How to secure an IVC cannula

 

In the retrieval setting, IV access is crucial. Oil/blood/dirt all create difficulties for adhesives. This method is an effective way to reduce the chances of cannula displacement.

Materials needed: 1 x gauze.

Step 1: Secure the cannula with normal adhesive dressing if possible

Step 2:  Start unrolling the crepe bandage from under the IVC, (1 roll)

Step 3:  Roll again over the IVC , and roll distally over the pump set line (3 rolls)

Step 4: Create a loop with the pump set distally and return the line towards IVC

Step 5: Roll proximally ensuring access port is visible (2 rolls)

Step 6:  Create a further loop proximally and return line distally, roll crepe (2 rolls)… secure end of crepe with tape

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Clinical Governance Day – Wed 30th Oct

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Education Day 16 October 2019

eduoct

Summary from Dr. Ben Porter (Consultant Anaesthetist working with Sydney HEMS) – thanks Ben!

Clinical Education Day Summary – 16th October 2019

Thank you to all those involved in both the presentations and in the background helping to make todays education day a success.

 

SALAD Simulator

The Suction Assisted Laryngoscopy and Airway Decontamination simulator was in action again to give some fidelity to the management of severe airway soiling during induction/intubation. The simulator provides realistic catastrophic soiling of the airway and helps our crews rehearse management of passive regurgitation to minimise aspiration and hypoxia. Key learning points from today’s session included the importance of having two suction units available, noting that the portable suction unit, whilst very effective, only has a small canister capacity and a backup should always be available (usually in the form of the helicopter or road vehicle main suction unit).

Secondly, the importance of turning the patient lateral to allow passive drainage of the secretions/blood/gastric contents by gravity and maintaining this position for intubation if necessary. Time was spent practicing intubation of the manikin in the lateral position with both direct and video laryngoscopy.

Finally, use of suction assisted laryngoscopy, where one suction device is held parallel to, and in the same hand, as the laryngoscope to provide continuous suction thus allowing the working hand to be free for a second suction, or for instrumentation of the airway.

 

US HEMS Crash

We were arrested by a very emotive and personal talk from Justin McLean about the HEMS helicopter crash sustained by his organisation in the US in 2015. The focus of the talk was around the recovery phases following the incident and how the organisation and individual staff responded over the days, months and years after. The need for a robust strategic plan in the event of an incident was covered, and in particular; that this is reviewed regularly, accessible to all levels of staff and provides for the immediate and longer term.

Specific reference was made to communication, both within the organisation and to the wider public. In the current internet climate of rapidly available social media and news streams, it is crucial that the organisation publicly acknowledges any significant incident within minutes, particularly where the incident may have been witnessed by media groups or occurred in a very public place.

Huge thanks to Justin for sharing these difficult issues and for allowing us a very small insight into some of the incomprehensible difficulties faced by the team after such a catastrophic event.

 

Geriatric Retrieval, ICU Outcomes and Case Discussion

The decision to admit an elderly patient to an ICU presents challenges that differ from younger patients. There is frequently a greater burden of comorbidities, complexities with advance care planning and increasing awareness of the significance of morbidity following ICU admission. The separation of patients likely to obtain benefit from an ICU admission from those that will not can present great challenges to critical care clinicians, however this does not mean it shouldn’t be considered in the context of retrieval medicine. Exactly how these decisions should be made when tasked to retrieve a patient remains unclear, however at least historically appears to be an infrequent occurrence within our service.

In NSW the Guardianship Act 1987 governs the process of making medical decisions for patients lacking capacity and is important knowledge for any health professional. Advance Care Directives are legally binding, but can only withhold consent to particular treatments, not compel a medical professional to perform a particular treatment. Establishing whether an Advance Care Directive exists remains an important part of the assessment of a critically-ill patient and should be considered in the context of retrieval taskings.

 

Retrieval Team Complex Decision Making

A 90 minute debate was had on the motion “There is little role for the retrieval team in making treatment limitation decisions”. This was an informative discussion with both sides represented well and some really good thoughts vocalised by the team. At the end there was a unanimous vote against the motion supporting the believe that the GSA HEMS retrieval teams should be delivering critical care expertise to the patient in any location and thus should deliver all that this encompasses. This includes complex discussions about ceilings of care and palliation where this is appropriate.

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Education Day Wed 16th October

HED Oct 16

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30 Second Drills for Intubation

Thirty second drills have 6 steps that can be used to optimise your view. This may be enough to successfully ensure first pass success during intubation.

 

The 6 steps:

  • Release cricoid and use ELM
  • Optimise operator position
  • Optimise patient position
  • Use suction
  • Insert deeply and withdraw until recognisable structures are seen
  • Change laryngoscope blade/handle/type… video laryngoscopes have been very useful in this regard!

If done efficiently, these steps can be performed within a 30 second time frame. Of course this does not negate the need to maintain situational awareness and one most always prioritise be aware of patient oxygenation and hemodynamics during intubation.

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Clinical Governance Day Wednesday 2 October

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AiR – Learning from the Airway Registry (September 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 Screen Issues

Fogging of the CMAC Screen

Fogging of the CMAC pocket monitor screen at laryngoscopy is commonly seen and can last 20-25 secs before it clears. One video which runs for 2m30s before laryngoscopy shows that turning the screen on during the checklist phase of preparation for intubation does not always prevent the fogging from occurring. It doesn’t always completely obscure the view but can make it tricky, so it’s something to be aware of. 

Why is it so Dark?!

Observation from one team member:

“My view of the CMAC screen was very dark when undertaking intubation (it had been fine when it was checked during the checklist phase). Only after intubation did I realise this was due to my polarised sunglasses!”

Other Topics of Discussion

A few months back we had our first awake fiberoptic nasal intubation of 2019 – and received helpful feedback that the new look topicalisation recipe was successful (see below).

Video Focus on: Contaminated Airways

We see many examples of airway contaminants, particularly during our prehospital missions but also during interhospital transfers. Some examples are shared below.

Dry Mucosa and Sputum

Dry mucosa and sputum are evident in this video from a patient with community acquired pneumonia and dehydration.

Burned Airway

This patient was trapped in a burning vehicle for some time.

Immersion – Frothy Airway

Any patient who is retrieved from water should be thought of as being at risk of immersion and near drowning pulmonary oedema.

Thick Secretions

This video from a patient with sepsis shows thickened oropharyngeal secretions.

Brown Goo – A Diagnostic Laryngoscopy?

This video shows intubation in a very sick patient with pneumomediastinum of unknown cause – at intubation oropharyngeal infection and abscess were apparent with fluid oozing from the epiglottis at laryngoscopy.

Further CMAC Videos:

Release the ELM!

In both of these cases, external laryngeal manipulation (ELM) was initially used to ‘improve’ the view at laryngoscopy. The video of ELM being released shows how ELM can actually make the view worse.

When performing ELM in the role of airway assistant, always get feedback from the laryngoscopist as to whether the ELM is helping – and when available the video screen may help aid ELM placement by the assistant. Both of the efforts seen on video here may be too high in the neck, resulting in pressure above the glottis.

Tracheomalacia – Seen Using Ambu A Scope via Tracheostomy

This video is from the A View monitor of the Ambu A Scope and shows the regular 5.0mm diameter scope placed into 7.0mm tracheostomy, demonstrating tracheomalacia – the floppy trachea collapses down on expiration and opens on inspiration. This was a great use of a bedside tool to demonstrate pathology and contributed to patient care.

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

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