Clinical Governance Day 27th January 2016

CGD 27 Jan

The next Sydney HEMS Clinical Governance Day is scheduled for next Wednesday, January 27th at Bankstown.

This CGD has been jam-packed by Soo Parkinson !! We have our regular segments of Airway Audit and Morbidity & Mortality plus some “extreme presentations”  by Rob Conway & Soo Parkinson who will discuss their unique experiences with polar expedition & hyperbaric medicine


The CGD will be bought to a close with a discussion regarding the introduction of our Emergency Action Checklists, so feel to bring your suggestions on the day.

All NSW Health staff are welcome, sign-in required. See here for directions.


Finally, they say that all good things come to an end. This CGD is the last for our current group of registrars who leave us for greener pastures (at lower altitudes). It marks the end of a brilliant & exciting year for some, whilst signalling the time for the induction & training of our new colleagues.

This also draws to an end my time as CGD organiser. Thank you to everyone who has helped me put these sessions together over the past 6 months & a huge thanks to those of you who attended and participated with great enthusiasm during this time. My trusty colleagues David McQuade and Preston Fedor will take the reins from here & I have no doubt they’ll do a spectacular job.

Looking forward to seeing you there on Wednesday.

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Airway microskills references

Here the references for articles quoted in the Airway Microskills Clinical Governance Day


Use of Storz C-Mac®
Khan RM, Haris A, Sharma P, Kaul N. Oxygenating patients during difficult videolaryngoscopy. Anaesthesia. 2015 Sep 15;70(10):1214–4

Masters J, Rope T. Suction tube-facilitated videolaryngoscopic intubation. Anaesthesia. 2015 Aug;70(8):1003


Awake flexible intubation
Durga VK, Millns JP, Smith JE. Manoeuvres used to clear the airway during fibreoptic intubation. Br J Anaesth. 2001 Aug;87(2):207–11


Clemency BM, Roginski M, Lindstrom HA, Billittier AJ. Paramedic Intubation: Patient Position Might Matter. Prehosp Emerg Care. 2014 Apr 3;18(2):239–43

Lee HC, Yun MJ, Hwang JW, Na HS, Kim DH, Park JY. Higher operating tables provide better laryngeal views for tracheal intubation. Br J Anaesth. 2014 Mar 18;112(4):749–55


Kim HC, Yoo DH, Kim HJ, Jeon YT, Hwang JW, Park HP. A prospective randomised comparison of two insertion methods for i-gel ™placement in anaesthetised paralysed patients: standard vs rotational technique. Anaesthesia. 2014 Apr 28;69(7):729–34


Unassisted Bougie
Eipe N. Preloading bougies. Anaesthesia. 2014 May;69(5):515–6


The “Anterior” Larynx (isn’t yours?!)
Bougie reflection off incisors

Biro P, Ruetzler K. The reflective intubation manoeuvre increases success rate in moderately difficult direct laryngoscopy. Eur J Anaesthesiol. 2015 Jun;32(6):406–10

Sivapurapu V. Scissor-like manoeuvre of tracheal tube. Br J Anaesth. 2014 Apr;112(4):769

Sharma R. Traction over inflation-tube of endotracheal tube to facilitate emergency intubation in a patient with anteriorly placed larynx. Resuscitation. 2010 Jan;81(1):134–5


Choosing a big enough tube
Farrow S, Farrow C, Soni N. Size matters: choosing the right tracheal tube. Anaesthesia. 2012 Aug;67(8):815–9

Isitt CE, Porter JRS, Vizcaychipi MP. Initial tracheal tube size for patients with burns. Anaesthesia. 2014 Apr;69(4):392


Paediatric Intubation
Gamble JJ, McKay WP, Wang AF, Yip KA, O’Brien JM, Plewes CE. Three-finger tracheal palpation to guide endotracheal tube depth in children. Cote C, editor. Pediatric Anesthesia. 2014 Jun 23;24(10):1050–5


Tying the tube
Williams DJ. Knots to secure airway devices. Anaesthesia. 2013 Nov;68(11):1204–5

