At our Clinical Governance Day on 15 June 2016, Dr. Clare Hayes-Bradley presented cases and lessons learned from our April Airway Registry. Thank you to her for the presentation and the pearls below which shed light on our airway practice.
Common things are common. All prehospital care teams need to plan (& ideally team train with simulation) for the following:
- Tissued IV/IO sometimes only apparent when RSI drugs don’t work. This reinforces the need for two working IV/IO access prior to RSI
- Laryngoscope light failure during laryngoscopy. Everyone needs to be aware of where to put their hands on a second blade and handle in case this occurs: Dropdown Airway (DEA) Kit, pediatric airway kit in the Red Primary Pack (short handle)
- Cuff leak? You pass the ETT between the cords and start to ventilate. A reassuring ETCO2 trace begins and the chest rises but there’s the noise of a cuff leak. Cuff rupture on intubation is a common problem necessitating ETT exchange over bougie, but there are other causes:
- Tracheal ETT with cuff deflated (cuff rupture or pilot balloon failure)
- Pharyngeal cuff (ETT too shallow)
Repeat laryngoscopy may reveal a pharyngeally sitting cuff. Take note of ETT depth at insertion and continue to reassess.
Does Hand ventilating save time? And Implications for cardiac output.
Severely injured and shocked patients are frequently moved by our service by road or air. It can be tempting to think that hand ventilating with the BVM is going to ‘save time’ to get the patient to definitive haemorrhage control, but there are many down sides. Unintentional overventilation is common in severe injury and can result in raising intrathoracic pressure from positive pressure breaths, further lowering venous return and worsening shocked state. The time taken to instigate mechanical ventilation may help care by lowering mean intrathoracic pressure; allowing the ETCO2 to reflect the cardiac output response to resuscitation, and free hands for putting on harnesses/loading patient/providing other care, etc. Particularly with the added times of preparing the helicopter and spinning up for takeoff, then cooling down after landing, helicopter transport often takes much longer than you think. In general, mechanical ventilation wins over hand ventilation for prehospital trauma care.