Module #2 – Objectives

Module #2 – Ventilation Strategies and the Management of Respiratory Emergencies.

Clinical and Technical Skills

Upon completion of module two, course participants should be able to complete the following:

1.1Respiritory Physiology
1.1.2 Define the following terms:
i. Total Lung Capacity
ii. Tidal Volume
iii. Vital Capacity
iv. Functional Residual Capacity
v. Expiratory Reserve Volume
vi. Residual Volume
vii. Inspiratory Reserve Volume
1.1.3 Define compliance
1.1.4 List 5 common causes for decreased compliance
1.1.5 List the difference between adult and pediatric respiratory physiology

1.2 Non-invasive Positive Pressure Ventilation Support
1.2.1 Describe the effects of PEEP on respiratory and hemodynamic physiology
1.2.1 Describe the use of NIPPV in pre-oxygenation
1.2.2 Demonstrate effective 1-person and 2-person BVM technique
1.2.3 List pulmonary conditions in which the use of NIPPV should be considered
1.2.4 Understand the use of CPAP/BiPAP.
1.2.5 List absolute contraindication to the use of NIPPV

1.3 Invasive Positive Pressure Ventilation
1.3.1 Describe the basic types ventilation control
1.3.2 Describe the basic modes of ventilation
1.3.3 Describe the following terms:
i.FiO2
ii. PEEP
iii. Peak inspiratory pressure
iv. Plateau pressure
v. Peak expiratory pressure
vi. I/E ratio
vii. Pressure support
viii. Frequency
ix. Basic understanding of flow-volume curves on ventilator
1.3.4 Demonstrate the initial ventilator setup for an intubated patient and explain your rational for doing so.
1.3.5 Describe the use of waveform capnography and outline variances with pathology

Common Presentations

1.4 Asthma
1.4.1 Describe the classic presentation of asthma.
1.4.2 Describe the pre-hospital management of severe asthma including (discuss pharmacokinetics, dosages and relative risks):
i. Nebulized salbutamol
ii. Nebulized Ipratroprium
iii. Hydrocortisone
iv. IV fluid
v. IV Magnessium
vi. IV Salbutamol
vii. IM/IV Adrenaline
1.4.3 Describe an approach to intubating a patient with status asthmaticus
1.4.4 Describe your initial approach to ventilating a patient with severe asthma

1.5 COPD
1.5.1 Describe the classic presentation of COPD.
1.5.2 Describe the pre-hospital management of severe asthma including (discuss pharmacokinetics, dosages and relative risks):
i. Nebulized salbutamol
ii. Nebulized Ipratroprium
iii. Hydrocortisone
iv. IV fluid

1.6 CHF
1.6.1 Describe the classic presentation of CHF.
1.6.2 Describe the pre-hospital management of severe asthma including (discuss pharmacokinetics, dosages and relative risks):
i. Position patient in an upright position
ii. NIPPV w/ BVM
iii. GTN
1.6.3 Describe your approach to intubating the patient with CHF
1.6.4 Describe your initial approach to ventilating a patient with CHF

1.7 Pneumonia
1.7.1 Describe the classic presentation of pneumonia.
1.7.2 Describe the pre-hospital management of severe pneumonia/sepsis including (discuss pharmacokinetics, dosages and relative risks):
i. Position patient in an upright position; provide O2 as necessary
ii. Fluid resuscitation
iii. Antibiotics
1.7.3 Describe your approach to intubating the patient with pneumosepsis.
1.7.4 Describe your initial approach to ventilating a patient with pneumosepsis.

1.8 Pneumonthorax
1.8.1 Describe the classic presentation of pneumothorax/ tension pneumothorax.
1.8.2 Describe the pre-hospital management of pneumothorax including (discuss pharmacokinetics, dosages and relative risks):
i. Diagnosis
ii. Oxygenation
iii. Decision to transport by helicopter
iv. Decompression: Finger vs. Needle Thoracostomy
v. Risks of positive pressure ventilation in pneumothorax.

