What is a Mental Health

Mental health is more than the mere lack of mental disorders. The positive dimension of mental health is stressed in WHO’s definition of health as contained in its constitution:
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
”Concepts of mental health include subjective well-being, perceived self-efficacy, autonomy, competence, intergenerational dependence and recognition of the ability to realize one’s intellectual and emotional potential. It has also been defined as a state of well-being whereby individuals recognize their abilities, are able to cope with the normal stresses of life, work productively and fruitfully, and make a contribution to their communities. Mental health is about enhancing competencies of individuals and communities and enabling them to achieve their self-determined goals


Mental health should be a concern for all of us, rather than only for those who suffer from a mental disorder. Mental health problems affect society as a whole, and not just a small, isolated segment. They are therefore a major challenge to global development. No group is immune to mental disorders, but the risk is higher among the poor, homeless, the unemployed, persons with low education, victims of violence, migrants and refugees, indigenous populations, children and adolescents, abused women and the neglected elderly. For all individuals, mental, physical and social health are closely interwoven, vital strands of life. As our understanding of this interdependent relationship grows, it becomes ever more apparent that mental health is crucial to the overall well-being of individuals, societies and countries. Unfortunately, in most parts of the world, mental health and mental disorders are not accorded anywhere the same importance as physical health. Rather, they have been largely ignored or neglected.

Referance
World Health Organitaton ( W H O ), 2000

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The Failed Airway !! (EAM part 5)

Although none of us wants to be in a “failed” airway situation, it will happen eventually to all of us. There are basically 2 scenarios, 1) can’t intubate but can ventilate with a BVM or 2) can’t intubate and can’t ventilate. In the first situation, one is at least able to maintain reasonable ventilation and oxygenation. However, the risk of aspiration increases as bagging continues. Even with adequate Sellick’s maneuver, some air will leak into the stomach causing gastric distension and eventually vomiting. The second situation is more desperate and if a decision is not made in seconds, the patient will die. Usually this involves one of two possibilities depending on time. The first is the creation of an immediate surgical airway either by cricothyrotomy, or percutaneous transtracheal jet ventilation.

If you do not have the transtracheal jet ventilation already set up before hand, you can not use this as you will NEVER be able to assemble the equipment in time to save the patients life. Neither of these options are viable in the pediatric patient and surgical airways should not be undertaken in children below the age of puberty! The second possibility is to use an airway adjunct. Obviously you need to have access to these adjuncts before the crisis arises. Adjuncts include the Combitube©, laryngeal mask airway, fiberoptic laryngoscopically assisted intubation, lighted stylette intubation, retrograde intubation using a cricoid puncture technique and wire, digital intubation and others. The success rates are dependent on availability of the equipment and operator training and experience. The time to plan for a failed airway is now, not in the crisis of the moment when it happens. The patient will pay for your lack of preparation!

Reference
Advanced Emergency Airway Management Walls RM, Luten RC, Murphy ME, Schneider RE. 1997

READ MORE - The Failed Airway !! (EAM part 5)

The Difficult Airway (EAM part 3)

Although the vast majority of emergency airways will go smoothly using the above technique of rapid sequence intubation, everyone, regardless of experience, is bound to have problems sometime. It is important to recognize which airways may give you problems before you begin down the road to a possibly failed airway attempt. It is important to choose the most appropriate technique for each particular airway situation before disaster occurs. I suggest that several simple questions be asked in every airway situation: If my intubation attempt does not succeed, will I be able to ventilate the patient with a bag-valve-mask? If I can not ventilate the patient with a BVM, what should be done next and what is my back up plan? Am I prepared to provide a surgical airway?

