ENDOTRACHEAL TUBE SIZE
Often-times we are faced with the question: How large of an endotracheal tube should I use for my patient?
The easy answer is the biggest tube you can pass, but thats not always the highest priority in the emergency department.
In general, bronchoscopy can be done through almost any endotracheal tube, but if the tube is smaller than an 8 mm, a pediatric bronchoscope may have to be used.
I was unable to identify any studies with evidence-based guidelines to the appropriate endotracheal tube size for adult males and females. Although, most texts recommend 7.5 - 9.0 mm tubes for males and 7.0 - 8.0 mm tubes for females. It is highly recommended to consider the pathology behind your reason for intubation and not add to the obstructive pattern with a small ET tube if not necessary.
In children, the general guideline for endotracheal tube size is [(4 + age(yr)) / 4]. Another recommendation is to use the width of the fingernail of the child's 5th finger as a "built-in" size guide.
References:
Slinger, Campos. Anesthesia for Thoracic Surgery. Miller: Miller's Anesthesia, 7th Ed. 2009.
McGill, Reardon. Tracheal Intubation. Roberts, Clinical Procedures in Emergency Medicine, 5th Ed. 2009.
ASYMPTOMATIC HYPERTENSION TREATMENT GUIDELINES
The only formal recommendations that we have been given are the following, which are all Level B recommendations:
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Those with BP >140/90 should have followup for their hypertension
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Initiation of treatment for asymptomatic hypertension in the ED for those with adequate follow-up is unncessary
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Rapidly decreasing BP in those that are asymptomatic is unncessary and could be harmful
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When you do treat, management should attempt to gradually lower the BP and should not be expected to be normalized during the initial ED visit
Studies have shown adverse outcomes in the short-term after discharge of those with diastolics over 115 mm Hg, yet there are several case studies of patients with acute complications in the ED from rapid lowering of the BP (MI, CVA, death).
Interestingly, one study of 143 patients with acute BP elevation showed that a urine dip that was negative for proteinuria or hematuria was sufficient to ensure no acute renal failure (100% sensitivity).
References:
ACEP's Complete Clinical Policy on Asymptomatic Hypertension
Frein ED, Arias LA, Armstrong ML, et al. Veterans Administration Cooperative Study Group. Effects of treatment on morbidity in hypertension. Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg.Veterans Administration Cooperative Study Group on Antihypertensive Agents. JAMA. 1967;202:1028-1034.
Karras DJ, Heilpern KL, Riley LJ, et al. Urine dipstick as a screening test for serum creatinine elevation in emergency department patients with severe hypertension. Acad Emerg Med. 2002;9:27-34.
