled parallel to the floor.  The needle should be nearly buried.  Aspirate before injecting to ensure you are not in a vessel (more on this below) and slowly inject 1.5 cc of bupivacaine.

6)Remove needle and dress wound.

Are there any risks of this procedure?

I think most people worry about the potential harms of this procedure, particularly the many vascular and nerve structures in the neck.  Rightly so, you should know the relevant anatomy before performing a procedure.

Looking at Netter’s Atlas of Human Anatomy, you can see that this area is pretty much all muscle, with the trapezius, levator scapula, splenius capitis and splenius cervicis all in that area.  If you do hit a vascular structure, it will usually be a vertebral vein, but rarely could be a vertebral artery. However, this is unlikely because it is deeper and protected by the foramen transversarium.  If you are injecting over the transverse process, that will further protect you from hitting a vascular structure.

Here are a few videos of this being performed by Drs. Mellick and Sacchetti.


Larry Mellick performing block (7:33)


Al Sacchetti video (3:25)

References:

Mellick LB, McIlrath ST, Mellick GA. Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients. Headache. 2006 Oct;46(9):1441-49.

Cheers,

Chris Bond

@socmobem

SOCMOB How To: Using the Ventilator for DSI with Dave Lendrum

Hi all,

Today we have a guest post from Dr. David Lendrum, an ER physician at the Foothills Hospital in Calgary.  Dave is a super brilliant doc, and this post will outline how to perform BIPAP using a ventilator, as opposed to bringing an extra BIPAP machine into an already crowded resus area.  This is particularly useful for delayed sequence intubation (DSI) or prior to intubating the severe metabolic acidosis patient.

These two concepts have been discussed by EM critical care guru Scott Weingart in the podcasts linked below.  If you haven’t heard them, stop reading and go listen now.
Intubating a patient with severe acidosis
Delayed Sequence Intubation
 
This post is to demonstrate how to actually accomplish this using our ventilators, and thus may be more useful for the local Calgary docs than others.  However, the steps should be applicable to most ventilators.  I also look forward to feedback regarding better, faster, easier ways to do this.
The post contains text and photos, with a video at the end.  You can also link to my other “How To” videos here.
On with the post.
1) To “BIPAP” a patient we are basically talking about providing a patient with an amount of pressure support when they inspire and an amount of PEEP when they exhale.  We almost always ask the RT’s to bring a “BIPAP” machine to the bedside as we don’t seem to use the actual ventilator to do this.  Why is this???  Mainly because these machines do BIPAP really well, the are simple to use and they are also portable, meaning they can be hooked up to an bottle of oxygen and the patient can be transported while being BIPAP’ed where as this can’t be done with the large ventilators.  The downside is that they are really large and take up a lot of real-estate in the trauma bays and such.
Pic1
FMC BIPAP MACHINE
2) You may not know that you need to use a special mask with the BIPAP machine!  I don’t mean that it is special in the fact that it is nice and soft and needs to be on the patient really tightly, but there are actually two different masks for non-invasive ventilation.
BIPAP MACHINE: As you can see there is only one tube going to the patient providing air, but no return circuit. As such, where does the patient exhale?  You MUST use a mask with exhalation holes in it with this mask or the patient can’t exhale at all other than leaking around the mask.  The photo below shows the mask the RT’s will put on the patient which has these holes or vents.
Pic2
3) You most definitely can do non-invasive ventilation with the regular ventilators we have in the department. However, you need to use a special NON-VENTED mask as the ventilator DOES have a exhalation tube that returns to the machine.  As you can see, the NON-VENTED mask has the blue nose looking thing and no holes in it.
Pic3
4) Bringing a BIPAP machine into a code room when I have every intention of intubating them in the near future makes no sense.  The RT’s agree with me.  As such, I have done some playing with the vent and figured out ONE of the ways of doing this.  I am sure some of you will have lots of comments on other ways of doing this as well.
5) Find a ventilator and let the RT know what you are thinking.  “I want to non-invasively ventilate this patient until I am ready to pass the ETT”.  Perhaps you are doing this for a patient with an ASA overdose or a severe DKA patient and you are really worried that if the patient becomes any more hypercarbic they really aren’t going to do well.  Or, maybe they are wild and crazy and have a severe pneumonia and you feel that they need some sedation and pre-oxygenation prior to intubation.
6) Here is what the ventilator looks like in standby mode.
Pic4
7) You can attach the ventilator hosing to the the NON-VENTED BIPAP mask if you wish.  Notice I have also hooked up the end-tidal CO2 to this set up which would be helpful as well.  If you can’t find the non-vented mask you could use the vented one, but there is just going to be a big “leak” out the holes.  It wouldn’t be dangerous, whereas doing the opposite (using a non-vented mask on the BIPAP machine would be).
Pic5
8) I also like this set up as it totally removes any concern of using a special mask and would solve the same problem, but just require someone to maintain a good seal with the patient.  I suspect to do this well you would have to have a obtunded or very cooperative patient.  This is where some Ketamine/Haldol might go a long way.
Pic6
Here’s a video showing the process.

