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.