Pearls from the Airway Registry – CGD 29/06/2016

(Thanks again to Dr. Clare Hayes-Bradley for presenting the latest Airway Registry and penning the subsequent discussion points below.)

To RSI or not to RSI, that is the question…

It’s foul weather, near zero degrees and torrential rain, it’s night, and you’re on a residential street 15 minutes away from the regional trauma centre by road. Your obese patient is unconscious with airway obstruction along with other signs of serious injury. To RSI or not to RSI? What factors might influence your decision making?

In favour of RSI in the vehicle would be the PEAM cover black.pngweather and a lack of nearby shelter (like a car port or service station). In favour of RSI at the hospital might be adequacy of basic airway manoeuvres & ventilation and short travel time. Your assessment of current airway patency and ventilation, together with your assessment of difficulty of intubation and patient positioning inside the vehicle may be factors (like can you physically adjust the stretcher head-up and place occipital padding). There may be other pressing clinical concerns that require urgent hospital intervention.

Our GSA-HEMS PHEA manual 2016 gives some suggestions on the pros and cons for on-scene versus hospital RSI.

Performing an RSI in a vehicle will feel different to an RSI at the back of the road vehicle with 360 degree patient access. Why not practice an ‘in-car’ RSI for your next RSI currency or sim?

 

My bougie is too rigid…..

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Borrowed from prehospitalmed.com, with permission

So you can see the cords but that bougie just won’t go where you want it to – what are your options?

  1. Consider optimal bougie ‘top control’ by your assistant
  2. Consider your bougie grip – for example, some practitioners report the ‘Shaka’ or ‘kiwi’ grips can improve bougie tip control
  3. Take the bougie out of the mouth to re-shape
  4. Use our other bougie (hollow blue or solid white)
  5. Intubate the trachea without adjuncts if able
  6. Use a stylet as an alternative adjunct

Another thing to consider practicing at your next RSI currency…

See the PHARM blog for numerous posts on bougie excellence

And from the American College of Emergency Physicians, this bougie article.

 

Agitation pre-RSI

Patients can appear agitated pre-RSI for many reasons including pain, fear, their pathology/injuries, or drug effects. In some cases IV or IO access for pharmacological control is impossible to achieve initially. Safe physical restraint of the patient to allow intramuscular sedation may be necessary. Needlestick injuries must be in everyone’s mind here and ‘safe sharps’ are paramount. Coordinating the sedation attempt with colleagues with clear language and explanation is important, as is being aware of your location and availability of resuscitation equipment if the response to the sedation is profound.IMG_0105.JPG

So what drug or dose would you choose in an adult male patient whom you suspect is agitated from severe pain. Consensus would suggest 2-4mg/kg IM Ketamine could be reasonably expected to produce the desired result – a patient calm enough to accept IV/IO access and further treatment.

Additional Reading

Weingart’s Delayed Sequence Intubation

RFDS document on managing acutely agitated patient in a remote environment

 

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Optimising Prehospital Scene Time

Cliff Reid, Karel Habig, and Geoff Healy discuss how to minimise prehospital scene time while providing meaningful interventions.

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Prehospital Basic Airway and Oxygenation

Cliff Reid, Karel Habig, and Geoff Healy discuss the approach to patients with hypoxia and obstructed airways, prior to rapid sequence induction. This is all about effective basic airway management.

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Penetrating Trauma

Cliff Reid, Karel Habig, and Geoff Healy discuss the approach to patients with penetrating injury.

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The Prehospital Primary Survey

In this podcast, Cliff Reid, Karel Habig, and Geoff Healy discuss how to do a prehospital primary survey

Reference:
Ware S, Reid C, Burns BJ, Habig K. Helicopter emergency medical service registrars do not comprehensively document primary surveys. European Journal of Emergency Medicine. 2012 Jul;:1.

 

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Lessons from the Airway Registry – CGD 15 June 2016

At our Clinical Governance Day on 15 June 2016, Dr. Clare Hayes-Bradley presented cases and lessons learned from our April Airway Registry. Thank you to her for the presentation and the pearls below which shed light on our airway practice.

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Common things are common. All prehospital care teams need to plan (& ideally team train with simulation) for the following:

  1. Tissued IV/IO sometimes only apparent when RSI drugs don’t work. This reinforces the need for two working IV/IO access prior to RSI
  2. Laryngoscope light failure during laryngoscopy. Everyone needs to be aware of where to put their hands on a second blade and handle in case this occurs: Dropdown Airway (DEA) Kit, pediatric airway kit in the Red Primary Pack (short handle)
  3. Cuff leak? You pass the ETT between the cords and start to ventilate. A reassuring ETCO2 trace begins and the chest rises but there’s the noise of a cuff leak. Cuff rupture on intubation is a common problem necessitating ETT exchange over bougie, but there are other causes:
  • Tracheal ETT with cuff deflated (cuff rupture or pilot balloon failure)
  • Pharyngeal cuff (ETT too shallow)

Repeat laryngoscopy may reveal a pharyngeally sitting cuff. Take note of ETT depth at insertion and continue to reassess.

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From the wall of the Esky

 

Does Hand ventilating save time? And Implications for cardiac output.

Severely injured and shocked patients are frequently moved by our service by road or air. It can be tempting to think that hand ventilating with the BVM is going to ‘save time’ to get the patient to definitive haemorrhage control, but there are many down sides. Unintentional overventilation is common in severe injury and can result in raising intrathoracic pressure from positive pressure breaths, further lowering venous return and worsening shocked state. The time taken to instigate mechanical ventilation may help care by lowering mean IMG_2503.JPGintrathoracic pressure; allowing the ETCO2 to reflect the cardiac output response to resuscitation, and free hands for putting on harnesses/loading patient/providing other care, etc. Particularly with the added times of preparing the helicopter and spinning up for takeoff, then cooling down after landing, helicopter transport often takes much longer than you think. In general, mechanical ventilation wins over hand ventilation for prehospital trauma care.

 

 

 

 

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CGD 29th June 2016

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Next week’s CGD begins with a pearl-packed Mortality & Morbidity session and is followed by the always revealing Airway Registry.

In the 2nd half of the day, Chris Partyka is returning with part two of the oustanding Sonography Training Oriented to Retrieval Medicine (STORM2) course. This is a fantastic opportunity to hone your ultrasound skills with real-time feedback from the pros and to log some proctored scans to add to your CPD portfolio or just increase your confidence.

STORM2 will include a refresher session on Basic Echocardiography in Life Support (BELS) and a 3-station workshop with volunteer patients. If you haven’t previously attended the STORM course, do not fret, you are still encouraged to attend.

To get the most out of the session, we suggest that you take a quick look at the following pre-reading with a focus on the echo section of the STORM course manual + the basic echo views.

Sonography Training Oriented to Retrieval Medicine Manual(sm)

TTE REFERENCE CARDS

For the enthusiasts, check out the links below as well.

STORM Course training page

Virtual Transthoracic Echocardiography (Toronto General Hospital)

Echocardiography in ICU (Stanford University)

We will conclude the day with a BBQ in the hangar. As usual all NSW Health staff are welcome to attend, a sign in is required. See here for directions:

https://sydneyhems.com/contact/

 

 

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