Greater Sydney Area HEMS

For a great review article of RSI in children check out the following article:

• BJA Educ (2016) 16 (4): 120-123  Place of rapid sequence induction in paediatric anaesthesia. R Newton, H Hack

Predicting difficult airways in children:

evaluation-of-difficult-airway-predictors-in-pediatric-population-as-a-clinical-investigation-2155-6148.1000256

Some key pearls when intubating an infant or small child:

• The HEMS paediatric bougie is too big for an ETT less than a 5.0
• If you’re using a straight blade (Miller) then prepare a straight tube (using a stylet) – the natural curve of the ETT is not helpful in this situation.
• Consider inserting the tip of your laryngoscope blade into the R of the valecula – when used in conjunction with ELM (external laryngeal manipulation) this will often allow a great view of the cords.
• Tying the ETT (with tape) centrally will reduce ETT movement (from side to side head movement) and the consequent risk of peri-laryngeal tip dislodgement BUT suctioning the oropharynx or re-inspection of tube placement with a laryngoscope is more difficult. The reverse balance of costs/benefits exists if the ETT is taped to the side of the mouth.

Peri-intubation management is of even higher priority in the care of sick children. Being prepared for a difficult airway is good but a haemodynamically unstable child during RSI is more likely:

• Rigorous CRM/Human Factors practice
• Optimisation of patient position (T-pod under the torso)
• Optimisation of your surroundings (people, environment, resources, a tidy kit dump will save you stress in the heat of the moment!)
• Optimisation of the patient physiology – see the NSW Health Guideline on Paediatric IV Fluid Management

NSW health paed fluid Guidelines Aug 2015

It’s not all about the airway! When treating children we must pay attention to our little patients. This means creating as calm & reassuring an atmosphere as possible with the aide of parents/caregivers as well as paying close attention to the relief of pain. Consider the following take home points and see Natalie’s excellent post for further detail:

• Pain is more than nociception
• Be creative, thoughtful and flexible with your drug-based approach
• Consider all routes of administration
• Distraction is key!
• Address the wider factors affecting pain response

http://stemlynsblog.org/paediatric-pain-and-sedation/

This week’s CGD will be an cerebral infusion of paediatric excellence. We have a host of bona fide paediatric experts in our midst and now’s your chance to pick up their pearls of wisdom and maybe to share some of your own.

The focus will be on emergency paediatric anaesthesia and pain management with a simulated case at the end to consolidate our learning.

There WILL be a BBQ in the hangar at lunch time. Please bring between $5 and $10 to cover the costs if you want to join in.

All NSW Health staff are welcome to attend, a sign in is required. See here for directions. https://sydneyhems.com/contact/

Review at CGD and summary by Dr. Alan Laverty

Romanowski KS, Palmieri TL, Sen S, Greenhalgh DG.
More Than One Third of Intubations in Patients Transferred to Burn Centers are Unnecessary
Journal of Burn Care & Research. 2015 Aug 17

We reviewed the above paper at our Clinical Governance Day on 23 March 2016. Below is the summary of the paper, the issues identified, and observations made by our paramedics, registrars, and consultants.

This was a retrospective chart review of burns patients requiring intubation and transfer to a single burn center. It found 416 patients over 10 years and divided them into appropriate vs non- appropriate groups based on length of intubation (≤2days vs >2days) and compared 16 variables (%TBSA, aetiology, intubating profession, age, distance to hospital etc). Intubation complications (10 total) included cardiac arrest, hypotension, seizure, aspiration and cricothyroidotomy. They concluded that there was a high incidence of unnecessary intubations and that flame burns and burns from enclosed spaces were good indicators of intubation requirement. They proposed guidelines for intubation in the prehospital setting. These included discussion with the burns unit pre-intubation where feasible, and lower need for intubation in non-flame burns, burns in non-enclosed spaces, less than 20% TBSA, no third degree burn to face and <3hour transfer time to burn centre.

Multiple methodological issues were identified which invalidate any robust conclusions from this study. The length of intubation is not a useful surrogate for appropriateness. Multiple confounders to this measure were suggested including concomitant trauma, low GCS, mode of transfer, lung disease, litigation risk, communication difficulties and humanitarian indications. There was no blinding of reviewers, no review of hospital and prehospital protocols for transfer and extubations. The prolonged nature of the study allowed for considerable changes in practice throughout the review period. Patients who subsequently died were not included. The study largely conflated two aetiologies (burns and thermal/inhalational airway burns). At a statistical level the two groups were not independent and a number of the variables were unlikely to be normally distributed which did not appear to have been corrected for with the student t evaluation. While statistical significance was achieved for a number of variables, the large number of variables investigated, the lack of a power calculation, and the overlapping confidence intervals combined with the poor methodology would preclude any strong real world conclusions or application. Any application of conclusions from this study would also fall foul of the fallacy of confusion of the inverse and would need prospective testing.

Group discussion felt that this was a missed opportunity for a useful study. Airway  management will still remain a clinical decision by the provider with the patient. Opportunities for expectant management are more applicable to road transfers than helo. Use of airway examination via our ambu A scope with topical anaesthetic is a good adjunct to standard clinical assessment. Involvement of ENT in the ED and interhospital transfers can lend weight to a decision not to intubate where receiving teams are requesting intubation. Taking photos when assessing the patient is recommended and discussion with the Senior Retrieval Consultant where decision is in doubt. Awareness of the NSW Burns retrieval guideline was highlighted.

NSW Burns Transfer Guidelines

AC Joint Injuries

• a non-evidenced based strapping technique which anecdotally controls pain and keeps patients mobile eg to walk out from a scene
• the aim is to provide a lifting mechanism to support the weight of the arm which is hanging below the distal end of the clavicle (and causing pain) due to rupture of the corococlavicular ligament complex

Strapping technique

1. 2.5cm brown tape + 7.5cm white elastoplast
2. make a large X directly over the AC joint
3. apply 3 x long lengths of the white tape in a figure of 8, staring over the anterior chest, wrapping behind the shoulder, under the elbow and over the anterior deltoid. over-lay each layer by 30% for added strength
4. reinforce the ends of the anteior + posterior chest straps with fastening brown tape
5. wrap around the mid-humerus with white +/- brown tape to secure the tension to the shaft of the arm
6. remove the restricting band from under the elbow by cutting below the securing layer you applied in step 5

Shoulder Dislocations

• remember the dynamic & functional anatomy
• one size does not fit all, consider which is the best technique for the patient in front of you (are they naturally sitting in abdution or adduction?)
• if they are in adduction, consider one of the following tehcniques: Kocher’s method or Cunningham technique
• if they are in abduction, consider the following: Modified milch
• for more detail, visit Dr Neil Cunningham and Dr Gerard Fennessy’s oustanding website shoulderdislocation.net or review the following article EMA Techniques for Shoulder Reduction – Cunningham 2005_04-Jul-11_1