Apnoeic Oxygenation: Essential in Prehospital RSI

This was a talk from the 2014 London Trauma Conference by Cliff Reid


How it works – review by Nicholas Chrimes

When it all started in #FOAMed in Dec 2010 – NODESAT article by Rich Levitan

We tried it and liked it, so introduced into our airway SOP in July 2011 (latest version written May 2012)

The definitive article by Scott Weingart & Rich Levitan in Annals (published online Nov 2011): Preoxygenation and prevention of desaturation during emergency airway management.

Not just in the EM literature – the principle described in 1959 in Anesthesiology: Apneic oxygenation in man

Other studies in anaesthetic literature, showing increased apnoea time in obese & non-obese subjects, including some RCTs – BestBET on apnoeic oxygenation

It’s on the Australaian ED airway registry form and every ED checklist I’ve seen

It’s recommended in the proposed critical care RSI operation procedure and checklist by Sherren

In prehospital care, “standards of practice and monitoring should be similar to those recommended for in-hospital anaesthesia” according to the AAGBI

It’s well tolerated and unlikely to lead to adverse effects

At Sydney HEMS, its use was associated with a decrease in desaturation (very conservatively defined as <93%, and included some already hypoxic patients prior to anaesthesia) from 22.6 to 16.9% – retrospective analysis of prospectively captured registry data accepted for publication in Annals of Emergency Medicine.

Do we need an RCT? – it would be nice but based on a power calculation it would take several years in our service and with observed improvements in our quality procuess we anticipate lower desaturation rates in the control group than historically shown, further increasing the number needed to show a difference, risking an underpowered inconclusive study after years of work. It might therefore be better to do a multicentre ED based study, although a low-cost, low-risk safety intervetion with good RCT data to support it from the anaesthesia literature may not require further evidence to support its use.

View the slides:

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Clinical Governance Day Summary 3 December

Clinical Governance was a day of two halves; a morning of hard hitting clinical governance in the form of the morbidity and mortality review, and the airway audit. The afternoon was a brief look at the management of head injuries followed by an entertaining simulation and skills station.

Morbidity & Mortality

Sarah C presented a packed morbidity and mortality session, full of useful nuggets of information:

  • In trauma, take into account the patients entire clinical state, not just blood pressure when considering the need for blood products
  • Consider medical causes of cardiac arrest following relatively innocuous trauma
  • The most common ECG rhythms in traumatic cardiac arrest are PEA and bradyasystolic rhythms, however VF and VT can occasionally be seen, requiring defibrillation
  • Patients with significant burns can rapidly become hypothermic – keep the patient warm with blankets and environmental heating when possible
  • In full thickness burns limiting neck movement or mouth opening then a primary surgical airway may be considered as the primary means of securing the airway


Airway Audit

Since Anthony Lewis has moved on from Sydney HEMS, Clare H-B has taken on the considerable task of compiling the airway audit. Unfortunately Clare couldn’t attend to present the data so Karel went through data from two months (August and September).

Over 90% of intubations were achieved on first-look, with the remaining cases intubated on the second attempt.

  • If the initial attempt at intubation is unsuccessful, change something prior to having another look (adjust patient/operator position, better suction etc.)
  • Additional rocuronium is held in the interhospital (3x50mg) and primary (2x50mg) packs if the retrieval team are not carrying sufficient in their own drug pouch
  • In cases with significant epistaxis/facial haemorrhage, consider keeping the patient in a lateral position until immediately before intubation, to aid airway drainage

Head Injury Management

Eoin talked us through a few controversies in head injury, as well as highlighting a potential new development in the diagnosis of minor head injury

  • S100b is a protein found mainly in astroglial cells and schwann cells. Levels are elevated following head trauma
  • Testing S100b is still at an early phase but with a reported sensitivity of 99%, it may be a useful rule-out test if applied to appropriate, low-risk patients.
  • However a specificity of 12-28% may lead to increased investigation of false-positive results. With time it could become the D-Dimer of head injuries!

Eoin talked us through the practice in Bergen, Norway where the EMS personnel have markedly reduced their use of cervical collars, replacing them by either:

  • Awake patient – stabilise their own neck
  • Unconscious patient – lateral trauma position
  • Intubated patient – a pillow to stabilise the cervical spine and manual stabilisation during movement/transfers

The Bergen EMS SOP recommends the use of a hard cervical collar in only two situations:

  • Difficult extrication of the unconscious patients where manual inline stabilisation cannot be maintained
  • Stabilisation of the cervical spine while carrying a patient over uneven terrain

An excellent article covering some of the (somewhat limited) evidence behind this move, along with a description of the lateral trauma position can be found on the Scancrit blog

 Neurosurgery for Dummies!

As our European HEMS registrars are discovering, Australia is a pretty big place and there can be lengthy transfer times to definitive care. It may be a rare occurrence but there have been occasions where it has been necessary for a non-specialist to decompress an extradural haematoma in a rural hospital.

