AiR – Learning from the Airway Registry (July 2018)

Intubations this month:         30

Airway Registry learning points reflect the challenges described and wisdom shared by Sydney HEMS personnel and guests at the Clinical Governance Airway Registry presentations for July 2018. 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.

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: Epiglottoscopy

These stills are taken from CMAC footage of a prehospital patient – see how lifting the epiglottis directly has improved the view of the tracheal opening.

Mac blade in vallecula

Mac blade as Miller – elevating epiglottis for improved view

You might remember this technique from our earlier video “Mac as a Miller”, which demonstrates how scooping the epiglottis with the Mac blade – as you would intentionally with the straight Miller blade – does not preclude intubation and may improve your chances in event of a grade II-III view.

Other discussions

Dry mucosa

As in our video focus section for May/June‘s clinical governance day, we were reminded that lubricating the laryngoscope blade can be particularly helpful for interhospital missions where patients often have very dry tongue mucosa from non-invasive ventilation or general dehydration. Intensivists present at CGD admitted they routinely lubricate a laryngoscope blade. We don’t think this point ever makes it onto an ‘airway assessment’ list but it should; keep it in mind. Here’s that double-learning-point video to remind you.

Bougie control

Trying to get a bougie to pass into the trachea can be a very frustrating experience. Practice can help – to aid us in identify when curving (or other manoeuvres to move the bougie tip anterior) are necessary, and to practice the ‘feel’ of rotation for moving the tip right to left.

Try practising laryngoscopy on a manikin and intentionally touching different parts of the laryngeal structures with your bougie tip to practice that control. Remember to practice with gloves & safety glasses on!

Video Focus on: the effects of blood and secretions

We discussed two videos. In the first, there are significant facial injuries. A gloved hand just visible providing good mouth opening – note how despite facial injuries, the larynx is quite identifiable and not flooded with blood.

In the second video, there are pooled airway secretions. You can see clear secretions filling the NPA visible in pharynx.

Other discussions

Bougie reflections

As mentioned in the May/June post, we carry a blue coudé tip bougie and a white straight bougie.

During this intubation, it was noted by the team member watching the screen (VL) that the approach of the white bougie caused a significant change in the screen image brightness, which dulled the view of the larynx in the background by comparison.

In the same patient the blue bougie had much less effect and the view of the larynx was maintained, allowing intubation.

Presumably this is the CMAC camera auto-adjusting for brightness in the visualised field on the video screen, so not an issue when using the CMAC for DL – but it is worth considering as a sudden reduction in illumination at the point of intubation could be most unhelpful when using the CMAC VL! We intend to discuss this with Storz, the manufacturer of the CMAC.

ELM obstructing the airway

In this video, a team member is providing external laryngeal manipulation in an attempt to improve the view at laryngoscopy which is released after bougie insertion. Note how on release of ELM, the cords appear to open wider. Care should be taken with any ELM (or cricoid, when used) to avoid closing the cords and making laryngoscopy more challenging.

 

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

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Joint HEMS/NETS Education Day 12th December

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AiR – Learning from the Airway Registry (May & June 2018)

Intubations this May:         31

Intubations this June:         28

 

Airway Registry learning points reflect the challenges described and wisdom shared by Sydney HEMS personnel and guests at the Clinical Governance Airway Registry presentations for May & June 2018. 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.

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: Getting Stuck

In May we reviewed some videos to talk about how our intubation equipment – bougie or ETT – can get stuck, and what we can do about it.

Stuck bougie

This patient has been exposed to fire/flames with a presumed inhalational injury – note sooty secretions and swollen arytenoids/posterior glottis structures.

We can see the blue (coudé-tip) bougie passes the cords but following that there is resistance to further advancement – seen as the glottis being moved by attempts to advance the bougie. The team remove the blue bougie and use the white bougie which is less curved.

Problem:

The coudé tip is likely impacting on the tracheal cartilages of the anterior tracheal wall.

This is more common with hyperangulated video laryngoscopy but occurs here with a Mac shaped blade.

Solutions:

  • Rotate the bougie (twist it) to disimpact the coudé tip from the anterior wall
  • Reshape the bougie to lessen the tip
  • Exchanged the coudé-tip bougie for a straighter bougie (as was done here – we carry a non-coudé-tip white bougie in addition to the blue bougie).

Stuck tube

We use Parker Flex-Tip‘GlideRiteTM’ tracheal tubes to reduce the potential for the leading edge of the endotracheal tube to ‘catch’ on glottic structures while railroading over a bougie, as is classically described for the arytenoid cartilages.

This video shows the gap that can exist between bougie and ETT tip that could lead to ‘catch’ (risking failure to advance and laryngeal trauma).