Lovett PB, Flaxman A, Stürmann KM, Bijur P. The insecure airway: a comparison of knots and commercial devices for securing endotracheal tubes. BMC Emerg Med. 2006;6:7

Albertyn R, Warburton J. A knotty problem resolved. Anaesthesia. 2007 Jun;62(6):637


Solving post-intubation issues

Cross Y, Byrne N. Handy salbutamol dispensing device. Anaesthesia. 2009 Feb;64(2):230

Featherstone P, Abdelaal A, Duane D. Airway emergency during anaesthesia using a metered-dose inhaler. Anaesthesia. 2011 Jan;66(1):58

McCormick T. Clamp to prevent collapse. Anaesthesia. 2010 Aug;65(8):861–2

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Clinical Governance Day 13th January 2016

CGD 13 Jan

Welcome back to the Sydney HEMS Clinical Governance Days for 2016…

This CGD is very much AIRWAY oriented with the inclusion of the November Airway Audit & a round-robin “Airway Microskills” session. This session will focus on bougie & ETT placement tips & tricks, a meet and greet with the Storz CMAC videolaryngoscope as well as a refresher of our Advanced Airway techniques at Sydney HEMS.

References for the Airway Microskills workshops are here

Looking forward to seeing you there.

All NSW Health staff are welcome, sign-in required. See here for directions.

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Clinical Governance Day 16th December 2015

CGD 16 Dec

The Sydney HEMS Clinical Governance Day is returning after a month long hiatus and is scheduled for next Wednesday, December 16th at Bankstown.

For this weeks CGD we have two cracking case dissections to discuss as well as the October Morbidity and Mortality. The afternoon session will centre around an ‘airway round robin’ complete with simulation, blind-intubation team races and challenging airway case discussions.

If you have been involved in a recent interesting or difficult airway case; feel free to bring this on the day…

All NSW Health staff are welcome, sign-in required. See here for directions.

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Clinical Governance Day 18th November 2015

CGD 18 Nov

The next Sydney HEMS Clinical Governance Day is coming up next Wednesday, November 18th at Bankstown.

This CGD will include our September M&M as well as review some recent challenging winch missions. A subtle theme of bleeding filters through this session with a look at coagulopathy in trauma, bleeding in non-compressible sites and a review of the recent literature on Idarucizumab (a potential agent for the reversal of dabigatran).

NSW Health staff welcome, sign-in required. See here for directions.

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New Traumatic Cardiac Arrest Guideline

TCAsmOur Standard Operating Procedure for the management of traumatic cardiac arrest prioritises the rapid management of reversible causes (hypoxia, tension pneumothorax, hypovolaemia, and cardiac tamponade). Although it has been in operation for several years, it can still appear unfamiliar to ambulance crews and other rescuers as external chest compressions and intravenous adrenaline (epinephrine) are often omitted so that other proactive clinical interventions can be instituted.

ILCOR (the International Liaison Committee on Resuscitation) has now completed its five-yearly consensus review and the European Resuscitation Council (ERC) and American Heart Association (AHA) have published their updated 2015 guidelines on cardiac arrest management, including traumatic cardiac arrest. The Australian and New Zealand Resuscitation Councils usually publish their guidelines a bit later, which do not tend to differ significantly from the European & American versions.

The ERC guideline for traumatic cardiac arrest management1 is available for download here. It is reassuringly up-to-date and constitutes a bold step away from traditional approaches. For us, the heartening finding is that it is entirely consistent with our operating procedures on traumatic cardiac arrest and haemorrhage control. Here is the algorithm:


Examples from the accompanying text that support our existing operating procedures and approach include:

1. Absence of nihilism:
Traumatic cardiac arrest (TCA) carries a very high mortality, but in those where ROSC can be achieved, neurological outcome in survivors appears to be much better than in other causes of cardiac arrest. The response to TCA is time critical and success depends on a well-established chain of survival, including advanced prehospital and specialised trauma centre care.

