Cliff Reid

Apneic Oxygenation Was Associated With Decreased Desaturation Rates During Rapid Sequence Intubation by an Australian Helicopter Emergency Medicine Service

STUDY OBJECTIVE The Greater Sydney Area Helicopter Emergency Medical Service undertakes in excess of 2,500 physician/paramedic out-of-hospital and interhospital retrievals each year, of which 8% require intubation. Emergency anesthesia of critically ill patients is associated with complications, including hypoxia. In July 2011, the service introduced apneic oxygenation with nasal cannulae to its emergency anesthesia standard operating procedure to reduce rates of desaturation during rapid sequence intubation. We evaluate the association between the introduction of apneic oxygenation and incidence of desaturation during rapid sequence intubation in both out-of-hospital and interhospital retrievals. METHODS This was a retrospective study of prospectively collected airway registry data. Consecutive patients who underwent rapid sequence intubation by Greater Sydney Area Helicopter Emergency Medical Service personnel between September 2009 and July 2013, spanning the introduction of apneic oxygenation, were included for analysis (n=728). We compared patients who underwent rapid sequence intubation before the service introduced apneic oxygenation (n=310) with those who underwent it after its introduction (n=418). We evaluated the association between the introduction of apneic oxygenation and the incidence of desaturation. RESULTS During the study period, 9,901 missions were conducted with 728 rapid sequence intubations (310 pre- and 418 postapneic oxygenation). The introduction of apneic oxygenation was followed by a decrease in desaturation rates from 22.6% to 16.5% (difference=6.1%; 95% confidence interval 0.2% to 11.2%). CONCLUSION Introduction of apneic oxygenation was associated with decreased incidence of desaturation in patients undergoing rapid sequence intubation.

Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service

Survival rates following traumatic cardiac arrest (TCA) are known to be poor but resuscitation is not universally futile. There are a number of potentially reversible causes to TCA and a well-defined group of survivors. There are distinct differences in the pathophysiology between medical cardiac arrests and TCA. The authors present some of the key differences and evidence related to resuscitation in TCA, and suggest a separate algorithm for the management of out-of-hospital TCA attended by a highly trained physician and paramedic team.See related commentary by Klein, http://ccforum.com/content/17/3/156

Case report: prehospital use of intranasal ketamine for paediatric burn injury

In this study, the administration of an intravenous ketamine formulation to the nasal mucosa of a paediatric burn victim is described in the prehospital environment. Effective analgesia was achieved without the need for vascular or osseous access. Intranasal ketamine has been previously described for chronic pain and anaesthetic premedication. This case highlights its potential as an option for prehospital analgesia.

Communication skills training for emergency department senior house officers—a qualitative study

Objective—To identify common weaknesses in senior house officer-patient consultation skills, and evaluate direct observation with feedback and negotiation of educational contracts, as a teaching tool in an emergency department setting. Method—Common weaknesses were identified through review of feedback charts by three trained observers. Alteration in clinical and learning behaviour, as well as senior house officer and observer perceptions of the teaching were evaluated qualitatively by a combination of semi-structured interviews and focus groups. Results—Several common weaknesses were identified, notably the use of closed questions, and poor negotiation and explanation of treatment plan and follow up. The senior house officers perceived improvement in their clinical practice, welcomed feedback, and subsequently set, though did not complete educational contracts. While comfortable with this style of teaching, the observers felt that it did not make efficient use of teaching time. Conclusions—This study identifies common weaknesses in the consultation skills of emergency department senior house officers and confirms the need for training in this area. Direct observation is effective in changing behaviour to this end, though self directed learning is not necessarily stimulated. Video recorded consultations with group feedback may be a more effective teaching tool.

