How do you resuscitate an acute anaphylaxis from 1000km away?
How do you simulate a blood filled airway for training?
here is a great interview of two fantastic Australian rural doctor medical bloggers.Continue reading “PHARM podcast 008 – Rural Australian Retrieval perspectives with Casey and Tim”
Minh has taken Laryngoscope as a Murder WeaponTM to a new level with his presentation: Doctors with Guns. See his slideset…
and even better, Minh dug up this lecture which deserves highlighting:
Today on the podcast I interview Dr Sean Keogh, an emergency and retrieval physician from Brisbane, Queensland, Australia. He is I believe the first prehospital doctor to ever have a reported case of a successful prehospital thoracotomy in which the patient survived in 1993.
Check out these references
Sean currently is the Director of Clinical Governance at Careflight Group Queensland. He will tell us about his extensive trauma training experience in South Africa and rural Asia as well as in London. Listen to his accounts of retrieval and telemedicine, as he talks rural doctors through procedures like surgical airway or even a thoracotomy!
As always we discuss a hypothetical retrieval case and hear how Sean deals with it!
Sean is obsessed with emergency airway management as much as I am. He has attended the Difficult Airway course in Las Vegas three times and written and updated his services airway SOPs in the last 12 months.
Pour yourself a beverage, sit back and enjoy the interview!
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Minh interviews Dr. Karel Habig, Medical Director, Greater Sydney Area HEMS, New South Wales, Australia
Tonight I interview Dr Karel Habig, Emergency Physician and Retrieval Specialist , in Sydney. He is a brother in arms with Dr Cliff Reid, of Resus.Me podcast and blog site. They both work for the Greater Sydney Area HEMS , a prehospital and retrieval medicine service doing up to 3000 missions per annum. This blogsite gives some useful information about their work and training.
They also have an awesome YouTube channel!
On the interview we discuss a recent annual training trip that Karel, Cliff and other retrieval consultants from their service do and this year they went to South Africa to learn from emergency doctors and trauma surgeons at some of the busiest units in the world! Tune in and hear some great tips described like balloon tamponade using a Foley catheter for vascular injuries.
I also pose a retrieval case to Karel on a patient with acute STEMI and prehospital thrombolysis, requiring aeromedical retrieval but with a low haemoglobin of 8g/dL.
Check out this useful reference article on aeromedical considerations of critically ill patients!
Enjoy the podcast, send in your feedback, post your ratings on iTunes and stay safe!
Dr Minh Le Cong
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Fibreoptic guided intubation via a laryngeal airway on a budget
– a resilient advanced technique for the emergency provider facing a potentially difficult airway
The following description is of an advanced airway technique that is readily taught and learnt by those already skilled in direct laryngoscopy and rapid sequence intubation , using affordable equipment combining two technologies : a reuseable semi-rigid fibreoptic stylet and a disposable intubating laryngeal airway. The technique offers the advantages of a staged approach to managing the potentially difficult airway or even a failed intubation scenario. The first stage, that of insertion of the laryngeal airway, establishes primary safety for the technique by enabling rapid oxygenation and ventilation. The second stage, that of fibreoptic guided stylet assisted intubation via the laryngeal airway maintains the principle of safety, by using the airway as a protected conduit for the stylet and tracheal tube and visual confirmation of correct tube placement. The stylet is simpler to learn and operate than a flexible fibreoptic or CMOS camera tip based scope.
The equipment required (the complete setup costs less than $2500 AU initially)
1. Clarus Levitan FPS semi rigid optical stylet, approximate cost $2100 AU
-sterilisable using STARRAD technique or standard endoscope cleaning protocols
-requires light source ( not included), usually a spare laryngoscope handle with light bulb
2. Mercury Medical Air-Q intubating laryngeal airway, approximate cost $12 AU ea
-disposable, in sizes 1.5 to 4.5
-newer Air-Q intubating laryngeal airway with oesophageal blocker tip , allowing occlusion and drainage of oesophagus. Approx cost $22 AU ea
3. Endotracheal tube
preferably a Fastrach intubating laryngeal mask tracheal tube, approximate cost $70 ea, disposable
-Fastrach ILMA tracheal tubes specially designed to not kink when passed at acute angle using wire reinforcement. Very flexible ETT, not stiff at all, so requires a stylet or an airway conduit to enable intubation.
