Lessons from our HEMS Airway Registry

Our monthly audit of airway cases held at our Clinical Governance Days seeks to improve identifies learning points at Clinical Governance days. Here are some key points from a recent Clinical Governance Day.


Slip, slop, slap, slide and SEEK SHADE!

The Australian sun can be brutal. Bright ambient light reduces the relative illumination of the larynx during prehospital laryngoscopy. Sun protection, in the form of shielding the airway & intubator from direct sunlight is essential to first look intubation success. Assistants can be utilised to hold sheets or blankets above our heads – but a single layer may not be sufficient, and adding a space blanket may help. Problems will be compounded if laryngoscope brightness is not optimal. It is best practice to check batteries and laryngoscope brightness in kit checks & before RSI.

How big is that kid?

We all know from hospital practice that children come in all shapes and sizes – ages and weights are not always predictable. In the prehospital & retrieval setting we have the added challenge of errors in the initial scene information conveyed to us. The child will often turn out to be a different age than the initial scene call information suggests. We can help to protect ourselves against ‘size’ errors by discussing the size of the child & equipment/drug dose choices with the team. Those team members with kids admit they frequently compare the patient’s size to their own children – or you could use a Broselow tape…..

HOP HOP HOP….. to our Helicopter Operating Procedure – Prehospital RSI

“If there are no features (apart from C-Spine immobilization) to predict a difficult airway the first attempt at laryngoscopy may be taken by the retrieval paramedic”

Or to put it another way ….

“If a difficult airway is anticipated or adequate pre-oxygenation is difficult then the physician should perform the laryngoscopy. “

It is always important to discuss who is to undertake laryngoscopy with your other team member to ensure you are both on the same page with respect to potentially difficult airway or anatomy before you pick up the laryngoscope.

Bloody airways – dental blocks before epistat inflation

In patients with life-threatening maxillo-facial haemorrhage the procedure for splinting the facial bones and tamponading epistaxis following control of the airway can be life-saving. The epistat balloons placed in the nasal cavity  splint the facial bones against the dental blocks and then the mandible. The mandible is splinted by the C-Collar to the clavicle.  We reminded staff of the correct procedure outlined in the Major Haemorrhage Control Operating Procedure.  You should insert the epistats prior to dental blocks (McKesson Props) but only inflate them once the C-Collar is on and dental blocks in place. Each posterior balloon is full inflated with saline and then anterior balloon gently inflated a little at a time alternating sides. This reduces the chance of misaligning fractures further – see reference below.

  1. Harris et al. 2010 The emergency control of traumatic maxillofacial haemorrhage. European Journal of Emergency Medicine 17:230–233

Hold your breath I’m giving Ketamine

Intravenous Ketamine is extremely effective for the prehospital management of agitated or combative head injured patients as it retains airway reflexes and spontaneous respirations better than other agents as well as having a superior haemodynamic profile. However on occasion a brief period of apnoea may be experienced immediately following administration.  Provided the patient is adequately monitored and the team are prepared this is rarely of clinical consequence but it can be avoided by slowing rate of administration. Speed of administration is the main factor correlated with occurrences of apnoea following ketamine injection particularly in sedation doses.

Slow down the “bolus” to avoid unwanted apnoea.

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