2. Lack of priority given to chest compressions:
Immediate resuscitative efforts in TCA focus on simultaneous treatment of reversible causes, which takes priority over chest compressions.

3. Proactivity regarding commencing resuscitation, and discontinuing based on response and sonographic cardiac standstill:
The American College of Surgeons and the National Association of EMS physicians recommend withholding resuscitation in situations where death is inevitable or established and in trauma patients presenting with apnoea, pulselessness and without organised ECG activity. However, neurologically intact survivors initially presenting in this state have been reported. We therefore recommend the following approach: Consider withholding resuscitation in TCA in any of the following conditions:
• no signs of life within the preceeding 15 min;
• massive trauma incompatible with survival (e.g. decapitation, penetrating heart injury, loss of brain tissue).

We suggest termination of resuscitative efforts should be considered if there is:
• no ROSC after reversible causes have been addressed;
• no detectable ultrasonographic cardiac activity.

4. Application of aggressive interventions in the prehospital setting:
all interventions other than definitive (surgical/radiological) haemorrhage control appear prior to ‘transport to hospital’.

5. Haemorrhage control measures:
the use of tourniquets…, topical haemostatic agents.., splints…, blood products…, and tranexamic acid while moving the patient to surgical haemorrhage control
Give TXA in the prehospital setting when possible

6. Open thoracostomy in preference to needle methods or chest tube insertion:
Thirteen percent of all cases of TCA are caused by tension pneumothorax. To decompress the chest in TCA, perform bilateral thoracostomies in the 4th intercostal space, extending to a clamshell thoracotomy if required. In the presence of positive pressure ventilation, thoracostomies are likely to be more effective than needle thoracocentesis and quicker than inserting a chest tube.

7. Resuscitative thoracotomy in penetrating traumatic cardiac arrest:
Cardiac tamponade is the underlying cause of approximately 10% of cardiac arrest in trauma. Where there is TCA and penetrating trauma to the chest or epigastrium, immediate resuscitative thoracotomy (RT) via a clamshell incision can be life saving. The chance of survival is about 4 times higher in cardiac stab wounds than in gunshot wounds.

8. Prehospital ultrasound in the shocked patient:
Ultrasonography should be used in the evaluation of the compromised trauma patient to target life-saving interventions if the cause of shock cannot be established clinically. Haemoperitoneum, haemo- or pneumothorax and cardiac tamponade can be diagnosed reliably in minutes, even in the prehospital phase.

Our Traumatic Cardiac Arrest Operating Procedure was first approved in 2009, and was based on the best available evidence and experience of our HEMS clinicians who have trained in many services within Australia and overseas. The apparent deviation from ‘standard ACLS’ practiced on trauma patients did require some discussion and defence. Our literature review and recommendations published in 20132 remain pertinent and our operating procedure is now consistent with international guidelines, thanks to the evolution of evidence and the consensus process of ILCOR. Of course, it is still an evidence-light zone and some measure of the effectiveness of this approach is much needed. Survival is still very poor from traumatic cardiac arrest and we all need to collaborate on improving practice in a clinical sphere where small gains can mean massive differences to patients and their families.

1. Truhlář A, Deakin CD, Soar J, Khalifa GEA, Alfonzo A, Bierens JJLM, et al. European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation. 2015 Oct;95:148–201. (Full text)
2. Sherren PB, Reid C, Habig K, Burns BJ. Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service. Crit Care. 2013;17(2):308. (Full text)

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Clinical Governance Day 4th November 2015

CGD 04 Nov

The next Sydney HEMS Clinical Governance Day is coming up next Wednesday, November 4th at Bankstown.

We will have our usual features of Airway Audit plus Morbidity and Mortality which always makes for brilliant discussion.  One of our paramedic/physician teams will dissect a challenging prehospital case involving an injured jet-skier and we will discuss the recently published FELLOW trial which lit up social media after challenging the usefulness of apnoeic oxygenation  !!

Here are some interesting takes on the FELLOW trial from around the #FOAM world for your pre-reading;

NSW Health staff welcome, sign-in required. See here for directions.

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