Preparation for patient retrieval – podcast and checklist

The first RFDS aircraft

The first RFDS aircraft

While Auckland HEMS does not currently perform many inter-hospital transfers, we anticipate that we will be doing more of this work in the future.

Our colleagues in Australia do a lot of these missions, and have produced some great FOAM resources.

This audio clip (right click to save) is a podcast from Minh Le Cong at prehospitalmed.com, in which he, along with Cliff Reid and Brian Burns from Greater Sydney Area HEMS discuss pearls and tips in preparing the critical patient for retrieval and transport.

Minh’s page for the podcast is here, and includes a very useful post by Tim Leeuwenburg from ruraldoctors.net in the comments section.

Tim’s checklist for patient transport is located here.

Paediatric prehospital trauma care resources

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With over half the Auckland HEMS team coming from a hospital that serves age 15 and up (and therefore not dealing with children on a daily basis), prehospital management of paediatric patients is a field to which we must pay considerable attention in our training. Simulation exercises have included paediatric scenarios on several occasions – our thanks to Mike Shepherd and Trish Wood from Starship Hospital for their assistance!

Below are some useful resources regarding prehospital care of paediatric trauma patients:

Podcasts from Dr Jeffrey Guy, Medical Director of PHTLS (right-click to download)

(he has also produced other PHTLS podcasts – found here)

A 2012 review of prehospital paediatric trauma from the Harbourview Medical Centre in Seattle can be found here. Take-home messages:

  • falls and MVA are the most common causes of paediatric trauma morbidity
  • despite a lot of research and intervention paediatric trauma patients are under-resuscitated on arrival compared to their adult counterparts
  • children have very different airways anatomically to adults; with full cervical spine immobilisation airway view can be improved with a towel under the shoulders to bring the neck into a neutral position
  • with a higher surface area/size ration children are more prone to hypothermia
  • due to their smaller blood volume a small amount of blood lost can represent a large percentage of their blood volume
  • contrary to traditional teaching, cuffed ETT are increasingly used at half a size smaller than the appropriate uncuffed ETT

 

 

 

NAP4 and its implications for prehospital airway management

In 2011 the U.K. Royal College of Anaesthetists and The Difficult Airway Society released a report called NAP4 – the 4th national audit of major complications of airway management.

Full text of NAP4 report

Full text of NAP4 report

The report covered airway complications that occurred in anaesthesia, ICU, and ED settings (approximately 20000 in total). Every reported complication of airway management was analysed for causes and learning points.

The findings relating to ED complications have direct implications for prehospital airway management.

‘Take-home’ messages relating to ED airway management:

  • in the event of an airway complication (most commonly failed RSI), patients were more likely to die in ED or ICU than OR
  • at-risk patients were often not identified prior to the attempt at airway management
  • waveform quantitative capnography should be the standard of care for EVERY intubation
  • situations where the capnography reading was zero (indicating misplaced or completely obstructed ETT) were incorrectly attributed to cardiac arrest (CPR always generates SOME CO2)
  • complications arose when there was a ‘failure to plan for failure’
  • obesity was a major risk factor for airway complications

and, most importantly:

  • in the event of a surgical airway being needed, surgical cricothyroidotomy was almost universally successful, while needle cricothyroidotomy had a failure rate of up to 60%
  • the success of surgical cricothyroidotomy included those where ED doctors (not surgeons) were the ones performing the procedure

Here is an excellent podcast – it is an interview by Cliff Reid of Jonathan Benger, a Professor of Emergency Medicine and one of the authors of the NAP 4 study (sourced from emcrit.org) regarding the implications of NAP4 for emergency department airway management.

So what are the implications for our HEMS service?

The most relevant findings for us form NAP4 are the findings relating to airway complications in ED, more so than anaesthesia or ICU. Patients who we would intubate pre-hospital are those who, if prehospital intubation were not available, would be intubated shortly after arrival in ED. The majority of our doctors are ED-trained, and are most familiar with ED airway management (translation: simple, fast, relatively low-tech, with the fairly standardised approach for the majority of our patients)

Bringing ED airway management to the prehospital arena has its challenges. The patients are more undifferentiated, comparatively under-resuscitated, and there may not have been enough time to get a sense of their ‘trajectory’.Environmental  factors (light, weather, physical access to patient) will have a huge impact on the execution of airway intervention.  We have a lot less equipment – no Glidescope, less rescue devices, and no telephone to call for an anaesthetist and a tech with a trolley full of difficult airway equipment. We may have team members (relatively junior ambulance staff, for example) who have much less experience with RSI than ED nurses who are often part of our RSI team.

Doing the basics right therefore becomes even MORE important:

  • equipment must be effective, functional, and familiar to us through training
  • there must be a ‘shared mental model’ – including a plan for success and a plan for failure – which must be vocalised for every patient with all team members understanding their role
  • we must actively consider patient specific elements that will affect the plan for success and the plan for failure (anatomy, injury, obesity etc)
  • we must be as prepared as possible – if the situation allows, taking several extra minutes to optimise positioning, place nasal cannulae for apnoeic ventilation etc may be crucial
  • we can overcome the disorienting effect of unfamiliar/unfriendly environments by using our RSI checklist – this was we are unlikely to forget something crucial (like capnography)
  • there must be a relatively ‘hands off’ team member whose task is to maintain situational awareness – in particular to initiate the ‘plan for failure’ should it become necessary
  • in the event of ‘can’t intubate, can’t ventilate‘, a surgical cricothyroidotomy should probably be our ‘go-to’ surgical airway of choice. If needle cricothyroidotomy has a failure rate of up to 60% in a hospital setting, it is hard to imagine how it could fare better in the prehospital arena. Of course there may be exceptions to this (difficult neck anatomy etc)

More commentary on the results and implications of NAP4 can be found here (British Journal of Anaesthesia, section of report relevant to ED and ICU) and here (from Cliff Reid)

 

“The best lecture on airway management – ever?”

In the continuing aucklandhems.com theme of not reinventing the wheel, here is a superb video podcast of a lecture about airway management by Dr Richard Levitan – emergency physician and airway guru.

It focuses on laryngoscopy, including techniques for improving your view, bimanual laryngoscopy, positioning and head elevation, apnoeic oxygenation, avoiding common pitfalls, and understanding the dynamic elements of airway anatomy.

In our prehospital setting, good laryngoscopy technique (or, as Dr Levitan puts it, the sequence of epiglottoscopy —> laryngoscopy —> tube delivery) is the cornerstone technical skill of airway management – not a Glidescope in sight!

This podcast was sourced from Scott Weingart’s emcrit.org

The slide set for the talk is here

The video podcast is here

The landmark paper Preoxygenation and Prevention of Desaturation During Emergency Airway Management (by Drs Levitan and Weingart) is here

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