– atraumatic silicone soft tip
Image of Levitan FPS stylet mounted on a standard laryngoscope with light bulb and a disposable 7.0 ETT specially designed for the Fastrach ILMA ( note white soft silicone tip and wire reinforced shaft)
Image of 4.5 Air-Q intubating laryngeal airway inserted into a TruCorps airway mannikin
Image of assembled stylet with loaded ETT. Note ETT proximal connector has been removed to make ETT correct length for loading onto stylet. The stylet needs to be bent into a S shaped curve as pictured. This is quite safe to do without damaging the device.
Image of tip of Levitan FPS stylet just emerging from tip of ETT. Note the wire reinforcing of the specially designed ETT
Image of insertion of stylet with loaded ETT into the Air-Q. The use of a water based lubricant is optional to apply on outside surface of ETT. Using the 7.0 special ETT shown there was no need for lubrication for insertion and removal of stylet or Air-Q in this mannikin setup.
Image of completed insertion of device. Note a short length of exposed ETT is required to enable reinsertion of proximal ETT connector and attachment to a bag-valve manual resuscitator or ventilator circuit. Once the ETT tip is visually confirmed to have passed the vocal cords, the stylet is removed carefully with one hand gripping the ETT proximal end to securely hold it in place. The ETT proximal connector can now be reattached and end tidal capnography be used to reconfirm tracheal position. At this stage after successful tracheal intubation via the Air-Q, my advice is to leave all airway devices in situ and avoid attempts to remove the laryngeal airway over the ETT, in the emergency airway scenario. The only advantage this might offer is to allow placement of a gastric drainage catheter. With the newer Air-Q airway which has an inflatable oesophageal blocker balloon tip, gastric drainage port and channel, there is simply no need to remove the airway once intubation as occurred. With the first generation Air-Q if you really must place a gastric drain then you can deflate the Air-Q bowl and withdraw the device out of the mouth to a small degree, all with leaving the ETT still in place. This should allow you to insert an orogastric drain and then still leave the Air-Q in place. For transport of the patient, one should secure the device with at least two ties. One tie should secure the proximal end of the ETT to the proximal shaft of the Air-Q, so the two devices are fixed as one to prevent dislodgement of the ETT within the Air-Q. The second tie should secure the Air-Q to the patient’s head by placing a knot around the shaft of the Air Q as close to the patient’s lips as possible then looping the tie around the patient’s neck in the standard manner of securing LMAs or ETTs. Whilst this sounds like a complicated process and one might regard removing the Air-Q and leaving the ETT alone in situ as being simpler to manage, having secured two devices in situ, is in fact an even more resilient technique. For example if the ETT becomes dislodged, it can be quickly removed by cutting one tie and rescue oxygenation can occur via the Air-Q still in situ, secured by its second tie. It remains as the same conduit in the same place for a repeat successful intubation using the stylet to redetermine the position of the laryngeal inlet again.
Image taken through the eye piece of the Levitan FPS stylet. Actual quality of fibreoptic visualisation is better but the image correctly shows the narrow field of view via the stylet.
This image demonstrates a simulated blind intubation via the Air-Q without using the stylet. Note the flat angle of the ETT as it exits the bowl of the Air-Q. This will likely lead to failure to correctly approach the laryngeal inlet, which will be sitting superior to the bowl of the Air-Q
This image demonstrates the benefit of using the stylet shaped into a S curve. The exiting angle of the ETT is now more acute and aimed in a superior direction to the bowl. This replicates the designed angle of the Fastrach ILMA that allows for a more than 95% blind successful intubation attempt within 2 tries. The advantage using the Levitan FPS stylet is that the intubation attempt is fibreoptic visually guided, emulating the benefit of flexible fibreoptic endoscope guided intubation.
