COVID-19 Thinking Cap: How To Protect Personnel During Intubation (Video)

There is a fascinating letter in the New England Journal of Medicine submitted by authors from the Boston Medical Center and Brigham and Women’s Hospital. Like all trauma professionals, they were concerned with droplet contamination produced during the intubation process. Most hospitals have modified their intubation procedures to try to protect personnel as much as possible.

The authors designed a Plexiglas box with two holes for the arms of the intubator that is placed over the patient’s head. This should serve to shield them, and other personnel in the room if the patient unexpectedly coughs during the process. They tested this concept using an intubation mannequin. First, they placed a balloon filled with fluorescent dye in its mouth and slowly inflated until it burst. Here was the result when viewed under ultraviolet light. Sputum everywhere!

Next, they placed the intubation shield over the patient. Here is a drawing of its dimensions.

The device is open on the bottom and on the side away from the intubator. The arm holes are 10cm in diameter.

The authors then repeated the balloon experiment with the shield in place and the intubator’s arms inserted through the holes. The resulting contamination was limited to their hands and forearms, and the inside of the shield.

Bottom line: This is a very interesting yet simple and cheap device that can be built by just about anyone and should protect personnel from droplet contamination. It will not have much effect on aerosols escaping into the room, but that’s what our other PPE are for! It’s a great example of how creativity is key in keeping us all safer during this pandemic.

You can view the video on the NEJM website at:
https://www.nejm.org/doi/full/10.1056/NEJMc2007589

Reference: Barrier Enclosure during Endotracheal Intubation. NEJM DOI: 10.1056/NEJMc2007589, April 4 2020.

Whaaat? Stuff You Sterilize Other Stuff With May Not Be Sterile??

When one works in the trauma field, or medicine in general, we deal with the need for sterility all the time. We use equipment and devices that are sterile, and we administer drugs and fluids that are sterile. In surgery, we create sterile fields in which to use this sterile stuff.

In the past few years, we’ve come to the realization that the sterility we take for granted may not always be the case. There have been several cases of contaminated implanted hardware. And a few years ago, supposedly sterile injectable steroids were found to be contaminated with fungus, leading to several fatal cases of meningitis.

An article in the New England Journal of Medicine brings a bizarre problem to light: microbial stowaways in the topical products we use to sterilize things. Most drugs and infused fluids are prepared under sterile conditions. However, due to the antimicrobial activity of topical antiseptics, there is no requirement in the US that they be prepared in this way.

A number of cases of contamination have been reported over the years:

  • Iodophor – contamination with Buckholderia and Pseudomonas occurred during manufacture, leading to dialysis catheter infection and peritonitis
  • Chlorhexidine – contaminated with Serratia, Buckholderia and Ralstonia by end users, leading to wound infections, catheter infections, and death
  • Benzalkonium chloride – contaminated with Buckholderia and Mycobacteria by end users, causing septic arthritis and injection site infections

Bottom line: Nothing is sacred! This problem is scarier than you think, because our most basic assumptions about these products makes it nearly impossible for us to consider them when tracking down infection sources. Furthermore, they are so uncommon that they frequently may go undetected. The one telltale sign is the presence of infection from weird bacteria. If you encounter these bugs, consider this uncommon cause. Regulatory agencies need to get on this and mandate better manufacturing practices for topical antiseptics.

Reference: Microbial stowaways in topical antiseptic products. NEJM 367:2170-2173, Dec 6 2012.

The March 2020 Trauma MedEd Newsletter: Coronavirus and Trauma Professionals

Welcome to the current newsletter. I am releasing this to nonsubscribers early due to the relevance of the information it contains.

Topics covered include:

  • Guidance from the American College of Surgeons
  • COVID-19 and the trauma surgeon
  • Coronavirus and your trauma service
  • Coronavirus and the trauma team
  • CT scan safety and the coronavirus
  • Changing trauma rounds for coronavirus safety
  • Coronavirus and your massive transfusion protocol (MTP)

The April issue will be released next month and will be a followup to this one. I’m sure we will learn quite a bit about the virus and our response to it in the ensuing month.

And please send me your comments, updates, or tips you have found helpful at your hospital! I’ll include them in the next newsletter.

To download the current issue, just click here! Or copy this link into your browser: http://bit.ly/TME202003.

 

Topic For The Next Trauma MedEd Newsletter: Coronavirus

Due to the high level of interest in all things Coronavirus that are related to trauma, I’ve changed the topic for the next Trauma MedEd Newsletter. The focus will now deal with this virus in detail.

As you know, I have already written a few posts on this topic over the last week. I’ve now retasked the next newsletter issue to share my thoughts on the virus and its impact on trauma professionals.

Topics will include:

  • Coronavirus and your trauma service
  • Coronavirus and the trauma team
  • CT scan safety and the coronavirus
  • Changing trauma rounds for coronavirus safety
  • Coronavirus and your massive transfusion protocol (MTP)
  • And more!

As always, this month’s issue will go to all of my subscribers first, in just a day or two. If you are not yet one of them, click this link right away to sign up now and/or download back issues.

Non-subscribers can pick up this issue when I release the issue on the blog this coming weekend. So sign up now!

How To MacGyver A Ventilator From Common Parts

A cardiac anesthesiology fellow, and several engineers from the University of Minnesota and a local device company got together over the past few weeks and cobbled together a ventilator from some spare parts. Here’s a picture to give you an idea of what it looks like:

It uses a metal toolbox tray, an Ambu bag, and some other spare parts lying around one of the medical device labs at the university. Essentially, a servo motor intermittently squeezes the Ambu bag, and there are adjustments for how often (rate) and how deeply (volume) the bag is compressed. There is a pressure limiting device included in the system as well.

This project illustrates how we will need to think outside the (tool)box in the coming weeks, especially as the number of severe Coronavirus cases begins to tax our supply of ventilators. And obviously, this thing will not get FDA approval in your lifetime. But if a choice needs to be made between using something like this in a pinch vs letting someone asphyxiate, the answer is pretty clear.

The group has produced a short YouTube video as well (see below), but it is rather short on details. You get to see some partial views of it as it is being tested on pigs. But so far, the concept is promising.

If you are trying to view this on my Tumblr feed, the video will not show here. Please click here to visit my main blog site to view it.

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