Airway Talk
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Elliot Long from RCH talks about improving the safety of emergency airway management.
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Airway Talk
- 1. Improving the safety of emergency airway management Elliot Long BSc BMBS FRACP PGCertCU
- 2. Disclosures
- 3. Cases • 5yo morbidly obese septic encephalopathy • 13 month old TOF/OA aspiration pneumonia hypoxic respiratory failure
- 4. Management strategy 10ya? • RSI
- 5. 7 p’s of RSI • Preparation • Pre-oxygenation • Pre-treatment • Paralysis (with induction of anaesthesia) • Protection • Placement • Post-intubation management
- 6. Actual management: • 5yo morbidly obese septic encephalopathy • 13 month old TOF/OA aspiration pneumonia hypoxic respiratory failure
- 7. KEY POINTS • Prioritise avoidance of hypoxia / hypotension • Plan for failure • Avoid fixation
- 8. What should we call this approach? • How To Not Completely Roger Your Patient During Airway Management in Emergencies?
- 9. Avoiding hypoxia: • Position • Pre-oxygenation • Apnoeic oxygenation • SpO2 stop point for intubation attempts • First pass success*
- 10. Avoiding hypotension • Fluid resuscitation • Inopressor infusion • Don’t sympatectomise your patient with induction (drug + dose) • Rescue (push) dose inopressor
- 11. Where is the money? • Operator skill? • Safe system for airway management?
- 12. NAP4 • ED / ICU intubations highest risk, most likely to lead to permanent disability / death • Failure to use capnography contributed to 74% of deaths or permanent neurological disability • AVOIDABLE DEATHS DUE TO AIRWAY COMPLICATIONS OCCUR IN ED AND ICU
- 14. Summary • Governance • Algorithm • Standardised / simplified equipment • Checklist • ETCO2 • Training • Regular audit
- 16. Audit • 71 intubations over 1 year • First pass success 78%, without hypoxia / hypotension 49% • Difficult airway: 2 (C&L grade 3) • 44% CVS compromise, 87% resp compromise, 70% GCS<9 prior to intubation
- 19. Equipment
- 22. Team training
- 23. Skills
- 24. Simulation
- 25. Goals of team training 1. Appreciate what a “difficult airway” means (anatomical / physiological / situational) 2. Resuscitate prior to intubation 3. Exposure to airway equipment / Mx 4. Non-technical skills are as important as technical skills 5. Understand fixation error 6. Orientation to RCH procedures 7. Improve individual & group practice
- 26. Barriers • Historical jurisdiction • Relationships • Culture change • Logistics • Evidence • Cost
- 27. Is zero iatrogenic harm possible during emergency airway management? • I think so! (ongoing QI project)
Editor's Notes
- Pre-ox: 8VC breaths or 3 min FM / resevoir bag; Pre-treatment: turbo-curarine ; Paralysis with induction using predetermined dose of thio; Protection: Cricoid force; Placement; Post-intubation Mx
- *skill of operator dependent
- Anatomically vs physiologically vs situationally difficult intubations
- Shared mental model. We have tried to address all aspects Not there yet with some of them
- An algorithm without foundation of teaching/training/maintenance of competency is just a pretty picture which may as well be framed before it is hung on the wall. On top of the trolley
- This is a site specific algorithm based on the DAS algorithm. Notice that it is not the APA algorithm, and has nothing specifically paediatric about it. It does not prescribe techniques. What good is an algorithm for airway management? It is a training tool, a learning tool, and the development of it made us think about what is important in our institution, and it is there to help avoid non-technical skill error “Perform initial attempts, make the best attempt, stop trying, cut the neck”. Or as we would say in Australia “have a crack, have the best crack, stop having a crack” Top tier of 3 layers of information. Colour coding.
- Some department specific eg ventolin and spacers in Eds; , bronchoscope in theatre
- Multidisciplinary simulation and education program that is hospital wide This photo is in our sim centre from our recent senior staff airway course in August Drs nurses anaesthetisis techs ED anaesthetics neonates picu sim team Faculty and participants blend Experts in the room. Run the workshops in the sim centre Broadly, goals are to Disseminate airway management knowledge via CPG, algorithm, lectures, prereading, simulation and education training sessions Focusing on the Human Factors, Non technical skills or CRM skills is key and is where we derive the most value from our larger group.
- Skills training tailored to the groups level of expertise and requirements