The fifth and final instalment of #60SecondCPD following our current Event CPD series for @StJohn Ambulance.
Today we look at Toxicology related presentations to medical facilities at Festivals and Carnivals.
We may not know what people have taken OR they may not know (Or care) what they have taken therefore our assessment, diagnosis and treatment may be dependent on recognising the Signs and Symptoms seen in the common syndromes. This useful chart can help with those decisions.
See the full image HERE:
The fourth instalment of #60SecondCPD following our current Event CPD series for @StJohn Ambulance.
Today we look at Alcohol intoxication a very common presentation to medical facilities at Festivals and Carnivals and many other Mass gathering events and of course also to front line ambulance crews at weekends. This image may surprise you at it looks at the REAL statistics (Not firm held dogma) for those who seek help!
We have to be careful that our personal feelings don’t blind us to the clinical issues!
See the full image HERE.
* OCU = Opiate and/or Crack Users.
The third instalment of #60SecondCPD following our current Event CPD series for @StJohn Ambulance.
Today we look at Exercise Associated Collapse a common risk from endurance events such as Marathons and Triathlons. This image from our presentation look at the multi-factorial reasons for collapse in these circumstances:
Its obviously clinically important to rapidly recognise the cause of the collapse so we can start the right treatment modalities.
See the full image HERE.
Working in event medicine AND with the current trend for mass participation extreme Sports events with repeated immersion in cold water or even winter open water swims, the risks of environmental hypothermia may be seen more commonly than in the normal responses seen in the UK Ambulance services given our normal temperate climate.
This chart from our current event CPD roadshow for St John Ambulance HCP’s shows an alternative way of assessing the predicted core temperature in these patients GIVEN that measurement of this is challenging in the Pre-Hospital environment. This emphasises for us the importance of rapid identification and initiation of rapid aggressive temperature control in this patient group at least to minimise further temperature loss if not to achieve some very hard won Pre-Hospital warming.
Chart as enlarged picture HERE.
At this time of year we see our Cold/Hypothermic patients from outdoor activities and sadly commonly in rough sleeping homeless people. Temperature has also become an important part of our thinking in trauma in the Coagulopathy Triad.
BUT with the summer event season on the way and the recent trends for prolonged heatwaves in the UK that we are poorly adjusted and prepared for then we need to also consider the coming risks of the Hot/Hyperthermic patients as seen in recent years with well publicised coroners enquiries related to heat related exercise induced deaths.
This chart from our current event CPD roadshow for St John Ambulance HCP’s shows the frightening rise in mortality related to core temperatures in the Heat Illness (Heat Stroke) levels of over 40C. This emphasises for us the importance rapid identification and initiation of rapid aggressive cooling in this patient group.
Chart as enlarged picture HERE.
Fresh from the mind of @keatingteam1 and a very topical discussion we have been having for some months we look at the movement of Bariatric patients from the upper floor domestic properties by multiple rescuers requested to assist ambulance crews.
When is more help more risk without specialist advice???
(Disclaimer – ALWAYS take expert advice rather than do sums in your head!)
The full sample calculation can be found HERE as a PDF to print and discuss!
When looking at an ECG, think of the leads as views. Leads I, II and III are three different ‘views’ of the heart. When electrical activity is travelling towards a positive electrode, there is a positive deflection on ECG (a deflection above the baseline). If electrical activity is therefore travelling away; there is a negative deflection (a deflection below the baseline).
Lead I is looking from the Right Arm (RA) to the Left Arm (LA) electrode. This draws an almost horizontal line across the heart from (RA) to (LA). Left Arm (LA) is therefore the positive electrode. Consider the normal expected movement of electrical activity in the heart – is the Left Arm (LA) electrode therefore likely to see electrical activity coming towards it, or away from it?
Lead II is looking from the Right Arm (RA) to the Left Leg (LL) electrode. Left Leg (LL) is therefore the positive electrode. This draws a line that follows the expected cardiac axis (meaning the average movement of electrical activity) from the sino-atrial (SA) node, to the atrioventricular (AV) junction, then toward the comparatively more muscular mass of the Left Ventricle (LV). The normal cardiac axis is therefore from the ‘top right’ to the ‘bottom left’ of the heart (SA —> LV). This is often why Lead II has the greatest positive deflections on ECG, as it most closely follows the normal expected cardiac axis; it is therefore a fantastic ‘view’ for rhythm analysis.
Lead III is looking from the Left Arm (LA) to the Left Leg (LL) electrode. Left Leg (LL) is therefore the positive electrode. This draws a line that is slightly more rightward, relatively from the left atrium toward the right ventricle.
Thinking of these three views, notice that Lead I = (RA) to (LA), Lead II = (RA) to (LL) and Lead III = (LA) to (LL)…… if you forget which leads are involved…. count the L’s !
Additional: On a standard ECG monitor there is often a fourth electrode for 3-Lead monitoring, normally black in colour. This electrode plays no part in Einthoven’s Triangle, and does not form any lead/view of the heart. It therefore can, in theory, be placed anywhere on the body. This electrode works similar in nature to noise-cancelling headphones. It listens to and distinguishes artefact, uses algorithms to turn unwanted noise ‘upside down’ and then re-enters it into the final mix. We are then left with an improved electrocardiogram from which an interpretation can be made.
