AiR – Learning from the Airway Registry (August 2019)

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: CMAC Use in Cardiac Arrest

Recently, the CMAC was used to intubate a patient in cardiac arrest during chest compressions. The operator found a difficult direct view and in trying to switch to VL, they found that the camera was covered with secretions.

The camera was cleaned, the airway was suctioned and intubation proceeded with video screen used. This is only our second experience of the CMAC camera being covered with fluids – the first also being during chest compressions with a bloody airway. It raises the question – is it preferable to suction the airway prior to laryngoscopy when chest compressions are ongoing (given that chest compressions will tend to force fluids out of the airway towards the videolaryngoscopy camera)? It is also a reminder of the need to retain good direct laryngoscopy skills. 

Video Focus on: Tube “Displacement”

ETT Found in Pharynx

The first video shows an ETT placed during cardiac arrest. The endotracheal position was not certain so the team decided to relook and found it to be in the pharynx; the patient was subsequently reintubated.

On review, the video shows the bougie, which is seen to pass cords a fair distance. After this, the view is lost – the tube is railroaded over the bougie but probably never enters trachea, rather just being pushed up to larynx. This is probably an extreme case of laryngeal holdup on railroading the tube.

“Short” ETT

In this and the subsequent video, the team seemed to have a sited an ETT which was sitting short.

Review of the first video shows a good view at laryngoscopy, but railroading of the tube becomes a blind action and the length of ETT at lips from initial placement is unknown.

The team noticed an immediate cuff leak and repeated laryngoscopy (second video) to assess cuff placement, finding the cuff herniating through the cords.

Further CMAC Videos:

ETT Catching at the Glottic Inlet

This is another example of the ETT catching at the glottic inlet despite the Parker tip – always think of the need to retract ETT from obstruction & twist 90 degrees anticlockwise to be able to advance the tube.

Glottic Hold Up And Blade Slip

Another example of ETT catch at the glottic inlet needing the ETT to be withdrawn and rotated anticlockwise. A personal recommendation from Clare Hayes-Bradley (who oversees the Airway Registry) is to rotate anticlockwise for all railroading over bougie. It’s especially interesting to see how the small movement of the blade tip along the tongue base affects the good glottic view.

You can see all the AiR videos here on our Vimeo page or here on the blog.

About Natalie May

EM and PEM-trained UK doctor working in Prehospital & Retrieval Medicine in Australia. Evolving medical education interest, running enthusiast, karaoke queen. Here for the #FOAMed.
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