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

cgd may 15

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Education day – Wednesday 1st May

educatiomay1

 

Post Day Wrap

(Thanks to Dr. Sandeep Gadgil for organising the day and producing the summary!):

This education day was performed in collaboration with NETS.

Morning

Dr Arieta Fa’asalele from NETS detailed the Mobile Paediatric Neurosurgical Service. This was developed in response to an audit showing prolonged transfer times to tertiary paediatric neurosurgical centre. A protocol was created with the aim of performing emergency neurosurgery at the patient’s home hospital, involving the NETS team and a neurosurgeon. A review of subsequent cases using this approach found that surgery was performed approximately 3 hours earlier. Further details are available here:

https://thejns.org/pediatrics/view/journals/j-neurosurg-pediatr/16/3/article-p340.xml

 

Afternoon

Dr Jimmy Bliss presented on the role of eFAST in paediatric trauma. EFAST has a higher rate of false negatives in the paediatric population so cannot be reliably used to exclude intraabdominal pathology in trauma.

Workshops

Dr Bliss facilitated an interactive workshop for the NETS team to practice performing eFAST examinations. This brief introduction was followed with an invitation for any interested NETS staff to attend the next STORM (ultrasound) course.

NETS provided an interactive workshop for the HEMS team on neonatal vascular access including emergency umbilical lines and scalp vein cannulation using HEMS equipment. Our triple lumen central line is probably the most suitable for an emergency umbilical line if a formal umbilical catheter is unavailable. A key consideration is the depth of insertion, particularly taking note of port locations.

CVCneo

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Critical care at Summer dance festivals: Pre-hospital management of illicit drug toxicity

lights-party-dancing-music
Source: Pexels.com

By Jess Hegedus

Sydney HEMS recently provided medical teams to attend a number of dance festivals, as part of a NSW Government plan to provide specialist critical care at events where there is a high risk of drug related illness.  Along with teams provided by a number of NSW Health emergency departments, NSW Ambulance paramedics and other services, our teams provided advanced critical care interventions on-site to numerous patients. This was a fantastic team effort, and it was suggested that without this effort, a number of these patients may not have survived or may have suffered serious neurological morbidity.

More details here: https://www.theguardian.com/australia-news/2019/jan/28/man-on-life-support-after-suspected-drug-overdose-at-sydney-music-festival

We’ve had much discussion on base over the last few weeks about the planning involved and potential management issues that might arise at such events.  This has been a great opportunity to consider more broadly the pre-hospital management of patients presenting with toxicity following illicit drug use.

Broadly, toxicity from illicit drug use can be divided into 4 syndromes.  Whilst the patient, or those accompanying them, may not be able to provide specifics on the substance/s consumed, appropriate management can often be guided by characteristic signs of toxicity.  Some more information about different drug classes, their presentation and management is provided in the table below (adapted from Anderson 2017, incorporating the other references listed below).

Presentation2

The remainder of this brief review will focus on stimulant associated toxicity, which is commonly seen in these settings.  In these patients, serious toxicity can occur acutely via a number of systemic effects. The sympathomimetic actions can create a hypertensive crisis, resulting in intracranial haemorrhage, and cardiac ischaemia or arrhythmias. Hyperthermia is an extremely common presenting symptom, particularly with methamphetamines (most commonly with MDMA), with extreme hyperthermia usually present in fatal overdoses from these agents.  The exact mechanism underlying hyperthermia from these agents is uncertain, and likely multifactorial, and it is exacerbated by other drug effects (e.g. agitation, seizures) and the environment in which they’re taken, such as hot and humid conditions during Summer festivals or in clubs. Hyperthermia in this context may also be part of a presentation of serotonin syndrome, as some stimulant agents (e.g. MDMA) increase synaptic serotonin levels.  Serotonin syndrome may develop within minutes to hours and is characterised by a triad of autonomic effects (e.g. hyperthermia, tachycardia), muscular hyperactivity (e.g. clonus) and neurological symptoms (e.g. agitation). Ultimately, significant hyperthermia requires urgent management, and can result in a 13-fold increase in mortality at temperatures greater than 39.5 degrees (Walter and Carraretto 2015). Other serious complications of hyperthermia include cerebral dysfunction (possibly exacerbated by direct drug effects), seizures, rhabdomyolysis, AKI and coagulopathy.

The management of stimulant toxicity is largely supportive, with early treatment of agitation and psychosis often required to facilitate further management.  When non-pharmacological methods are unsuccessful, parenteral agents are usually required in the pre-hospital setting.  Antipsychotic agents are often administered as a first line agent, and are particularly useful when the cause of agitation is unknown, with droperidol (a butyrophenone antipsychotic) available for use by NSW Ambulance paramedics.