Are physicians required during winch rescue missions in an Australian helicopter emergency medical service

Background A helicopter emergency medical service (HEMS) capable of winching offers several advantages over standard rescue operations. Little is known about the benefit of physician winching in addition to a highly trained paramedic. Objective To analyse the mission profiles and interventions performed during rescues involving the winching of a physician in the Greater Sydney Area HEMS (GSA-HEMS). Methods All winch missions involving a physician from August 2009 to January 2012 were identified from the prospectively completed GSA-HEMS electronic database. A structured case sheet review for a predetermined list of demographic data and physician-only interventions (POIs) was conducted. Results We identified 130 missions involving the winching of a physician, of which 120 case sheets were available for analysis. The majority of patients were traumatically injured (90%) and male (85%) with a median age of 37 years. Seven patients were pronounced dead at the scene. A total of 63 POIs were performed on 48 patients. Administration of advanced analgesia was the most common POI making up 68.3% of interventions. Patients with abnormal RTSc2 scores were more likely to receive a POI than those with normal RTSc2 (84.8% vs 15.2%; p=0.03). The performance of a POI had no effect on median scene times (45 vs 43 min; p=0.51). Conclusions Our high POI rate of 40% (48/120) coupled with long rescue times and the occasional severe injuries support the argument for winching Physicians. Not doing so would deny a significant proportion of patients time-critical interventions, advanced analgesia and procedural sedation.

Availability and utilisation of physician-based pre-hospital critical care support to the NHS ambulance service in England, Wales and Northern Ireland

Background Every day throughout the UK, ambulance services seek medical assistance in providing critically ill or injured patients with pre-hospital care. Objective To identify the current availability and utilisation of physician-based pre-hospital critical care capability across England, Wales and Northern Ireland. Design A postal and telephone survey was undertaken between April and December 2009 of all 13 regional NHS ambulance services, 17 air ambulance charities, 34 organisations affiliated to the British Association for Immediate Care and 215 type 1 emergency departments in England, Wales and Northern Ireland. The survey focused on the availability and use of physician-based pre-hospital critical care support. Results The response rate was 100%. Although nine NHS ambulance services recorded physician attendance at 6155 incidents, few could quantify doctor availability and utilisation. All but one of the British Association for Immediate Care organisations deployed ‘only when available’ and only 45% of active doctors could provide critical care support. Eleven air ambulance services (65%) operated with a doctor but only 5 (29%) operated 7 days a week. Fifty-nine EDs (27%) had a pre-hospital team but only 5 (2%) had 24 h deployable critical care capability and none were used regularly. Conclusion There is wide geographical and diurnal variability in availability and utilisation of physician-based pre-hospital critical care support. Only London ambulance service has access to NHS-commissioned 24 h physician-based pre-hospital critical care support. Throughout the rest of the UK, extensive use is made of volunteer doctors and charity sector providers of varying availability and capability.

Sustained life-like waveform capnography after human cadaveric tracheal intubation

Introduction Fresh frozen cadavers are effective training models for airway management. We hypothesised that residual carbon dioxide (CO2) in cadaveric lung would be detectable using standard clinical monitoring systems, facilitating detection of tracheal tube placement and further enhancing the fidelity of clinical simulation using a cadaveric model. Methods The tracheas of two fresh frozen unembalmed cadavers were intubated via direct laryngoscopy. Each tracheal tube was connected to a self-inflating bag and a sidestream CO2 detector. The capnograph display was observed and recorded in high-definition video. The cadavers were hand-ventilated with room air until the capnometer reached zero or the waveform approached baseline. Results A clear capnographic waveform was produced in both cadavers on the first postintubation expiration, simulating the appearances found in the clinical setting. In cadaver one, a consistent capnographic waveform was produced lasting over 100 s. Maximal end-tidal CO2 was 8.5 kPa (65 mm Hg). In cadaver two, a consistent capnographic waveform was produced lasting over 50 s. Maximal end-tidal CO2 was 5.9 kPa (45 mm Hg). Conclusions We believe this to be the first work to describe and quantify detectable end-tidal capnography in human cadavers. We have demonstrated that tracheal intubation of fresh frozen cadavers can be confirmed by life-like waveform capnography. This requires further validation in a larger sample size.