Other discussions

Identifying airway anatomy

This CMAC video is a great example of how the oesophageal inlet can look a lot like a trachea – re-emphasising the need to see arytenoids cartilages in order to positively identify the trachea prior to passing a bougie or ETT.

Soiled airway in cardiac arrest

A medical cardiac arrest can present healthcare workers with an airway flooded with gastric contents. Such soiling can be particulate and thick which can block common Yankauer suckers.

A work-around can be to remove the blocked Yankauer sucker and simply use the end of the suction hosing itself. The hosing is a much larger diameter and is often very successful at clearing the pharynx when used directly.

Be aware that small portable units may have a volume capacity that can be easily exceeded by large volumes of soiling; vehicle-based suction units have a larger capacity.

At Sydney HEMS we carry a longer suction tubing set so we can connect to the in-ambulance vehicle suction while intubating at the back of the ambulance.

Video Focus on: two learning points from one video

This CMAC video from June has two separate learning points! The learning points below both refer to this CMAC video:

1. Dry mouth

Patients who have spent some time prior to intubation breathing non-humidified wall O2 (for example, via a non-rebreathe mask) can have very dry mucosa in their oral cavity on airway assessment. An assessment of the dryness of oral mucosa is not classically part of a pre-intubation airway assessment but it can cause issues, so it is important to notice. Pre-lubricating the blade can make the laryngoscopy much easier; lubricating gel can be Lseen on the blade in this video.

You might remember similar “dry mouth” issues from this earlier CMAC video:

2. DL to VL

Initial attempts to intubate this patient were made using a direct laryngoscopy technique. During DL, the operator struggled to identify the inter-arytenoid notch landmark. The intubator proceeded to use the video screen (VL technique) which gave them a clearer view of the glottis and allowed placement of the bougie.

It became evident that a sputum plug was obscuring the inter-arytenoid notch landmark that the operator had been trying to visualise. Having the back-up of video laryngoscopy on this Mac 4 blade intubation was very useful.

 

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

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Clinical Governance Day – Wed 28th November

CGD 28:11

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Burns education day wrap up

(Courtesy of Dr Sandeep Gadgil)

Burns Education Day – Summary

On 14thNovember we had the pleasure of hosting members of the Concord Hospital Burns team for our Burns Education Day.

NSW Ambulance Burns Audit

Dr Clare Richmond kicked us off with data on burns patients from the last 3 years, prepared by Dr Efrem Colonetti. The key findings for this period (2015 to 2018) were:

  • 241 burns patients, 141 were intubated, 46 by the retrieval team
  • 8 escharotomies were performed by the retrieval team
  • 58% of cases were flame burns, 19% were flash / explosion
  • 67% of burns case sheets had a documented TBSA
  • 73% of those with documented TBSA were consistent with hospital findings
  • 95% of the burns patients did not have any significant concomitant trauma

These findings were compared with the Audit published by Dr Brian Burns last year (https://www.researchgate.net/publication/317316935_A_review_of_the_burns_caseload_of_a_physician-based_helicopter_emergency_medical_service).

The main take home points highlighted by Clare were to ensure documentation of TBSA and airway findings, assess for concomitant trauma and consider transfer to Concord if nil significant trauma. We were reminded of the feature on the ITIM app to assist in TBSA burns calculations (https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/ed-applications/trauma-apps)

Concord burns team

We had a fantastic set of presentations from the burns team covering burns assessment, pathophysiology, first aid, fluid resuscitation, airway considerations and surgical options. Throughout the day, the team emphasised that they want to be consulted early in relation to burns patients. For those interested in learning more about burns management they recommended the EMSB course (https://anzba.org.au/education/emsb/).

Dr Justine O’Hara (Plastics / Burns Surgeon) discussed the assessment and initial management of burns and provided some key messages:

  • Accurate assessment of burns area and depth can be difficult
  • Importance of good first aid (running or sprayed / sponged tap water for 20 minutes)
  • No ice or iced water, no antibiotics
  • Appropriately dress burns, do not debride (covering with cling wrap is ok)
  • Know the NSW burns transfer guidelines
  • If large burns (>15%) – IV fluids, analgesia, IDC & retrieve to burns unit

She also described a range of current and emerging surgical options (traditional debridement, fascial excision, hydrosurgical debridement) and wound closure options (allografts, xenografts and cultured epithelial autografts).

Dr Mark Kol (Intensivist) gave an overview of fluid management and the pathophysiology of shock in a burns patient. Points he highlighted were that fluid resuscitation in burns improves outcomes, the modified parkland formula (3ml/kg/%TBSA with half in the 1st8 hours) was an appropriate starting point with lactated ringers being the preferred fluid. Ongoing fluids are titrated to clinical endpoints, with urine output being commonly used.