Some estimation of the degree of difficulty of an airway is made possible from the following observation and simple maneuvers.
Facial hair- facial hair (beards and moustache) in men make it difficult to form a tight seal with a mask. If you need to provide ventilation with a BVM, you will get an air leak which may prevent you from providing adequate ventilation. Simply smearing a water soluble lubricant (like K-Y jelly) on the beard may make bagging easier and more effective.
C-spine mobility- C- spine immobilization makes most airway management more difficult as the neck can not be extended to provide visualization of the cords on laryngoscopy. It also affects performance of the Sellick’s maneuver. Some cervical collars will have holes in the front to access the cricoid cartilage for either a cricothyrotomy or Sellick’s maneuver. In reality, these holes do not provide enough access to make a real difference. In the C-spine immobilized patient, it is often best to remove the collar and have a colleague hold in-line stabilization of the head and neck during intubation which makes intubation easier. It has been said in the past that blind nasotracheal intubation was the airway of choice in the C-spine immobilized patient. However, the complication rate is higher in blind intubation and the movement of the C-spine with blind nasotracheal intubation is as much or more than with in line traction. The success rate for blind nasotracheal intubation is 40-50% compared to nearly 99% with oral intubation combined with RSI. Another example where the C-spine interferes with intubation is in the patient with arthritis of the C-spine or ankylosing spondylitis of the C-spine. Not only will this interfere with extension of the neck but the C-spine can actually be fractured if extended.
Mouth opening- an adult with normal TMJ will be able to open the mouth to accommodate 3 or 4 fingers between the incisors. TMJ disease or rheumatoid arthritis may limit mouth opening and thus oropharyngeal and laryngeal visualization. Rheumatoid arthritis can affect the stability of the atlanto-axial joint causing subluxation and instability.
Physical characteristics- Patients with small mandibles or receding mandibles have tongues that will obstruct access to the airway during intubation. All children basically fall into this category as they all have tongues proportionately larger than their developing mandibles. A good rule of thumb is that if you can look into the mouth without a tongue blade and visualize the uvula, peritonsillar area and posterior pharynx easily, you should be able to visualize the larynx on intubation. If you struggle with visualization of the posterior aspects of the throat before intubation, you will struggle during the intubation. The length of the neck and the position of the larynx is important.
The larynx in the adult should be at the C5-6 level. A larynx that is higher will be difficult to visualize. Typically, there should be 2 fingerbreaths between the top of the thyroid cartilage and the base of the neck in the normal adult.
Teeth- All false teeth should be removed prior to intubation. Large upper incisors may obstruct visualization of the larynx because they elongate the AP axis of the mouth. Jagged teeth may lacerate balloons on the ET tubes. [If the patient can eat an apple through a picket fence - you are in for trouble.]
Oral dimensions- patients with narrow facial features and high arched palates may have difficult airways. Access will be limited because of reduced space side to side in the mouth.

Reference
Advanced Emergency Airway Management Walls RM, Luten RC, Murphy ME, Schneider, 1997

READ MORE - The Difficult Airway (EAM part 3)

Rapid Sequence Intubation (EAM part 2)

Rapid sequence intubation (RSI) consists of a series of discrete steps that are best followed to insure the greatest success. The patient should first be evaluated for the presence of a difficult airway and the ability to ventilate with a bag-valve-mask should intubation not be successful. It is obvious that the intubation should take place in a room that is prepared in advance with all equipment needed for resuscitation should that be necessary. It is the physician’s responsibility to make sure that all equipment is present and in working order before proceeding! Although nurses may assure you that everything is in working order, the physician is ultimately responsible and will be the one to have to handle the problem if some critical equipment is not functioning or a critical drug is not available.