This image demonstrates the limitations of using the Levitan FPS optical stylet in other laryngeal airway devices such as this Fastrach ILMA. The acute angle of the bend of the shaft of the Fastrach prevents passage of the stylet adequately.
The same situation can be seen with the LMA Supreme.
How this technique adapts to the novel concept of the Rapid Sequence Airway:
The described technique of inserting a laryngeal airway primarily then a fibreoptic guided stylet assisted tracheal intubation fits perfectly into the concept of a Rapid sequence airway, in which standard RSI drugs are used to place a supraglottic airway device, as the first stage. Then when critical hypoxia is corrected using the supraglottic device, a more controlled tracheal intubation is performed as a second stage. Usually this would mean removing the laryngeal airway device and performing traditional laryngoscopy or newer video laryngoscopy for the intubation. With the Air-Q/ Levitan FPS combination, there no longer needs to be the step in removing the supraglottic device to perform the intubation.
I have described a novel technique that addresses most of the major issues in the predicted and unpredicted difficult airway. I did not conceive this technique and I stand on the shoulder of giants in emergency airway management. Using a blended airway approach that combines technologies and concepts, the end result is a technique that is resilient, simple to learn and teach and affordable to most emergency services and even individual providers. The ability to stage your airway intervention yet remain grounded in the safety principle of primary oxygenation at all times, is analogous to the strategy to conquer Mount Everest. One does not simply do this in one single attempt as hypoxic physiology remains a lethal complication at all times, as is the case in emergency airway management! Laying siege to the mountain and making the ascent in planned stages has always been the time tested strategy that is not only most successful but carries the least risk of death. So when you predict the airway is going to be difficult and become your own personal Mt Everest, remember this technique and hopefully you would have prepared yourself and the correct gear to make the outcome safe and successful!
I acknowledge Dr James DuCanto, Dr Scott Weingart, Dr Darren Braude and Dr Richard Levitan for their teachings and concepts that have been synthesized into writing this article.
This month on ‘Own the Airway Audio’ Minh speaks to Dr Seth Trueger (@MDaware), a chief resident (i.e. senior registrar equivalent) who works with EMCrit‘s Scott Weingart in New York. Seth’s training has taken him down a resuscitation sub-specialty track, with a focus on the airway. He has a special interest in awake intubation in the ED.
Go to Life in the Fast Lane to see the Post
Key points of the podcast
- In the prehospital setting, personal equipment should be light, portable, small, cheap , easily replaceable and serve multiple functions
- A portable light source is essential, day or night, as a clinical examination tool and portable illumination
- My shopping list for a prehospital light source include : minimum 200 lumens intensity, LED, standard battery power(AA or CR123), hand carried or mountable with a clip, converts to head mounted illumination
- Hands free lighting is the way to go. Examine and do procedures like chest drain insertion or finger thoracostomies in low light conditions where your line of sight is illuminated!
- Transillumination or pan illumination using LED high intensity light source to find superficial non palpable veins. Traditionally used in paediatrics to find veins, this technique can be used in all age groups. Refer to accompanying demonstration video. Transillumination is technique of illuminating through the full thickness of a body part like a hand or foot. Pan illumination is the technique of localised soft tissue illumination allowing vessels to be shadow outlined locally. Yes with IO access in prehospital medicine, this is not so useful but still handy to know in case no IO or USS available. Useful areas to look for superficial veins with this technique are lateral infraclavicular area, medial lower humeral area, volar forearm, lateral neck, medial ankle and dorsum foot.
- Closeup image of LED Torch privately purchased from www.zebralight.com
- Image of camping head torch, baseball type peaked cap with clip mounted LED torch, LED torch. This is my prehospital personal light set
- Closeup image of LED Torch with reversed mounting clip attached to cap peak
Acknowledgements : Dr Thien Le Cong,my brother, who taught me the above techniques and suggested the LED high intensity light source
Conflicts of interest : None. All devices were privately purchased and no sponsorship is provided or sought
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This is not an EMCrit Podcast, this is the first episode of a possible new podcast from EMCrit frequent poster Minh Le Cong.
You know Minh from posts like:
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