The neuroprotection SOP recommends that for patients with an extradural or acute subdural haematoma where the transfer is likely to take more than two hours, the case should be discussed with the receiving neurosurgeon, with one of the options being on-site burr hole exploration.

  • Aim to place the burr hole at the centre of the haematoma
  • Use the CT to find the best site – count the number of slices of the CT from the vertex down to the centre of the haematoma and multiply this by the slice width
  • Try to avoid ‘plunging’ into the brain as the burr hole is completed. This can be better avoided with the use of a modern perforator drill bit with clutch mechanism
  • With a subdural haematoma, incise the dura in a cruciate manner – subdural blood is likely to be more clotted than extradural blood and gentle efforts to remove it (forceps or careful suction) may not be sufficient

There are several excellent articles describing simple burr hole placement for the non-neurosurgeon:

And remember, in the words of Mitchell & Webb, ‘brain surgery – it’s not exactly rocket science!’

Neuro Trauma Simulation

One of the new registrars coped admirably after being thrown in at the deep end with a tricky simulation, written by resident sim maestro Morgan

The team were tasked to a remote rural hospital,  to retrieve a patient who had sustained a skull fracture with underlying extradural haemorrhage following an assault. Unknown to the retrieval team, he had also been stabbed in the back with a developing pneumothorax and was becoming increasingly hypoxic as the scenario progressed.

The team successfully identified the pneumothorax as well as the patient’s deteriorating conscious level and instigated the necessary neuroprotective measures prior to transferring the patient to Sydney for neurosurgical intervention.

But despite their best efforts, a combination of bad weather and the helicopter breaking meant that there was no way they were leaving the hospital without decompressing that expanding extradural haemorrhage…

Temporal Burr Hole Placement


Learning points

  • Don’t forget to look for injuries other than the ones stated in the initial handover – every patient has a front, two sides and a back
  • Once you’ve found one stab wound, look elsewhere for another one
  • A complete primary survey is essential
  • Even after being highlighted earlier, our registrar demonstrated that it is surprisingly easy to ‘plunge’ into the brain when drilling a burr hole with a standard perforator and burr


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London Trauma Conference

References from talks from the 2014 London Trauma Conference

Apnoeic Oxygenation: Essential in Prehospital RSI by Cliff Reid

Quality Training in Prehospital Trauma Care by Cliff Reid – to be completed


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Clinical Governance Day Summary 19 November

AKA ‘The Matt Ward Show’

There was a really great turnout for a jam-packed Clinical Governance Day with a series of great presentations. It was clear that everyone involved in presenting had put a great deal of time and effort into their talks, which was appreciated by the entire audience.

We were fortunate to be joined by Matt Ward, lead paramedic for Emergency Care at the West Midlands Ambulance Service in the UK. He was able to share a wealth of experience, having worked as a paramedic in th e UK for over 15 years.

Pearls from AusTRAUMA 2014

Aidan gave us a whistle-stop tour of some of the many highlights of the Australasian Trauma Society conference, recently held in Sydney. With an all-star international cast including Karim Brohi and John Kortbeek, as well as SydneyHEMS’ own Brian Burns and Oran Rigby it sounded like the audience were treated to a smorgasbord of high quality lectures, covering every aspect of trauma imaginable.


The conference was also an opportunity for the Australian Trauma Registry to publish their inaugural report into trauma care across Australia with 25 of the 27 designated Trauma Centres contributing data between 2010-2012.

Trauma 2015 is happening on 2-4 October in the Gold Coast – for those of you who haven’t blown your entire study leave budget on SMACC Chicago!

Optimising Acute Stroke Care

Matt presented work carried out in the West Midlands looking at the impact of prehospital assessment and hospital pre-alerts on the subsequent acute stroke care pathway.

Paramedics applied the FAST (Face, Arm, Speech, Time) rule, as well as recording the time of onset of the suspected stroke. Results showed that FAST tests were positive in 75% of cases, with the time of onset recorded in 40%. A pre-alert was phoned through to the hospital in 44% of the cases.

After adjusting for confounding factors, the study found that there was an association between a positive FAST, a recorded time of onset or a hospital pre-alert and a timely CT scan.

West Midlands Ambulance Service have recently started piloting the use of AVVV, as an equivalent to FAST but for identification of posterior circulation strokes. Although it is at a very early stage, anecdotally it sounds as though it has aided the service in the identification of a number of stroke patients who may otherwise have been missed.

  • Ataxia
  • Visual field changes
  • Vertigo
  • Vomiting

Mechanical Compression Devices in Cardiac Arrest

Screen Shot 2014-01-07 at 6.57.22 pm

Sydney HEMS team practicing with the LUCAS 2 device

Hot off the press, Matt talked through the recently published PARAMEDIC trial, comparing manual CPR to mechanical CPR in the treatment of adult non-traumatic cardiac arrest. With 4471 patients recruited, it was suitably powered to find a 2.5% difference in 30 day mortality.

In keeping with the previously published LINC trial, there was no evidence of increased survival at 30 days (6% in the LUCAS-2 group and 7% in the manual CPR group).