Module #1 – Airway Management

Module one of the pre-hospital critical care curriculum focuses on advanced airway management. This module will run for three consecutive weeks and will cover a wide range of topics. Upon successful completion of this module participants will have mastered the material as outlined in the course objectives and have completed a total of three different simulation scenarios (although you may complete the same simulation more then once – your role will be different each time).

Below you will find links to the module objectives and to the pre-simulation podcast lectures. Module one is composed of three chapters. Each chapter will focus on specific material that will be reinforced with in-situ simulation.

Module # 1 – Objectives

Airway Module – Chapter 1 – SOPs:Difficult Airway:Surgical Airway

Airway Module – Chapter 2 – The Neuroprotective Intubation:Pediatric RSI

Airway Module – Chapter 3 – Video Laryngoscope – Working in Austere Environments

Reference material: Below you will find links to material referenced in the podcast lectures.

Observational study of the success rates of intubation and failed intubation airway rescue techniques in 7256 attempted intubations of trauma patients by pre-hospital physicians.
Lockey D1, Crewdson K2, Weaver A2, Davies G2.
Br J Anaesth. 2014 Aug;113(2):220-5. doi: 10.1093/bja/aeu227.

Prehospital anaesthesia performed by physician/critical care paramedic teams in a major trauma network in the UK: a 12 month review of practice.
McQueen C1, Crombie N, Hulme J, Cormack S, Hussain N, Ludwig F, Wheaton S.
Emerg Med J. 2013 Oct 16. doi: 10.1136/emermed-2013-202890. [Epub ahead of print]
http://www.ncbi.nlm.nih.gov/pubmed/24132327

Development of a standard operating procedure and checklist for rapid sequence induction in the critically ill.
Sherren P, Tricklebank S, Glover G.

Scand J Trauma Resusc Emerg Med. 2014 Sep 11;22(1):41.

Delayed Sequence Intubation: A Prospective Observational Study.
Weingart SD1, Trueger NS2, Wong N3, Scofi J4, Singh N5, Rudolph SS6.
Ann Emerg Med. 2014 Oct 23. pii: S0196-0644(14)01365-1.[Epub ahead of print]

http://lifeinthefastlane.com/ccc/pretreatment-drugs-for-rapid-sequence-intubation-rsi/

The ketamine effect on ICP in traumatic brain injury.
Zeiler FA1, Teitelbaum J, West M, Gillman LM.
Neurocrit Care. 2014 Aug;21(1):163-73.

Pediatric airway management.
Santillanes G1, Gausche-Hill M.
Emerg Med Clin North Am. 2008 Nov;26(4):961-75

Pediatric airway nightmares.
D’Agostino J.
Emerg Med Clin North Am. 2010 Feb;28(1):119-26.

Module #1 – Airway Management Objectives

Module #1 – Pre-hospital Airway Management Objectives

Clinical and Technical Skills.

Upon completion of module 1 – Airway Management – course participants should be able to complete the following:

1.0 Anatomy
1.1 Describe basic airway anatomy
1.2 Describe the differences between the pediatric and adult airway

2.0 Identify the need for definitive management including:
2.1 Anatomical obstruction.
2.2 Lack/loss of airway protection.
2.3 Projected clinical course necessitating definitive airway management prior to arrival at receiving hospital.

3.0 Perform an accurate airway assessment and develop a management plan including:
3.1 Identification of (potential) difficult BMV
3.2 Identification of (potential) difficult intubation
3.3 Identification of (potential) difficult supraglottic airway
3.4 Identification of (potential) difficult surgical airway
3.5 Describe algorithm for both difficult and failed airways.

