- RT @tollambulance: Through the eyes of the bystander: Nathan Croxton was recently at the Figure Eight Pools front and centre as a mission u… 6 hours ago
- RT @FLTDOC1: If anyone out there is in the position of raising young girls, you must also show them this great video featuring @SydneyHEMS… 3 days ago
- AiR – Learning from the Airway Registry (August 2018) sydneyhems.com/2019/01/02/air… https://t.co/rFq8xlEgRq 2 weeks ago
- Prehospital TEG in a helicopter? In this month's EMJ from @SydneyHEMS: The reliability of thromboelastography in a… twitter.com/i/web/status/1… 1 month ago
- RT @jbwatterson: @amfeuerbach True story: I’ve been climbing and canyoneering as part of training exercises. @SydneyHEMS take training seri… 1 month ago
(Courtesy of JP Favero)
Associate Professor Dr David Heslop kicked off the day with a talk on CBRN Issues explaining the characteristics of these type of threats – usually deliberate, sometimes accidental, often used to kill or incapacitate military and/or civilian targets. They an be engineered to defeat defences with strategic and political effects. We noted the 5 Pillars of CBRN-D: Warning and Reporting; Detection, Identification and Monitoring; Physical Protection; Medical countermeasures and supports; Hazard management.
There was explanation of Mission Oriented Protective Posture (MOPP), types and levels of Personal Protective Equipment. We touched on the effectiveness of decontamination and principles to employ both pre and post this type of terrible event. Our senior doctors, many of whom lead major Sydney emergency departments, appealed for advice on who to call in real time.
The Grenfell Fire Experience
Laurence Ioannou gave us a first hand run down of his Grenfell Tower Fire experience as Ambulance Scene Commander. You probably know the story… A 24 storey block of flats in North Kensington, West London, went up in flames early on the morning of 14 June 2017. It took 60 hours to put it out. There were sadly 72 deaths, about 80 people were treated on the scene, 70 transported. At the peak there were 71 ambulance vehicles in play and approximately 30 patients had intensive care post the event.
The value of Joint Emergency Services Interoperability Principles (JESIP) was emphasised – 5 important principles for joint working in major incidents – Co-Locate, Communicate, Coordinate, Jointly understand risk, Shared situation awareness. Laurence found it was vital to brief and share info between agencies every 45 mins or so. He also explained the value of Pre-Determined Attendance. London Ambulance has PDA for ‘Significant’ and ‘Major’ Incidents – early declaration and resource activation saves lives. Simple things make a huge difference – disposable carry sheets / frameless transport devices for patients and coloured tarpolines on the ground for casualty clearing stations, weather allowing.
There’s a great deal of trust in managers and peers during this type of response. Paper log books and a scribe are a must if you find yourself in charge, and don’t forget it takes a long time to complete formal handover, an important consideration in a protracted incident alongside fatigue. Oversight is difficult. Delegate another senior colleague to walk through the casualty ‘journey’, optimise and report back. Control can do a lot to offload scene commander(s), determine hospital destinations and streamline communications – it’s next to impossible to receive information on multiple channels and properly monitor the radio when you’re the on scene boss.
Later in the morning Oli Ellis and Scott McNamara had a chat about Tactical Medicine and the need to practice it in any incident that involves the risk of imminent physical harm to the responder(s).
Remember Rule No 1: Manage your own trauma and don’t willingly expose yourself to these environments without proper training
We know it’s about the correct intervention at the correct time, and that there’s a continuum of BLS to ALS dependent on threat. Unfortunately, when in the hot zone, a medically correct intervention at an incorrect time can lead to further injury. And it’s worth remembering a threat can shift, capturing you and your team in what may have been a previously clear or apparently benign environment. Increased Threat = Decreased Treatment
It was a shame Ben Roberston wasn’t there – he was probably out saving lives in the place where he lives, the danger zone. Meanwhile we noted its all about:
Hot – Danger – Threat suppression
Warm – Not Secure – Haemorrhage control, Rapid extrication
Cold – Safe – Assess and treat patient, Transport to Hospital
The boys made Tactical Emergency Casualty Care (TECC) look HOT, ready to rapidly treat or exclude the 3 big preventable causes of death Haemorrhage, Obstruction of the airway and Tension pneumothorax. They touched on RAMP Triage (Rapid Assessment of Motor and Pulse) and utility in predicting mortality from US military data.
