AiR – Learning from the Airway Registry (August 2019)

Airway Registry learning points reflect the challenges described and wisdom shared by Sydney HEMS personnel and guests at the Clinical Governance Airway Registry presentations. Cases are discussed non-contemporaneously, anonymised and amalgamated over a time period to draw together unifying take-home messages. Details of specific cases are removed and/or changed, such that any similarity to real-life patients or scenarios is coincidental.

Sydney HEMS is proud of its commitment to excellence in airway management. In 2018, we achieved:

387 Intubations

352 RSIs

96.5% First look laryngoscopy success at RSI.

These learning points form part of our commitments to governance, excellence and education. All CMAC videos are shared under a Creative Commons Licence: Attribution 2.0 Generic. Please familiarise yourself with the terms of the licence before reusing our videos.

To view these videos, you will need this password: AiRblogVideos

Focus on: CMAC Use in Cardiac Arrest

Recently, the CMAC was used to intubate a patient in cardiac arrest during chest compressions. The operator found a difficult direct view and in trying to switch to VL, they found that the camera was covered with secretions.

The camera was cleaned, the airway was suctioned and intubation proceeded with video screen used. This is only our second experience of the CMAC camera being covered with fluids – the first also being during chest compressions with a bloody airway. It raises the question – is it preferable to suction the airway prior to laryngoscopy when chest compressions are ongoing (given that chest compressions will tend to force fluids out of the airway towards the videolaryngoscopy camera)? It is also a reminder of the need to retain good direct laryngoscopy skills. 

Video Focus on: Tube “Displacement”

ETT Found in Pharynx

The first video shows an ETT placed during cardiac arrest. The endotracheal position was not certain so the team decided to relook and found it to be in the pharynx; the patient was subsequently reintubated.

On review, the video shows the bougie, which is seen to pass cords a fair distance. After this, the view is lost – the tube is railroaded over the bougie but probably never enters trachea, rather just being pushed up to larynx. This is probably an extreme case of laryngeal holdup on railroading the tube.

“Short” ETT

In this and the subsequent video, the team seemed to have a sited an ETT which was sitting short.

Review of the first video shows a good view at laryngoscopy, but railroading of the tube becomes a blind action and the length of ETT at lips from initial placement is unknown.

The team noticed an immediate cuff leak and repeated laryngoscopy (second video) to assess cuff placement, finding the cuff herniating through the cords.

Further CMAC Videos:

ETT Catching at the Glottic Inlet

This is another example of the ETT catching at the glottic inlet despite the Parker tip – always think of the need to retract ETT from obstruction & twist 90 degrees anticlockwise to be able to advance the tube.

Glottic Hold Up And Blade Slip

Another example of ETT catch at the glottic inlet needing the ETT to be withdrawn and rotated anticlockwise. A personal recommendation from Clare Hayes-Bradley (who oversees the Airway Registry) is to rotate anticlockwise for all railroading over bougie. It’s especially interesting to see how the small movement of the blade tip along the tongue base affects the good glottic view.

You can see all the AiR videos here on our Vimeo page or here on the blog.

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Education Day Wednesday July 24th (Update)

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Chief Inspector Phillip Brooks of NSW Police Crash Investigation Unit (CIU) opened the day with insights into the state’s road mortality. With 185 000km of public roads and over 7 million people, Ch Insp Brooks believes that mobile phones will present the newest obstacle to road safety. Illicit drug use has been a target of the NSW police with rural areas showing high rates of drivers testing positive to substances like methamphetamines in particular. Ch Insp Brooks suggested that medical personnel may aid the CIU with information such as: survivability, nature of injuries and aerial photographs.

Two workshops were conducted thereafter. The first was a triage and tasking exercise by Dr. Clare Richmond, who works in the state retrieval office. The fictional tasking day commenced at 7am and quickly demonstrated the many constraints and logistics in tasking the assets of the state – a feature often overlooked when performing our retrieval missions. Dr. Jill Lee covered the next workshop on difficult ventilation, using the Oxylog 3000 plus. The benefits of volume control vs pressure control, waveform use, ramping and non-invasive ventilation strategies were discussed.

A quick trip to Virtual Reality sim suite placing doctors in the position of aircrewmen/paramedics/pilots, rapidly highlighted how complex and important radio communication and winching strategies were.

