Karel Habig rigged up a SALAD simulator (Suction Assisted Laryngoscopy and Airway Decontamination – the brainchild of Airway Master Educator Jim DuCanto) and ran a vomit-control workshop at our recent HEMS Education Day.

Here are the learning points as summarised by Karel:

Management of massive emesis/Upper GIT Haemorrhage

Prevent – head-up position for all intubations to reduce passive regurgitation as specified in the Prehospital Emergency Anaesthesia Checklist

Plan – where apparent/likely – Double suction tested, briefed Airway Assistant, PPE esp eye protection for all staff – as specified in Prehospital Emergency Anaesthesia Checklist

Considerations
Prehospital Laerdal Compact Suction Unit – very effective BUT fills at 330mL and stops working if filter wet – ALWAYS use alternative suction from vehicles/venturi first

Understand the sucker – Yankauer with hole takes up one person’s hand and doesn’t work unless the hole is occluded. Not ideal.

Large bore suction with no hole is ideal or just use tubing (esp where vomitus is chunky or large clots)

A size 6.0 tracheal tube without airway adaptor can be inserted into all of our suction tubing – good alternative “suction catheter”

IF unexpected Massive Emesis/GIT Haemorrhage post induction:

Initial steps
1. Take a deep breath. Expect to become extremely task focused and lose situational awareness. Verbalise this. ALL staff running through SALAD noticed this

2. Consider log-roll to toilet airway immediately

3. Once returned to supine position – Suction to the cords (don’t try to clean the entire oropharynx) and intubate trachea with bougie (standard intubation)

4. Double suction – place fixed suction along left-hand side of laryngoscope, lock into groove of DL blade and use second device to suction to cords.

5. If not able to control rapidly then deliberately intubate oesophagus (blind placement) inflate cuff (may need 20mL air) and divert flow (take care to avoid spraying assistants)

6. Suction to cords and intubate

7. Large bore suction catheter or Size 6 tube attached to suction can be used to suction down to and then intubate the trachea. Tube change over bougie may be needed in large patients

8. Digital Intubation is an option for those who have practised it

9. Some airways are surgically inevitable.

Haven’t had enough vomit? Listen to EMCrit’s Having a Vomit SALAD with Dr. Jim DuCanto