1. Preoxygenation “Bagging” the patient unnecessarily prior to RSI increases the possibility of vomiting and aspiration. Critical to the philosophy of rapid sequence is the “no bagging” principle. Pre-oxygenation is the establishment of an oxygen reservoir within the lungs to permit several minutes of apnea to occur without arterial oxygen desaturation. Pre-oxygenation not only establishes an oxygen reservoir in the lungs, but also creates an oxygen surplus in the blood and body tissue protecting from hypoxia. In the spontaneously breathing patient, administration of 100% oxygen (15 liters of O2 in a non rebreather mask provides 80-90% oxygen) for 5 minutes prior to using paralyzing drugs allows for approximately 5 minutes of apnea before the hemoglobin desaturates below 90% in the adult. (It is of note that this is not the case in a child who has a much lower functional residual capacity and may desaturate after 1 or 2 minutes.) A pulse oximeter should be used throughout the procedure to allow the physician to gauge the oxygen saturation. In situations wherein time is more critical and it is not possible to pre-oxygenate for 5 minutes, a significant pre-oxygenation effect can be obtained by having the patient take 3-5 large capacity breaths on high oxygen.
2. Pretreatment “Pretreatment” is the administration of medications to attenuate the normal physiologic and pathophysiologic reflex responses that are caused by airway manipulation and the physical presence of the endotracheal tube. These are usually medications used to blunt the sympathetic discharge that accompanies laryngoscopy from insertion of the laryngoscope or manipulation of the airway. Situations where pretreatment is desirable include 1) conditions where there is increased intracranial or intraocular pressure, as in a head injured patient; 2) conditions where sympathetic discharge would have deleterious effects on the heart or cardiovascular system as in patients with coronary artery disease, or in children who might have bradycardia and hypotension from airway manipulation; and 3) in patients with airway disease, as in asthma, who might have laryngospasm with airway manipulation. There are also times when it might be advisable to administer a small defasciculating dose of a competitive neuromuscular blocking agent three minutes prior to the administration of succinylcholine. Lidocaine (1.5 mg/kg given 3 minutes prior to intubation) has been shown to suppress the cough reflex and attenuate the increased airway resistance, which results from bronchospasm caused by irritation of the larynx. It also mitigates the effects on a potential increase in intracranial pressure. Thus it should be considered in all patients prior to the administration of a neuromuscular blocking agent who have reactive airway disease or elevated ICP.
Fentanyl (3 micro-gms/kg IV 3 minutes before induction) also attenuates the reflex sympathetic response to laryngoscopy. Fentanyl has no effect on ICP and will cause some hypotension and may suppress respiratory effort. However, it is useful in patients who might be adversely effected by an increase in heart rate or blood pressure. This is especially true in patients with ischemic heart disease, pulmonary edema and cardiogenic shock and in patients with vascular catastrophes like a AAA, subarachnoid hemorrhage or thoracic dissection. Defasciculating agents like vecuronium and pancuronium in small, nonparalyzing doses, given 3 minutes before succinylcholine mitigate against potential increases in intracranial pressure and should be considered when increased ICP is of concern. Lastly, almost all children should receive atropine before airway manipulation to mitigate against the bradycardia and hypotension induced from airway manipulation and laryngoscopy.
3. Paralysis and Induction Approximately 5 minutes after pre-oxygenation has begun and 3 minutes after pretreatment drugs are administered, a sedative and a neuromuscular blocking agent should be rapidly administered to induce rapid loss of consciousness and paralysis. This should not be titrated or done tentatively, but should be done as a push to allow for the full effect of the medication. This provides the best chance at rapid intubation without the possibility of partial or incomplete paralysis. Succinylcholine is the drug of choice for almost all emergency department intubations and should be given in a full dose of at
least 1.5 mg/kg IV push. Since there are no complications from succinylcholine in larger than normal doses, the medication should be “rounded up” and a slightly higher dose given rather than a low dose, which might not induce full paralysis. A sedative should be given almost simultaneously by IV push. This usually will be midazolam and care must be taken as midazolam may cause some hypotension. Another but more expensive drug, Etomidate, is gaining rapid popularity in emergency medicine and eventually may replace Versed. A few seconds after administration of the neuromuscular blocker and sedative, the patient will loose consciousness and respirations will cease. Between 20-30 seconds of apnea is almost universal. Sellick’s maneuver should be applied to the cricoid cartilage to prevent regurgitation of gastric contents and should be maintained throughout the entire sequence until the endotracheal cuff is inflated. It should be noted that Sellick’s maneuver is often improperly performed. Most often those doing the Sellick’s maneuver will press down on the thyroid cartilage instead of the cricoid cartilage. This actually makes intubation more difficult by pushing the cords posterior and out of visualization of the laryngoscopist. It also does not protect the airway as the esophagus is not occluded. Pressure on the cricoid cartilage occludes the esophagus and tilts the cords upward toward the visual axis of the laryngoscopist.
4. Place the tube Approximately 45 seconds after succinylcholine is administered the patients jaw should be tested for flaccidity and intubation should be undertaken. Intubation attempts before 45 seconds and full relaxation are rarely successful. It is hard to wait the full 45 seconds when the patient is apneic. It is also hard not to want to “bag” the patient when he/she is apneic. However, the full 45 seconds should pass before the tube is introduced. Remember- we pre-oxygenated the patient, so there is plenty of oxygen to last for several minutes (usually 5), which is plenty of time to get the patient intubated with minutes to spare. Intubation can proceed calmly in a non- rushed manner. The success rate should be very high and approach 99% using this algorithm.
5. Post intubation care Tube placement must be confirmed. One of the most disastrous complications from RSI is unrecognized esophageal intubations. Proper placement of the tube can be confirmed if the operator actually saw the tube go through the cords. Otherwise, the best method of confirming tube placement is by end-tidal CO2 monitoring or aspiration techniques. An end tidal CO2 monitor can be easily attached to the ET tube and color changes noted. Purple (“problem”) means you are not in the right place. Yellow (“yes”) means you are in the trachea and CO2 is passing by the monitor. If an intermediate color (tan) is detected, tube placement should be immediately checked. In a small number of cardiac arrest cases, no color change may be detected even though the tube is properly placed in the trachea. This is caused by cessation of carbon dioxide production and delivery to the lungs. If a CO2 monitor is not available, another test, based upon the knowledge that rigid walled structures (trachea) will hold their shape in comparison to structures with no support (esophagus) which collapse, may be used. A 30 cc syringe can be attached to the ET tube and the plunger quickly withdrawn. If there is easy flow of air, you are in the trachea, if there is resistance, you are probably in the esophagus. Chest x-ray can not confirm tube placement in the trachea as the esophagus lies directly behind the trachea- placement in either structure will appear the same on the AP chest film.
Absence of breath sounds over the epigastrium, the presence of breath sounds in the lungs and observation of the rising and falling of the chest with ventilation are unreliable signs of endotracheal intubation and should not be relied upon. Pulse oximetry should be used throughout the intubation. Desaturation may suggest esophageal intubation, but desaturation may be delayed several minutes if the patient was properly pre-oxygenated. Desaturation may also occur precipitously when precious little time is available to correct the problem. Therefore, oxygen saturation should not be the only basis used to confirm tube placement. After tube placement is confirmed, attention must be turned to the long term care of the patient on the ventilator. Remember that succinylcholine will last only about 6 minutes and a long acting nondepolorizer such as vecuronium should be administered in full paralyzing doses before the succinylcholine effects subside. Also, since paralysis does not afford sedation or analgesia, a long acting sedative and or analgesia should also be administered to make the patient comfortable.