The day ended with case study of Sydney HEMS’ most recent clamshell thoracotomy. Interesting points which were discussed included:

  • mitigating bystander trauma
  • intubation vs LMA in this traumatic cardiac arrest
  • delegation of duties such as aortic compression
  • team leadership in the operating theatre, where there may not be a clear team leader, such as in the emergency department
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AiR – Learning from the Airway Registry (July 2019)

Airway Registry learning points reflect the challenges described and wisdom shared by Sydney HEMS personnel and guests at the Clinical Governance Airway Registry presentations. Cases are discussed non-contemporaneously, anonymised and amalgamated over a time period to draw together unifying take-home messages. Details of specific cases are removed and/or changed, such that any similarity to real-life patients or scenarios is coincidental.

Sydney HEMS is proud of its commitment to excellence in airway management. In 2018, we achieved:

387 Intubations

352 RSIs

96.5% First look laryngoscopy success at RSI.

These learning points form part of our commitments to governance, excellence and education. All CMAC videos are shared under a Creative Commons Licence: Attribution 2.0 Generic. Please familiarise yourself with the terms of the licence before reusing our videos.

To view these videos, you will need this password: AiRblogVideos

Focus on: Front of Neck Access & Surgical Airways

Will a 6.0 COETT Create a Seal in an Adult Male Trachea?

We carry a 6.0 ETT in our surgical airway kit to fit through the adult crico-thyroid membrane. Although we have never experienced a leak from our 6.0ETT surgical airways, it has been questioned elsewhere how the outer diameter of the balloon compares with tracheal diameter. For our equipment the following pictures were made:-

Centre of gravity for patient & stretcher stability

It is our practice to reposition the patient with their neck extended for a surgical airway and to achieve this position by placing the head extended over the end of the stretcher. This temporary position may render a change in the centre of gravity of the patient on the stretcher for further moves or interventions and therefore extra vigilance is warranted.

Paediatric Surgical Airways

It is worth remembering that for smaller children (usually <8 years), our standard scalpel-finger-bougie approach to surgical airways may not be appropriate, not only because our fingers are too big but also because we may not be able to site a 6.0 ETT (which is what we carry in our surgical airway pack).

We carry the ENK for oxygenation via front-of-neck in these patients – below is a video made at our Dec 2018 joint HEMS/NETS education day in which one of our registrars (Dr David Gale) explains how the ENK is used.

There is a second ENK video on our YouTube channel, this one from 2017 presented by another registrar – Dr Amy Gospel.

Laryngectomy patients

Patients presenting with a hole in the front of their neck may have a stoma which directly connects trachea to skin. Having had a laryngectomy there is NO route from the nose & mouth to the lungs. All oxygenation & ventilation must occur via the stoma. Management of such airways, including in cardiac arrest, is well described by algorithms and videos by the National Tracheostomy Safety Project at http://www.tracheostomy.org.uk

Hospital Hyperangulated blades

A discussion was had surrounding the use of hospital equipment for intubations in interhospital missions. Some intubation equipment is more familiar to our teams than others. Some equipment, such as the hospital CMAC monitors can appear familiar, but a different blade e.g. plastic disposable rather than metal can make them less familiar than first thought. Hyperangulated rigid introducers are a learned skill.

Video Focus on: Paediatric Intubation with CMAC

This month we are able to share two more good uses of CMAC Mac 4 blade in paediatric intubations. For more information on how/why this works, see this AiR blog post.

Intubation in a 4-year-old:

Intubation in a 23-month-old:

 

Further CMAC Videos:

Regurgitation During Laryngoscopy

This footage captures regurgitation and soiling of the larynx at laryngoscopy.

Suction Catheter in Pharynx With Bougie

This video shows a Yankaeur sucker being positioned to the left of the Mac blade throughout laryngoscopy for continuous suction. It is worth remembering that our Yankaeur suction catheters currently have side holes that need occluding for suctioning to work. Occluding the hole during laryngoscopy is challenging. Two options would be to use a friend, or to remove the Yankaeur and place the tubing itself into the left side of the pharynx.

You can see all the AiR videos here on our Vimeo page or here on the blog.

