Welcome back to the Sydney HEMS debrief! In this episode 8, we are joined by the extraordinary Dr Nat Kruit. Dr Kruit is a Sydney HEMS Consultant, Cardiac Anaesthetist, and ECMO Specialist. Given the increasing global chatter around ECMO, and to give it its full name, extracorporeal membrane oxygenation is going to be the focus of this episode. Join us as Dr Kruit takes us through the physiology, patient selection, and retrieval considerations of this fascinating – and very specialised – area of medicine.
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 period of time 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 2022, we achieved:
95% overall first pass successrate (first pass of laryngoscope into mouth results in successful intubation, from both prehospital and inter hospital cases, including cold tube and RSI. A change of operator or removal of the blade from the mouth ends the attempt).
96.5% first pass success rate from RSI.
These learning points form part of our commitments to excellence, governance and education. All CMAC videos are shared under a Creative Commons Licence: Attribution 4.0 International. Please familiarise yourself with the terms of the licence before reusing our videos.
To view these videos, you will need this password: AiRblogVideos
Our burns videos are now collected together in a handy vimeo showcase! Follow this link to see all our burns-related airway videos: https://vimeo.com/showcase/9365611
These two videos come from the same patient, who had life-threatening burns. Due to geography, it was some time after the initial insult before airway management could be attempted. They show two attempts at DL/VL before ultimately the team progressed to front-of-neck access.
This first video shows full thickness burns of the lip, shedding of tongue mucosa and the epiglottis off midline to the right in view initially, then overcome with secretions.
This second video shows the best view achieved on second look – secretions form a veil around a very swollen epiglottis – the laryngeal inlet is not seen. The patient went on to have a surgical airway.
Airway management in advanced burns is notoriously tricky, from a combination of secretions, oedema, soot/carbon and tissue trauma. Often neck movement is also reduced if there is significant burnt neck tissue.
NOTE here – in both videos, bubbles seem to come from everywhere with many secretions, so the adage of “aiming for bubbles” is NOT advisable here – it’s likely there are also bubbles from the oesophagus after difficulty bagging during pre-oxygenation.
Video Focus: Contaminated Airways
The following videos showcase some challenges with contamination.
This older child had a reduced GCS. The video shows significant regurgitation during laryngoscopy; likely swallowed blood and gastric contents.
This patient was intubated as part of resuscitation after drowning. The airway is contaminated with seaweed, appearing as a green foreign body on laryngoscopy.
This is a video from a second look and intubation of a patient in cardiac arrest. The first look yielded “thick vomitus with no discernible landmarks”. It was too thick for the Ducanto catheter but too soft and fragmented for removal with Magill forceps. Improvement of positioning with cessation of compressions gave this view on second look.
Where Can I Find More CMAC Videos?
Try our Vimeo Channel! Don’t forget, you’ll need the same password: AiRblogVideos
In the seventh episode of the Sydney HEMS Debrief series, Sydney HEMS CCP and Educator Jackie Buckthought shares a challenging case from her training. Jackie discusses how this case has affected her work flow, resilience, and more recently her perspective as an educator. It’s a cracker!
As ever, any feedback is welcome – please get in touch, and until the next time, have a great week.
1. Time for re-attachment of a limb is longer than you might expect! The severed limb can be viable for up to 12 hours.
2. Guidance for amputated parts:
– Rinse with saline and cover with saline-soaked dressing
– Place in an airtight bag and place this bag in a 1:3 ice:water slurry
– Avoid direct contact with ice
3. Don’t forget to register to be a GoodSAM responder. Sign-up page can be found here.
4. Record cine loop during cardiac arrest to review echo images. The COACHRED protocol for incorporating focused echo into the rhythm check can be found here.
5. In low perfusion states expect to wait more than 60 seconds for paralysis to work.
6. Penetrating neck injury with hard signs (e.g. arterial/brisk bleed, massive surgical emphysema, air bubbling through wound) – Prehospital RSI almost certainly required. Hard and soft signs of penetrating neck injury can be found here.
7. Penetrating neck injury is one of the few trauma scenarios where femoral CVC placement is appropriate.
8. Nasendoscopy for prognosticating airway burns:
– Topicalise nose and throat with co-phenylcaine spray
– Use NPA for scope passage
– Can leave NPA in (if tolerated) for subsequent scopes
9. Morbidly obese patient with challenging IV access? Consider subclavian CVC option.
10. Neonatal life support – the heart rate of a newborn baby is best judged by listening with a stethoscope.
C+C Update
Robbie has done an incredible job developing the C+C QI project over the last year. He has recently headed back to the UK / Spain for the next adventure so Tom will be taking on the role of C+C lead registrar.
Check out the Sydney HEMS blog to read all about how the C+C project started and how far we’ve come. And listen to the HEMS Debrief podcast with Robbie and Sam to hear about the project.
In episode six of the debrief series, NSW Aeromedical Retrieval Staff Specialist Dr Sarah Aldington discusses a formative experience, highlighting the profound impact cases may have on clinicians and the importance of a dedicated debrief.
Sydney HEMS acknowledges the Australian Aboriginal and Torres Strait Islander peoples as the first inhabitants of the nation and the traditional custodians of the lands where we live, learn and work.
Greater Sydney Area HEMS 