The advantage of these agents are that they are relatively safe, with a low incidence of respiratory depression and an intubation rate of 4% reported in the literature (Richards, systematic review).  A study of methamphetamine-affected patients presenting to a tertiary ED in Brisbane reported adequate sedation in 87% of patients receiving IM droperidol, with a further 8% increase in efficacy following a further dose (Isoardi et al. 2018). Duration of action is reported as 80 – 120 minutes in the literature, usually sufficient for pre-hospital transport without further dosing (SR). Disadvantages include a risk of extra-pyramidal side effects and QT interval prolongation, along with a relatively longer onset of action (may require 15-25 minutes for effect) compared with other agents. Another commonly used parenteral agent for undifferentiated agitation is the benzodiazepine midazolam, however the efficacy of this agent appears to be more variable and difficult to titrate in these settings.  The incidence of both under- and over-sedation were reported as more frequent in the literature, with a well documented risk of paradoxical agitation with midazolam.

Ketamine (both IM and IV) has emerged as a useful agent to manage agitation in the prehospital setting, and is successfully utilised by our service.  Advantages of this agent are a low risk of compromised airway reflexes or respiratory drive and a predictable, rapid onset by IV or IM injection.  Isoardi et al. (2018) reported ketamine as providing successful sedation in the small number of patients in whom droperidol did not, and other sources have reported ketamine as more effective than droperidol, midazolam and the combination of the two (Gottlieb et al. 2017).  Potential disadvantages include a risk of emergence delirium and a shorter duration of action (reported as 5-30 minutes), compared with droperidol, and may therefore require re-dosing in the prehospital setting. Furthermore, ketamine may result in a catecholamine surge causing hypertension, which may theoretically worsen hypertension seen in hyperadrenergic states (e.g. following cocaine overdose). However, hypertension and tachycardia seen following ketamine use is usually brief and there has been no evidence that this effect is significant.

Whilst a review of the management of amphetamine toxicity (Richards et al. 2015) reported further studies are needing assessing the utility of ketamine sedation in amphetamine toxicity, there is a reasonable volume of literature assessing ketamine use in undifferentiated agitation which can guide its use in this setting. A systematic review published in 2018 (Mankowitz et al. 2018) has analysed the use of ketamine for undifferentiated agitation in the pre-hospital and ED setting, with a total 650 patients included. They reported adequate sedation following IM ketamine in a mean time of 7.2 minutes following a mean IM dose of 315mg or 4.9mg/kg.  The most common side effects were hypertension and hypersalivation, with other reported side effects being vomiting, emergence delirium and, uncommonly, transient hypoxia and laryngospasm. The intubation rate following ketamine administration was reported at 30.5%, however this was mostly associated with pre-hospital use and is suggested that intubation was the likely clinical course in these cases. The intubation rate in the ED was 1.8% and 4.9% in aeromedical transport.

Another important management consideration in amphetamine affected patients, is the management of temperature.  There is no determined safe level of hyperthermia in stimulant toxicity, and patients should be actively cooled using an escalating approach depending on their level of hyperthermia.  Basic interventions include moving to a cool environment, misting with water and administration of cold IV fluids.  Some patients will require ice pack application, sedation, progressing to RSI, anaesthesia and paralysis to reduce heat generation.  Antipyretics are not useful as the hyperthermia is driven by excessive heat generation due to the stimulant drug, rather than an alteration in their hypothalamic set point.

References:
Anderson, M. (2017). Poisoning with illicit drugs. Paediatrics and Child Health. 27.

Gottlieb, M. et al. (2017). Approach to the agitated emergency department patient. Journal of Emergency Medicine, 54 (4)

Isoardi, K. et al. (2018). Methamphetamine presentations to an emergency department: Management and complications. Emergency medicine Australasia

Mankowitz, S. et al. (2018). Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis. The Journal of Emergency Medicine, 55.

Matsumoto, R. et al. (2014). Methamphetamine-induced toxicity: An updated review on issues related to hyperthermia. Pharmacology & Therapeutics,144.

Richards, J. et al. (2015). Treatment of Toxicity from Amphetamines, Related Derivatives, and Analogues: A Systematic Clinical Review. Drug and alcohol dependence, 150

Walter, E., & Carraretto, M. (2015). Drug-induced hyperthermia in critical care. Journal of the Intensive Care Society16(4), 306-311.

 

 

 

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Clinical governance day – Wed 17th April 2019

cgd April 17th 2019

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Education day – Wednesday 3rd April

Edu Day 3rd April 2019

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