Subgroup analysis found a marginally worse neurological outcome in patients presenting with an initial shockable rhythm. This should be interpreted with caution however; one hypothesis was that there was a pause in manual chest compressions as well as a delay delivering the first shock due to the time taken for placement of the LUCAS device

For more detail, head over to St Emlyns where theres is an excellent review of the article

Adrenaline: Friend or Foe?

Matt then went on to talk about the upcoming PARAMEDIC2 trial, which is an exciting randomised controlled trial comparing adrenaline to placebo in the management of out of hospital cardiac arrest. The study started in March 2014, running across five different ambulance services in both England and Wales.

Population – 8000 patients following out of hospital cardiac arrest. Children and pregnant women are excluded but interestingly trauma patients will be included in this trial.

Intervention – standard ACLS treatment, receiving either adrenaline or placebo

Control – standard ACLS treatment with adrenaline as per UK resuscitation guidelines

Outcome – the primary outcome is survival at 30 days.

It is thought that data collection will be ongoing for the next three years, with a plan to publish the results by 2019.

Command and Control

Following lunch, Cameron Edgar updated the doctors and paramedics on the latest developments in the command and control policy, in particular its relevance to pre-hospital jobs where winch insertion or extraction are likely to be required.

The bottom line seems to be that:

  • The air crew do not require permission to winch into a patient’s location. The pilot and aircrew will perform a winch risk assessment prior to insertion
  • In order for a patient to be extricated by winch, a Zone Manager first needs to determine the most appropriate method of patient extrication
  • The decision will be based on advice from ground and air crews
  • Winch extrication should not be undertaken when other safe, clinically and operationally appropriate options exist
  • A pause point has been introduced prior to winching the stable, non-time critically injured patient to ensure that all available information has been thoroughly assessed before committing to a decision

Next Clinical Governance Day is on Wednesday 3 December

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Wilderness Major Incident response: as challenging as it gets?

Interesting videocast involving our very own Yash discussing the improvised medical response at Everest Base Camp to the devastating avalanche earlier this year.

If you’re interested in wilderness medicine and want to see more stuff like this, check out their website: http://theadventuremedic.com/.

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Escharotomy Man 2.0

By Sydney HEMS registrar Jamie Andrews

For Clinical Governance Day on 5th of November 2014, (Burns theme for Guy Fawkes Night care of the UK contingent!) I was tasked with re-producing Dr Ed Burns’ escharotomy model. Ed had previously hoped that the model could be made to bleed when cut to the appropriate depth to more accurately simulate the procedure itself.

Using the instructions on the Sydney HEMS website  I obtained the necessary equipment from K-mart and Bunnings (No financial incentives provided).

Keen to rise to the bleeding challenge, I used fake-blood purchased from a costume shop (in plentiful supply post-halloween) to fashion blood packets using sandwich bags.






The blood packets were then strapped to the red (deep-tissue) layer that had been attached to the resus mannequin.


I taped the bags over the anticipated incision areas on the model and then completed the model again as per Ed’s instructions.


The final finish was applied with spray paint and charcoal.


The finished Escharotomy Man 2.0


During our first Burns simulation scenario (brilliantly authored and run by Dr Morgan Sherwood) the model was put through its paces. The bleeding was quite variable depending upon where the cuts were made, but quite successful in the end.




After completion of the scenario other staff had the opportunity to participate and perform their own escharotomies on unused parts of the mannequin.

I aim to refine the bleeding packets for the next time we run a burns scenario by using a larger number of smaller bags, and placing them widely in areas that may be incised.


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Education Inservice Tuesday 18 November 2014

A session with consultants from Sydney HEMS will be held on Tuesday 18 November as part of the Education Inservice week in Rozelle, NSW. This will be an opportunity to discuss current approaches to trauma and critical care.

Please bring details of any cases you would like to discuss that involve:

  • Resuscitation
  • Major adult or paediatric illness
  • Trauma
  • Interaction with medical teams / retrieval services


1300 Introduction – Dr Cliff Reid

1310 Prehospital & retrieval medicine & the role of HEMS – Dr Karel Habig

1340 Trauma update: the bleeding patient – Dr Geoff Healy

1410 Break

1430 Rural trauma case discussions – Dr Brian Burns

1530 Education & clinical Q&A – Dr Cliff Reid

1600 Finish

Dr Cliff Reid is an emergency physician and the Supervisor of Training for Greater Sydney Area HEMS, and a Clinical Associate Professor with the University of Sydney

Dr Karel Habig is an emergency physician and the Medical Manager for Greater Sydney Area HEMS

Dr Brian Burns is an emergency physician and the Head of Research for Greater Sydney Area HEMS, and a Clinical Associate Professor with the University of Sydney

Dr Geoff Healy is a consultant anaesthetist and the Medical Equipment Lead for Greater Sydney Area HEMS

All consultants are employed by NSW Ambulance as staff specialists in prehospital & retrieval medicine

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