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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Clinical Governance Day June 12

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Education Day Wednesday May 29th

Edu Day 29th May 2019

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AiR – Learning from the Airway Registry (May 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: Apnoeic Oxygenation

Using Nasal Cannulae During Apnoeic Oxygenation

In our standard operating procedure for prehospital emergency anaesthesia we use nasal cannulae with oxygen flow at 10L/min during laryngoscopy as a form of apnoeic oxygenation. As the following stillshots from CMAC videos show, the placing of nasal cannulae can be more challenging with nasopharyngeal airways in place.

One team’s CMAC video showed a possible solution to this – placing one of the nasal cannula prongs within the lumen of one NPA, and the second alongside the nasopharyngeal airway (between NPA and nasal septum) – see sim photo below.

Discussion at clinical governance day included using tape to secure NC in place (but this is an extra step and may worsen facemask seal for preoxygenation and bagging), and concerns were voiced about the functionality of the NC in this position. Certainly there is a need to be vigilant about NC position with NPA use.

Video Focus on: Near Drowning

Near drowning (and drowning) is a common tasking for our service, particularly during the summer months. Both drowning and near drowning are associated with large volumes of fluid and oedema which can overwhelm laryngoscopy despite suction. This example is less extreme but shows the ‘froth’ we can expect in near drowning laryngoscopy.

Further CMAC Videos

ETT Tip Catching on Vocal Cords

This motor vehicle accident patient was being intubated during a prehospital mission. On railroading the ETT over the bougie, the ETT catches on the right vocal cord. This is despite using Parker Flex-Tip/GlideRite tubes to reduce the gap between bougie and ETT during railroading. Should this occur, the ETT should be withdrawn slightly to detach the tip, then twisted (or turned counterclockwise 90 degrees) to bring the tip into the centre and avoid the glottic structures.

Housefire Slough

An adult patient from a housefire had some burns to their face, neck and hands. Despite having no stridor, the team did note a hoarse voice and a cough so made a decision to perform a prehospital RSI and intubation. At laryngoscopy these sloughy mucous membranes were found.

Unhelpful ELM

The VL capability of CMAC allows us to apply ELM with real time feedback as to improving laryngoscopy view. This video shows ELM pressing over the epiglottis and making the glottis view worse.

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

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Clinical Governance Day – Wednesday 15th May

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