Our afternoon workshops covered off HEMS Team PPE, mask application, Tyvec suits and a real tasking cased based discussion. There were examples of PPE carried by the Special Operations Team, SOT tactical apparel and equipment. Scott gave us a demonstration of wound packing, great fish hook, tourniquet application and labelling. Oli provided an excellent look at patient assessment – radial pulse and simple assessment of level of motor function RAMP style along with a ‘sweep’ in the hostile environment. Integrating “tactical breathing” into the primary survey is something we can all do. We spoke a little about the utility of posturing expectant and deceased patients in a mass casualty scenario and sharing that with other services or those accessing the scene later. Positioning, maintenance of situational awareness, scanning, tactical breathing and great commentary were all on show.
Intubations this month: 34
Airway Registry learning points reflect the challenges described and wisdom shared by Sydney HEMS personnel and guests at the Clinical Governance Airway Registry presentation for April 2018. 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.
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: Blunt Neck Trauma
Our main discussion focused around the management of patients with potential/known upper airway injury. The majority of our potential laryngotracheal injuries are in multiply injured patients where the other injuries dictate patient management, including intubation, and the airway injury becomes an interesting (sometimes unexpected) finding on the hospital CT scan.
Occasionally we attend patients with isolated neck/laryngeal injuries. Examples include:
- motorbike rider crossing wire fences
- direct front of neck blunt trauma.
Laryngotracheal injuries can be challenging anywhere and as a retrieval team we are often faced with early presentations in non-tertiary institutions with the added challenges of an unfamiliar team & environment, limited investigations, and the need for long distance transport to tertiary care.
Potential for further harm to the patient comes from worsening the injury (e.g. turning a partial tracheal tear into total tracheal disconnection), creation of false passages (by blind instrumentation of the airway), loss of effective spontaneous negative pressure ventilation, generation/worsening air leak from positive pressure ventilation with failure of ventilation.
Principles of management for these patients are therefore:-
- Assess need for intubation as urgency varies between patients, and they may be best transported without RSI.
- Cervical spine collars or other constrictions around the neck may be best avoided
- Maintain spontaneous ventilation where possible
- Avoid positive pressure ventilation above the injury (e.g. BVM, LMA)
- Avoid instrumenting the injury (e.g. bougie/ETT) as it may complete a partial tracheal transection, or create a false passage
- Small ETT e.g. 6.0mm I.D in adults is prudent
- Place cuff of ETT below injury (visualization of defect ideal)
- Perform any surgical airway below the level of injury (e.g. tracheostomy rather than cricothyroidotomy for neck injury). Placing an ETT through the defect has been performed but is not without risk of completing a transection.
- Visualised actions preferable to blind interventions
Our clinical practice standard for Prehospital Intubations recommends using a bougie for every intubation. Despite visualizing the larynx above the vocal cords with laryngoscopy, the bougie is not seen as it passes below the cords where further damage to tracheal injuries is possible. There is an argument for not using a bougie in easy intubations. It is advisable to place the ETT deep so placing the cuff below likely injury level (which carries an endobronchial injury).
In smaller hospitals, the options for intubation increase and decision making can be less clear. A prehospital approach to intubation is not contra-indicated and could be used in lower resource settings alongside preparation for a surgical airway approach. Intubation under a spontaneous breathing general anaesthetic technique (gas induction or total intravenous technique) is most familiar. Awake fibreoptic intubation is an option though care needs to be taken to ensure a cough/struggle-free experience; remember also that the subsequent railroading of the ETT will be blind so the same risks apply.
Articles have described a two-operator technique involving spontaneous breathing anaesthesia with videolaryngoscopy and flexible intubating scope to assess tracheal injury at time of intubation and avoid creating a false passage. This is likely to need prior practice and a strong team.
The best plan of action may be both resource-dependent and context-dependent and we strongly recommend discussion with local staff and/or Duty Retrieval Consultant at the time.
Video Focus: Epiglottis
This video shows how adjusting the position of the tip of the laryngoscope in the vallecula can improve your view at laryngoscopy.
This video shows how we can sometimes use our Mac blade as a Miller blade by picking up the epiglottis: you may not have intended to pick up the epiglottis but if you get a good view as the one shown here, you might decide to proceed with passing the bougie or ETT rather than trying to get into the vallecula (especially as the earlier part of the video shows this might have been challenging).
This video appears to show a mass below the epiglottis when the laryngoscope is in the vallecula. This is, in fact, a normal variant – an epiglottic tubercle (see this anatomy diagram from this site).
In this video, the epiglottis appears swollen (this may be a result of local trauma caused by the use of an oropharyngeal airway or related to drug use). You can also see an issue with control of the coude (curved) tip of the bougie. This occurs because of the way we transport the bougie in our airway packs: we cannot transport the bougie without bending it and this case reminds us to ensure that the bending occurs along the plane of the coude tip curve during our pack checks.