He also gave a summary of the ventilation strategies used to manage the ARDS-like picture seen in burns patients.

Dr Kar-Soon Lim (Anaesthetist) spoke about airway considerations in burns patients. His take home points were:

  • In large TBSA burns, the airway will swell even without airway burns (consider early intubation)
  • An endotracheal tube is the definitive airway – have a low threshold for front of neck access if failed intubation (LMA likely to fail)
  • Use normal sized tubes (larger ETTs are not necessary and may cause future vocal cord morbidity)
  • Consider the need for chest escharotomy with trunk burns that are difficult to ventilate

Dr Andrea Issler-Fisher (Plastics / Burns Surgeon) gave an excellent description of burns wounds and the assessment of burn depth in relation to skin layers. She also described the indications and technique for performing an escharotomy (if in doubt, do it!) and contrasted this with performing fasciotomy (preferably in theatre by a surgeon).

The afternoon was spent with small group interactive workshops led by the Burns team consolidating three main topics covered in the morning lectures – airway considerations, fluid management and escharotomy. They provided valuable insights and tips from the Burns team and nicely rounded out a day addressing burns care in both the pre-hospital and hospital settings.

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Education Day – 14th November 2018

Education Day 14:11

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Clinical Governance Day Wrap Up 3rd Oct

The October CGD involved discussion of several outstanding examples of prehospital trauma care provided by teams within our service. These were explored by Dr Karel Habig in his ‘Learning from Excellence’ presentation and Dr Chris Partyka, Chris Wilkinson (critical care paramedic) and Dr Simon Keane in a review of major trauma cases requiring prehospital activation of the code crimson pathway. We use this pathway to provide rapid, streamlined transfer to definitive care, for exsanguinating haemorrhage that is refractory to standard resuscitation (more info here: https://www.aci.health.nsw.gov.au/networks/itim/clinical/trauma-guidelines/Guidelines/trauma-code-crimson-pathway).

Part of the code crimson guideline is a reminder of the importance of optimal prehospital trauma care and there were several useful discussion points, throughout the day, about the prehospital management of these patients.

  1. Point of care ultrasound (POCUS)

The group considered the benefit of utilising US on scene for initial assessment and stabilisation vs. concerns that it may increase scene time in a patient who requires transfer to definitive care. Our US audit team reported that GSA HEMS data suggests that the use of POCUS adds between 0-6 minutes to scene time. They suggested that in most cases it is appropriate to do a quick lung US to check for pneumothorax on scene, followed by the rest of the eFAST scan en-route to hospital.  The use of eFAST is highlighted in the Code Crimson guideline, and in the prehospital setting can allow early identification of likely bleeding source to facilitate rapid transfer to the correct intrahospital location and involvement of the correct teams.

Another use of POCUS discussed was the identification of injuries that may be amenable to prehospital intervention to allow early consideration of potential issues that may arise during transport. Awareness of a problem allows the team to team to pre-brief, prepare equipment and mark the patient, if required.  They may benefit from the opportunity to talk through and/or mentally rehearse the procedure and consider access and logistics issues early.

  1. Pre-RSI stabilisation

Another discussion was around the importance of optimising patients prior to RSI. This can be difficult in the prehospital setting, with limited people to perform interventions and will require careful consideration of the appropriate order of interventions to ensure this.  This may involve some time spent on resuscitation prior to RSI, consideration of procedures or management of agitation with judicious use of sedation to allow pre-oxygenation and usual preparation (i.e. delayed sequence intubation).

  1. Communication and coordination of care

We have multiple protocols that may be required in tandem with the code crimson guideline, such as a prehospital massive transfusion protocol (MTP), which can facilitate the delivery of blood products to the retrieval team en-route to hospital.  These protocols work well when there is rapid identification of exsanguinating haemorrhage and early communication to allow for logistical coordination.  Our MTP protocol suggests considering activation for scenes distant from major trauma centres, entrapped patients, rendezvous on route from scene, or patients bleeding in rural and remove hospitals.  The below poster summarises the process that our teams can utilise to arrange prehospital MTP activation. The use of the code crimson guideline and prehospital MTP have contributed to good patient outcomes, and highlight the benefit of clear early communication between different teams, applying organised processes within an integrated trauma service.

Further discussion was the regarding the effective use of communication within well-functioning teams. Chris Wilkinson described an excellent example of team communication as everything being “heard, visualised and discussed” between them. This allowed them to maintain a shared mental model and overview of the situation whilst they were independently managing multiple time critical tasks and maintaining momentum to definitive care. This was a great reminder that this continuous, open communication is what we should be aiming for in our teams.

The next CGD will occur on 31/10 – please see flyer below.

MTP protocol C.L.O.T handover tool:

CLOT poster

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