Agree/disagree?  I look forward to your comments.  Post them here, or tweet @socmobem.

Dave Lendrum

 

Digital Intubation, and I Don’t Mean Video

Hey all,

Listening to the May edition of EM:RAP yesterday, there was a segment by Patrick Shipsey on digital intubation.  At first I thought this would be the same old, same old.  That is, someone discussing the pros and cons of video and direct laryngoscopy.  What I didn’t expect to hear was someone talking about using their fingers to intubate someone. No laryngoscope, no glidescope, just two fingers.

I must admit, I knew nothing about this technique, and by the end of Dr. Shipsey’s talk, I was pretty damn curious.  For those of you who don’t have an EM:RAP subscription, here is the link to Dr. Shipsey’s YouTube video demonstrating the technique on a mannequin.

I spent part of today looking up the literature on this topic, and found a few articles of note. “Digital Intubation” (Bluhm and Hardwick, JEM 1984) describes the elegant technique with the following photos.

A picture is worth a thousand words.

In this study, 10 paramedics were trained to digitally intubate (DI) “mongrel dogs and human cadavers” and when deemed adequately trained (no mention of how this was assessed), they were allowed to use the technique in the field under the following conditions:

1) Cramped quarters (i.e., patient trapped in vehicle)
2) Copious oral secretions (i.e., large amount of blood or vomitus in oral cavity, obscuring visualization with a laryngoscope)
3) Inability to visualize vocal cords with laryngoscope
4) Severe head trauma, requiring immobilization of cervical spine
5) Personal preference.

In the following 20 months, DI was attempted 66 times, and was successful in 59 cases (89%).  They also breakdown the indications and success rate of each of the 10 paramedics in the study; one paramedic successfully intubated 22 of 23 patients by DI with the indication being personal preference 100% of the time.  On average he/she had his fingers in someone else’s mouth > once per month during the study period. I wonder if any colleagues took him aside and asked about his mental health when they saw his positive Russell’s Sign.

150px-Russell's_Sign

I think of the 5 indications in this study, the 3 bolded ones are probably a little better indications that the inability to visualize and personal preference.  In reality, the risks of being bitten and advancement of airway devices makes indications 3 + 5 weaker.

The next study “Tactile Orotracheal Intubation” (Stewart, Ann Emerg Med 1984) describes the technique again and lists the following as particularly valuable times to use DI:

1) Trauma patients

2) Obese or short-necked patients

3) Secretions or bleeding obscured visualization of landmarks

The article also contains this sentence, “Gloves are advised, although to date most of our field intubations have been performed without them”. Awesome.

After those two articles in 1984, we jump ahead to a 2006 study looking at 18 EM residents and 4 EM attendings performing DI on 6 human cadavers. (Young et al. AJEM 2006)  While they began with 6 cadavers in the study, one developed a false passage near the vocal cords during the study and was excluded from their analysis.  Excluding this cadaver, they report successful intubation 90.9% of the time (CI 85.5%-96.3%) and average time to success or failure as 20.8 seconds (CI, 16.9-24.8).  The average number of intubation attempts was 1.5 per study participant.

Sounds pretty good, right.

Unfortunately, first pass success was only 64.5% and the 90.9% success rate is a cumulative score when up to 3 attempts were made per physician.  The study participants had only a brief explanation of the technique before performing the DI, and as with any technique, practice makes perfect.

I just hope no false passages are created in real life situations. Eek!

Ultimately, here are the pros/cons of the technique as I see it.  However, having never performed this technique, I’d love to hear from those who have.

