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.
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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.
Hi Natalie,
Great post as always. Congratulations for the Airway Registry and the fantastic RSI results.
Regarding apox through npa – we at the Hungarian HEMS also noticed the dislodgement problem.
Here’s are workaround: https://www.ncbi.nlm.nih.gov/pubmed/26796114
And a short video: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4721006/bin/13049_2016_200_MOESM1_ESM.mp4
Not sure if it is applicable to your practice given the fact your primary preox equipment is the bvm, but let me know it it is helpful in any way.
Kind regards,
Attila Eross (Hungarian Air Ambulance)