Coming to you a little later than the release date, here are the top coffee and cases learning snippets from November 2023.
In cases of major haemorrhage or difficult IV access – consider inserting a trauma line.
If you feel that a job is running too slowly, declare this to the team and ensure both members are matching their speeds. Slow is smooth, smooth is fast.
Promethazine 12.5mg IV – effective for motion sickness and light sedation for long transport times to hospital.
QuikClot is for compressible haemorrhage. It requires pressure for at least 3 minutes in order to be effective. Consider it as an extension of your finger into the hole.
If a patient is haemodynamically unstable or has a labile BP, double pump your inotropes. The medical team should be prepared to maintain oversight of this at BOTH ends of the transfer.
Two NPAs and an OPA with jaw thrust (“tripod” or “supported tripod” with jaw thrust) should be used if there is difficulty maintaining an open airway.
Apply a pelvic binder, when indicated, ASAP. There can be a tendency to lay the binder across the stretcher and apply it after moving the patient there – this may however involve multiple moves with the pelvis not stabilised. Try to get the binder onto the spine board (which is used for extrication) or slide it directly under the patient prior to rolling/extrication.
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Welcome to episode 11 – likely our last episode of the year!
The feedback has been fantastic – thank you to all who have taken the time to let me know your thoughts, and for helping to shape the episodes into what they are.
In this end of year episode, we are joined by Sydney HEMS Staff Specialist Dr Ruby Hsu. Ruby and I sat down for a chat with no real agenda, but knowing that she had a fantastically varied and colourful pre-hospital career across several countries, I thought it valuable to hear Ruby’s thoughts on – amongst other things – safe systems, career building, and luck.
I hope you enjoy it, and speak to you in the New Year.
In the ninth episode of the Sydney HEMS Debrief series, we have the first half of a two-part episode!
Join us as Sydney HEMS Senior Staff Specialist Dr Brian Burns discusses the recognition, aetiology and treatment of different types of shock in our pre-hospital trauma patients. Whilst pre-hospital clinicians may have a natural bias towards hypovolaemic shock secondary to blood loss, Dr Burns discusses the many mimics of hypovolaemic shock, and how it is crucial we remain mindful of other causative acute and subacute pathologies.
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
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