Pros:

Fast (in experienced hands)

No requirement for optimal positioning

Minimal c-spine movement for trauma patients

Ideal for those predicted to be difficult airway (eg. underbite, short neck, obese)

Can be used if copious secretions/blood in airway and cannot visualize landmarks

Cons:

Requires training (cadaver or sim lab)

Being bit by patient

Airway trauma

Patient must be paralyzed or comatose/dead

Benefits operators with long, slender fingers

Others may think you’re crazy when you jam your fingers in someone’s mouth.

 

Personally, I find this technique fascinating, and as someone with really long and skinny fingers, I’ll definitely be trying this at our next simulation day.  There are a few failed airway stories I’ve heard in the last six months in which this technique may have saved the day.  Regardless of whether we ever use this technique, it never hurts to have an extra airway trick up your sleeve.

For some reason, this technique reminds me of this Canadian Boston Pizza commercial.  Take note of the fine Vanna White technique, clearly learned while watching my homemade cric trainer video.


Instead of Finger Cooking, imagine “Finger Tubin’ with Chris”

Um, yeah, Canadian commercials are pretty weird.

 

If you have experience with this technique, your comments, criticisms, tips and tricks would be greatly appreciated.

Special thanks to Minh Le Cong (@rfdsdoc) of the PHARM podcast for peer reviewing this post.

Cheers,

Chris Bond

@SOCMOBEM

 

SOCMOB How To: Jet Insufflation and Bougie Assisted Cric

Hi all,

A few months back we looked at how to make your own cricothyrotomy trainer.  Easy and inexpensive, you can find the video here.

Today I’m adding two more procedure videos which demonstrate a simple jet insufflation setup, as well as the bougie-assisted cricothyrotomy.  Shout out to Darren Braude of EM:RAP and many other podcasts who this idea came from originally. You can find his paper here.

Combining these videos with the aforementioned cric trainer is useful for training large groups of medical students, paramedics and residents.  If you want to see other procedure videos, check out my videos page.  There are also loads of procedure videos over at GMEP.org.

First is the Macgyver’d jet insufflation setup, which requires only a BVM, 3 cc syringe, large bore (eg. short 14 gauge) iv cannula and 7.0 ETT adapter.  I think this technique would be feasible for a pediatric patient only, as there is quite a bit of airway resistance.  In an adult patient, I’m not sure that you could adequately oxygenate the patient doing this.

 

Here is the bougie assisted cric video.  Much simpler than a cric tray, all you require is a scalpel, bougie and 6.0 ETT.

 

If you like these videos, tweet about it.

Happy cric-ing!

Chris Bond

@socmobem

 

SOCMOB How To: Make an atomizer device

It’s time for another video.  Today I’ll be showing you how to MacGyver your own atomizer for intranasal and orotracheal drug administration.  Shout outs to fellow USask FOAMite Dr. Nadim Lalani (@ERMentor) and Dr. Whit Fisher for the idea behind this one.  Today’s video is a modification of the design outlined by Whit Fisher here.   For more of my “How To” videos, check out the videos page here or GMEP.org.

The intranasal (IN) route of drug administration is becoming ever more popular, specifically in pediatrics and awake intubations. This PK SMACC Talk video from Italian Valerio Pisano Brasca (His blog is here), who has a much cooler name than me, is a good 6 minute overview on the types of medications and doses that can be used via the intranasal route.  Some of the big ones are fentanyl, ketamine, and midazolam.  Administering these drugs without intranasally is useful for procedures and pain in children, and could also be used before establishing IV access as well.  Another drug that can be given IN is naloxone, useful for your narcotized post-op patients on the ward, and drug users in the ED.

What I like most about the atomizer is that you can effectively deliver topical anesthetics to the posterior oropharynx and have the patient hold it themselves for elective intubations.  Rather than stick something in their mouth, the patient or a parent could do it for them.

To test this out, I tried it on myself with 2% lidodan and it did a pretty good job of decreasing my gag reflex.  Definitely to the point that I could easily get a MAD back there to spray the cords.  A common question is “why not just use a nebulizer”?  I’ve tried the nebulized 4% lidocaine for topicalizing the airway, and I find most patients say that it just coats their tongue and inner cheeks, while not actually getting their oropharynx.  The atomizer does a much better job of this.

Onto the video.  If it’s not working, check the YouTube link here.

 

Questions and comments on how to improve are always appreciated.

Cheers,

Chris

@SOCMOBEM

 

Post written by Chris Bond.  Peer reviewed by Nadim Lalani (@ERMentor)