Reference
Advanced Emergency Airway Management Walls RM, Luten RC, Murphy ME, Schneider RE. 1997

READ MORE - Rapid Sequence Intubation (EAM part 2)

Indications for Intubation (Emergency AirWay Management (EAM) part 1)

Airway skills are perhaps the most important skills that an emergency physician possesses. If the airway is lost in a critically ill patient for any reason, any of the other interventions you might make, or any great diagnoses are superfluous. It is good to remember that in the ABC’s of resuscitation, airway is first and foremost. With the exception of defibrillation in a cardiac arrest situation and possibly a needle decompression in the patient with a tension pneumothorax, airway control always assumes first priority. Since the need to protect the airway most often occurs in a crisis situation in the ED, the emergency physician can not rely on others, like anesthesia, to assist. Even moments of delay can spell disaster for the patient. Since every airway emergency presents in a different fashion, the emergency physician must be proficient in multiple techniques to protect and intubate the airway, and must be prepared with all the necessary equipment to perform these alternative procedures should the initial plan fail.

Indications for Intubation
There are several indications for intubation. The first occurs when the patient is unable to protect or maintain his/her airway. An example of this might be someone deeply comatose from a head injury or drug overdose who can not protect his airway from aspiration if vomiting should occur. It has been taught that the absence of the gag reflex is a reliable method of assessing whether or not the airway is protected. In fact this might not be the case. Up to 20% of the normal population may not have a gag reflex. A better assessment of airway protection is evaluation of the ability to swallow spontaneously and handle secretions. Even if the patient is “breathing on his own” and ventilation is adequate, this does not assure us that the patient will be protect his airway if vomiting were to occur, and the morbidity and mortality from aspiration is quite high. The second indication is failure of oxygenation or ventilation as might occur in someone with asthma, COPD or pulmonary edema. If the PaO2 can not be maintained with supplemental oxygen or such techniques as BiPAP, the patient will ultimately need ventilation through endotracheal intubation. The third is an anticipated clinical course that makes airway management imperative. This might include such patients as those with oropharyngeal burns from a house fire, facial trauma or facial abscesses. Airway compromise in these conditions is a real possibility and airway management often becomes increasingly difficult as time passes. If there is an anatomical distortion that will make intubation more difficult as time goes on, it is the wise physician who will recognize the problem and provide simple protection before the process progresses.
Once it has been established that airway intervention will be necessary, there are several questions the emergency physician must ask: How much time do I have? Is this a critical airway and a crash situation? Do I need to intubate now or do I have a few minutes to prepare? If you are in a crash situation like a full cardiopulmonary arrest, orotracheal intubation must proceed without further delay. If there is time to prepare, then the physician must predict which airway intervention is best and most likely to succeed. He must evaluate whether this will be a difficult airway to intubate and if it is a difficult airway and the first attempt at intubation fails, can the patient be ventilated with a bag-valve-mask. [If I am unable to intubate and I can not ventilate with a bag-valve-mask, am I prepared to manage the situation?]