4.0 Airway Management
4.1 Demonstrate use of Pre-RSI checklist
4.2 Clearly assign airway roles (ICP vs HEMS physician vs. Crewman)
4.3 Optimize pre-oxygenation (eg. Nasal trumpets/OPA/etc)
4.4 Optimize patient position
4.4.1 Helicopter vs. Ambulance vs. Roadside
4.4.2 Anatomical positioning
4.4.3 Scene management
4.5 Describe the pharmacology of the following RSI medications:
Induction Agent
4.5.1.1 Ketamine
4.5.1.2 Etomidate
4.5.1.3 Fentanyl
4.5.1.4 Midazolam
Neuromuscular Blocking Agent
4.5.2.1 Suxmethonium
4.5.2.2 Rocuronium
Pediatric specific medications
4.5.3.1 Atropine
Rescue Medications
4.5.4.1 Adreniline
4.5.4.2 Metarminol
4.6 Intubation
4.6.1 Use Cormack-Lehane grading system to describe view of glottic opening.
4.6.2 Demonstrate correct placement of ETT tube under direct vision.
4.6.3 Demonstrate effective use of bougie
4.6.4 Demonstrate a working knowledge of video-laryngoscopy
4.6.5 Demonstrate correct placement of supra-glottic airway device

4.7 Surgical airway
4.7.1 Demonstrate a working knowledge of appropriate surgical anatomy required to perform a needle/ open cricothyrotomy
4.7.2 Demonstrate appropriate surface land-marking required to perform needle/open cricothyrotomy.
4.7.3 List the equipment necessary to perform a needle/open cricothyrotomy.
4.7.3 Demonstrate a needle/ open cricothyrotomy.

4.8 Confirm correct placement of ETT
4.8.1 Understand use of ETCO2 for confirming placement of ETT
4.8.2 Describe alternative methods to confirm placement of ETT

4.9 Post –Intubation Care
4.9.1 Appropriate use of Post-RSI checklist
4.9.2 Demonstrate an appropriate technique to secure ETT for potential rough/turbulent transport.
4.9.3 Describe the pharmacology of the following post-intubation medication used to:
Sedated/ Analgesic for transportation:
4.9.3.1 Ketamine
4.9.3.2 Fentanyl/ Morphine
4.9.3.3 Midazolam
Neuromuscular Blockade for transport
4.9.3.1 Rocuronium

4.10 Transport
4.10.1 Formulate plan for potential complication related to/ during transport phase.

Introduction

Chapter #1 – Introduction to the Course

Welcome to the introductory podcast episode of the Auckland Helicopter Rescue Trust simulation based, pre-hospital critical care curriculum. This episode will introduce the ARHT education team and outline the goals and structure of the curriculum.

Below you will find some more information relating to the concept of a “flipped classroom” as well as the use of simulation in medical education.

Web links:

Review of Flipped classroom – http://www.flippedlearning.org/cms/lib07/VA01923112/Centricity/Domain/41/LitReview_FlippedLearning.pdf

The 7 thing’s you should know about the flipped classroom – https://net.educause.edu/ir/library/pdf/ELI7081.pdf

How Flipping the Classroom can improve the Traditional Lecture – http://moodle.technion.ac.il/file.php/1298/Announce/How_Flipping_the_Classroom_Can_Improve_the_Traditional_Lecture.pdf

Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence.
McGaghie WC1, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB.
Acad Med. 2011 Jun;86(6):706-11.

Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review.
Issenberg SB1, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ.
Med Teach. 2005 Jan;27(1):10-28.

Could simulated emergency procedures practised in a static environment improve the clinical performance of a Critical Care Air Support Team (CCAST)? A literature review.
Lamb D.
Intensive Crit Care Nurs. 2007 Feb;23(1):33-42.

The utility of simulation in medical education: what is the evidence?
Okuda Y1, Bryson EO, DeMaria S Jr, Jacobson L, Quinones J, Shen B, Levine AI.
Mt Sinai J Med. 2009 Aug;76(4):330-43. doi: 10.1002/msj.20127.

Simulation as a tool to improve the safety of pre-hospital anaesthesia–a pilot study.
Batchelder AJ1, Steel A, Mackenzie R, Hormis AP, Daniels TS, Holding N.
Anaesthesia. 2009 Sep;64(9):978-83.