Life, limb and sight-saving procedures—the challenge of competence in the face of rarity

Emergency physicians require competence in procedures which are required to preserve life, limb viability or sight, and whose urgency cannot await referral to another specialist. Some procedures that fit this description, such as tracheal intubation after neuromuscular blockade in a hypoxaemic patient with trismus, or placement of an intercostal catheter in a patient with a tension pneumothorax, are required sufficiently frequently in elective clinical practice, that competence can be acquired simply by training in emergency department, intensive care or operating room environments. Other procedures, such as resuscitative thoracotomy, may be required so infrequently that the first time a clinician encounters a patient requiring such an intervention may be after the completion of specialist training, or in the absence of colleagues with prior experience in the technique. Some techniques that might be considered limb or life saving may be too technically complex to acquire outside specialist surgical training programs. Examples are damage control laparotomy and limb fasciotomy. One could, however, argue that these are rarely too urgent to await arrival of the appropriate specialist. The procedures which might fit the description of a time-critical life, limb or sight-saving procedure in which it is technically feasible to acquire competence within or alongside an emergency medicine residency, and that cannot …

Logistics and Safety of Extracorporeal Membrane Oxygenation in Medical Retrieval

Abstract Objective. This article reviews the logistics and safety of extracorporeal membrane oxygenation (ECMO) medical retrieval in New South Wales, Australia. Methods. We describe the logistics involved in ECMO road and rotary-wing retrieval by a multidisciplinary team during the H1N1 influenza epidemic in winter 2009 (i.e., June 1 to August 31, 2009). Basic patient demographics and key retrieval time lines were analyzed. Results. There were 17 patients retrieved on ECMO, with their ages ranging from 22 to 55 years. The median weight was 110 kg. Four critical events were recorded during retrieval, with no adverse outcomes. The retrieval distance varied from 20.8 to 430 km. There were delays in times from retrieval booking to both retrieval tasking and retrieval team departure in 88% of retrievals. The most common reasons cited were “patient not ready,” 23.5% (4/17); “vehicle not available,” 23.5% (4/17); and “complex retrieval,” 41.2% (7/17). The median time (hours:minutes) from booking with the medical retrieval unit (MRU) to tasking was 4:35 (interquartile range [IQR] 3:27–6:15). The median time lag from tasking to departure was 1:00 (IQR 00:10–2:20). The median stabilization time was 1:30 (IQR 1:20–1:55). The median retrieval duration was 7:35 (IQR 5:50–10:15). Conclusion. The process of development of ECMO retrieval was enabled by the preexistence of a high-volume experienced medical retrieval service. Although ECMO retrieval is not a new concept, we describe an entire process for ECMO retrieval that we believe will benefit other retrieval service providers. The increased workload of ECMO retrieval during the swine flu pandemic has led to refinement in the system and process for the future.

Does end-tidal capnography confirm tracheal intubation in fresh-frozen cadavers?

Background Life-like end-tidal capnography (ETCO2) waveforms have been demonstrated in recently deceased and fresh-frozen cadavers following tracheal intubation, offering potential for high fidelity airway simulation training. As the mechanism for carbon dioxide production is not fully understood, it is possible that oesophageal intubation may also generate a capnograph. Our aim was to measure ETCO2 levels following (1) oesophageal and (2) tracheal intubation in fresh-frozen cadavers, and to observe the size, shape and duration of any capnographic waveform. Methods Four fresh frozen cadavers underwent oesophageal intubation by an emergency medicine specialist with confirmation by a second specialist. Hand ventilation with room air via a self-inflating resuscitation bag was provided at 12 breaths per minute for 2 min or until ETCO2 was zero for 10 consecutive breaths. ETCO2 and waveform morphology were examined and video recorded. The oesophagus was then extubated and the process was repeated for tracheal intubation. Results In no case was oesophageal ETCO2 detected. For two cadavers, life-like ETCO2 waveforms were achieved immediately after tracheal intubation, with maximum ETCO2 achieved by the second breath. In these cases waveform morphology was normal and persistent. Conclusions Cadaveric oesophageal intubation did not result in a capnography waveform, simulating live patients. When present, ETCO2 following tracheal intubation showed normal morphology which was sustained for 2 min. However, ETCO2 was not present following tracheal intubation in all cadavers. These results represent instrumentation on the cadavers for the first time after thawing and further work should assess the repeatability of the findings with subsequent intubations.