Rapid Sequence Intubation
In most cases, airway management will be amenable to standard practices. “Rapid sequence intubation is the cornerstone of modern emergency airway management.
Although other techniques, such as blind nasotracheal intubation and intubation using sedation along with neuromuscular blockade, have been used widely in the past, the superiority of rapid sequence intubation in terms of success rates, complication rates and control of adverse effects, renders it clearly the procedure of choice for the majority of emergency department intubations.” (ACEP-Advanced Airway Management) “Rapid sequence intubation is the virtually simultaneous administration of a potent sedative (induction) agent and a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation.” (ACEP- Advanced Airway Management) Although there are no absolute contraindications for rapid sequence intubation, the presence of a potentially difficult airway requires a careful assessment and a plan with alternatives should the intubation attempt fail.
Rapid sequence intubation (RSI) consists of a series of discrete steps that are best followed to insure the greatest success. The patient should first be evaluated for the presence of a difficult airway and the ability to ventilate with a bag-valve-mask should intubation not be successful. It is obvious that the intubation should take place in a room that is prepared in advance with all equipment needed for resuscitation should that be necessary. It is the physician’s responsibility to make sure that all equipment is present and in working order before proceeding! Although nurses may assure you that everything is in working order, the physician is ultimately responsible and will be the one to have to handle the problem if some critical equipment is not functioning or a critical drug is not available.

Reference
Advanced Emergency Airway Management Walls RM, Luten RC, Murphy ME, Schneider RE.
1997

READ MORE - Indications for Intubation (Emergency AirWay Management (EAM) part 1)

What is a Primary Survey

The Primary Survey is the initial patient assessment, intended to rapidly and systematically identify and treat any immediately life-threatening problems. It follows the ABC format familiar from other courses, but extends this into more detail. Assessment and treatment proceed simultaneously – as a problem is identified,
appropriate action should be taken before moving on. After any intervention, or if there is any sign of a change in condition, repeat the primary survey.
The primary survey relates to patient assessment and treatment, and should only be
started after ensuring safety of self and scene

Primary Survey
Airway with control of c-spine
Breathing
Circulation
Disability
Expose and evaluate
Full assessment
Following a look, feel, listen approach, things to look for are:
Airway
Look for wounds, swelling, foreign bodies. Listen for noises (snoring indicates
tongue/soft tissue obstructing, stridor obstruction at or above vocal cords, wheeze
obstruction below, gurgling fluid in airway, silence complete obstruction)
Breathing
Look for wounds, bruising, deformity, paradoxical movement. Feel for expansion,
irregularity, tenderness. Assess rate and depth of breathing. Listen over five points on each lung for air entry and added noises (e.g. wheeze), comparing like for like on each side.
Circulation
Assess radial pulse for presence, strength, and rate. If absent, check for carotid.
Alternatively assess cap refill. Check for major external bleeds. Examine the
abdomen, looking for wounds, bruising, or swelling, and then feel four quadrants for
tenderness, rigidity, or guarding
Dissability
Assess level of consciousness using AVPU. Check pupil reactions – a light shone in
one eye should make both constrict. Will need to use light four times (twice in each
eye) to adequately assess this.
Expose and evaluate
Remove clothing to full examine the patient, remembering to check front, back, sides,
and to check areas such as the axillae where wounds can be ‘hidden’. After this recover
to prevent heat loss, and make a decision (if not already done) as to how serious
the condition is.

Minimum assessment
As a minimum, for a possibly seriously hurt or unwell patient, c-spine should be
immobilised (if indicated), airway noises looked for; breathing rate and air entry
assessed; radial pulse felt, quick check for bleeding made, and abdomen palpated;
level of consciousness and pupils checked. If a problem is identified at any point, a
more thorough check (as detailed above) should be performed, and appropriate
treatment given.

READ MORE - What is a Primary Survey