The clinical focus of Module 2 is centred on the diagnosis and pre-hospital management of respiratory failure. The non-technical/CRM topic for this module is leadership. Chapter one of this module reviews the management of paediatric asthma. Chapter two focuses on the differential diagnosis and management of respiratory failure – it is divided into two separate lecture focusing specifically on both adult and paediatric medicine. Chapter two also explores the pros and cons of different leadership styles and team dynamics.

The simulations to be completed in this module are closely related to the content contained in these lectures.

Module #2 – Objectives

Module #2 – Chapter 1 – Pediatric Asthma Management

Module #2 – Chapter 2a- Respiratory failure-Leadership – Adult

Module #2 – Chapter 2b – Respiratory failure-Leadership – Pediatrics

Below you will find reference material to supplement the above lectures:

Childhood asthma: a guide for pediatric emergency medicine providers.
Kline-Krammes S1, Patel NH, Robinson S.
Emerg Med Clin North Am. 2013 Aug;31(3):705-32.

Starship Clinical Guidelines – Asthma: Acute Management

More coming soon!!!!

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 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 – 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.