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Education Day Wednesday July 24th

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Clinical Governance Day July 10

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Education Day Wednesday June 26th

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AiR – Learning from the Airway Registry (June 2019)

Airway Registry learning points reflect the challenges described and wisdom shared by Sydney HEMS personnel and guests at the Clinical Governance Airway Registry presentations. Cases are discussed non-contemporaneously, anonymised and amalgamated over a time period to draw together unifying take-home messages. Details of specific cases are removed and/or changed, such that any similarity to real-life patients or scenarios is coincidental.

Sydney HEMS is proud of its commitment to excellence in airway management. In 2018, we achieved:

387 Intubations

352 RSIs

96.5% First look laryngoscopy success at RSI.

These learning points form part of our commitments to governance, excellence and education. All CMAC videos are shared under a Creative Commons Licence: Attribution 2.0 Generic. Please familiarise yourself with the terms of the licence before reusing our videos.

To view these videos, you will need this password: AiRblogVideos

Focus on: Cold Intubation

For patients in cardiac arrest, we generally omit our longer pre-intubation checklist as well as RSI drugs – but we do not intubate without anychecklist. Instead, we use a “cold intubation” checklist – a shorter version, printed on the reverse of our standard RSI checklist card and designed to help remind teams of the common mishaps encountered in cold intubation attempts. Ideally, attempts to oxygenate an arrested patient should continue whilst position is optimised and equipment e.g. EtCO2 are sought.

Other Discussions

New AMBU SPUR II – “single patient use resuscitator”

These resuscitation bags are now carried by NSWAmbulance – the following PDF is a summary of the company literature. Of note, with spontaneous ventilation, there is no air entrainment via the exhalation valve giving a high FiO2. There are two ports that could be a source of leaks and need their caps in place (M port & Medication port). The PEEP valve fits on the exhalation valve as previously.

Cuff leak & ETCO2

After intubation the presence of EtCO2 waveform may depend on the inflation of the cuff. If EtCO2 does not appear, it is worth having a quick check of the cuff pilot balloon before concluding that the ETT is misplaced. Cuff deflation, obstructed ETT/trachea and extreme bronchospasm have all been seen by our team as causes of an absent ETCO2 waveform.

Video Focus on: Bougie Benefits – and Bothers

In our service, we routinely carry a white (straight-tipped) and a blue bougie. We allow our teams to decide which of the two is used (although our standard practice is to use a bougie for every intubation) and both have benefits and downfalls, as explained below.

Ambient Temperature: Bendy or Brittle?

The Sydney sunshine can make our blue bougies become warm and floppy this time of year. Conversely, we regularly hear from the Orange base, that winter make the white bougies unbendable. This may influence choice of bougie during RSI setup.

Bougie Tips

In this laryngoscopy video, the cords appear in the upper portion of the video screen (and the epiglottis is lifted directly). Our straight tipped white bougie cannot be redirected to the upper screen. Our blue bougie with the Coude tip is more suited to this view.

Right for Rings

Above is some good footage of a bougie catching on anterior tracheal rings along with successful rightward rotation to disconnect from rings. “Right for Rings”, as people say.

Twenty Seconds to Pass the ETT

And finally, one for the bougie-sceptics: in this CMAC video, one of our paramedics shows that even using our standard ETT-over-bougie technique, the ETT cuff can be past the cords within 20 seconds of starting laryngoscopy.

Further CMAC Videos:

ETT Catching the Cords & ETT Catching the Epiglottis

Another two examples of how any tube can potentially catch when railroading over a bougie and the need to ‘detect catch and stop, withdraw slightly and turn 90 degrees anticlockwise’ still exists. Some practitioners will automatically turn 90 anticlockwise when feeding an ETT over a bougie to avoid this catch (as it closes the gap between ETT & bougie).

ELM Closing the Cords

External laryngeal manipulation (ELM) can act to ‘pinch cords together’ and make passing the bougie harder – we would advise an assistant to both look at the video screen and asking the laryngoscopist for feedback while applying ELM.

Really Long Epiglottic Tunnel

This normal variation of epiglottis can be challenging. The long ‘tunnel’ created may appear darkened in a lit room.

You can see all the AiR videos here on our Vimeo page or here on the blog.

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