Full Image and Text HERE:
By Phil Poskitt @PhilDrummer64
Another @60SecondCPD post to promote and develop discussion for current topics of interest and this week its Pre-Hospital PoCUS and how it can help us provide better patient focused care in trauma incidents (Rather than just be a shiny and exciting non-contributory gadget!)
See the discusson points HERE which is a slide from the Clinical Integration lecture of our @thepocuscourse One day Introduction to Pre-Hospital Trauma Ultrasound course.
Capnography is used to monitor end-tidal carbon dioxide (PetCO2). It often provides valuable information about a patient’s alveolar ventilation, cardiovascular performance & metabolic state.
‘End tidal’, in this context, refers to the last portion of expired air.
To monitor end-tidal CO2 the capnography device should be the last piece of equipment before the expiratory valve on the manual resuscitator or ventilator circuit. This is in the same way that spontaneous ventilation is monitored at the nose/mouth, being our natural ‘inspiratory/expiratory valves’.
Positioning the capnography at this location guarantees that we monitor the whole ventilation cycle, from the inflow of ‘fresh’ gas/oxygen through to the elimination of CO2.
If we do not position the capnography at this location, we are measuring mid-tidal CO2 (not a thing) & we will have unaccounted instrumental dead-space ‘behind’ the monitoring before exhalation eventually ends at the expiratory valve.
Don’t build in unnecessary variables that have the potential to reduce the reliability or accuracy of meaningful monitoring.
Scott Hardy CCP
We commonly use filters in our airway circuits #AirwayNerds so what do we know about them?
Well the Yellow one on the LEFT is a Bacterial filter designed to protect the proximal parts of the ventilation circuit (Not needed in a BVM based circuit if all items used are disposable) or to protect an Entonox/Nitronox administration system ( The exhalation port of the Regulator which is reusable) from contamination carried by patient exhalation and for this purpose it is the right item BUT is often the ONLY one stocked by UK ambulance services.
If you wish to protect your Waveform ETCO2 Sidestream or Mainstream Adaptor from moisture AND prevent the drying and cooling effects of pressurised oxygen when ventilating a patient using a BVM or Mechanical Ventilator then the PATIENT needs the Green one on the RIGHT which is an HME (Heat and Moisture Exchange) Filter. I only know of ONE UK ambulance service that stocks both types for appropriate use but of course there may be more??
P.S If you were not aware of the above differences it is not necessarily your fault but is down to the people educating you and making decisions on clinical kit purchase on your behalf!
P.P.S Both dependent on the manufacturer in ADULT sizes ADD about 60 Mls of DEAD AIR SPACE which is VERY important knowledge for #AirwayNerds when it comes to Paediatrics.
Until recently in Simulation (Where if it is done properly we safely learn skills and make mistakes before we do them to real people!) there was no realistic way to simulate the suctioning of an airway and it was just either verbalised or the suction catheter was waved around in the air like a wand! With Suction being a critical part of maintaining an airway this seems somewhat remiss given how much money is spent on super advanced ALS dolls.
#AirwayNerds who have been on our courses have experienced the “Fear” and “Thrill” of the SALAD vomiting mannequin especially now we have a closed loop vomit circulation system! (Sounds technical like it should be part of a Dyson!) and this means we now have a way to prepare clinicians for “The day” when they find “That” Patient.
Some evidence for it HERE and a UK trial ongoing HERE.
We use a custom made item from Nasco HERE available in the UK from HERE
OR you can make your own from an Airway head and DIY parts HERE!
The Introduction of mandatory Waveform ETCO2 use by UK Ambulance clinicians and the recognition of addressing standards of Airway management in Pre-Hospital Care was highlighted in a Coroners Ruling sadly following a tragic patient death.
I thought it would be useful to highlight these OPEN ACCESS documents so our #AirwayNerds could review the circumstances and promised actions themselves and see if the standards have been met in their region?
Coroners Ruling: https://www.judiciary.uk/wp-content/uploads/2014/07/Perrons-2014-0158.pdf
Response For Actioning: https://www.judiciary.uk/wp-content/uploads/2014/04/2014-0158-Response-by-Association-Ambulance-Chief-Executives.pdf
Historically #AirwayNerds we have used an Adult BVM with a potential maximum ventilation volume of 1500-1600 Mls but why do we use this size device and is this still required?
The Resuscitation guidelines at the turn of the Millenium suggested that 10-15 Mls per KG should be used in the ventilation of an adult in cardiac arrest. As the maximum IDEAL body weight (IBW) of an adult human is approx 100KG then you can see how the adult BVM size was set!
Since then the idea of lesser ventilation in Cardiac Arrest to keep Intra-Thoraccic Pressure down (To Keep Cardiac Output up) and ideas surrounding lung protective strategies now mean we have a recommended tidal volume of 6-8 Mls per KG and many suggest if 5 Mls per KG produces slight chest rise then it is perfectly adequate in Cardiac Arrest.
This means for a 70KG adult at 5 Mls per KG the desired tidal volume in Cardiac Arrest may be as low as 350 Mls! It is incredibly difficult to ventilate this amount precisely using a 1500-1600Ml BVM and the potential for over ventilation with the associated complications is fairly obvious particularly in the inexperienced and/or over excited provider.
One idea often suggested and supported by us is the use of a Paediatric 500-600 Ml BVM for adults which then means one BVM can be used for all patients, especially as many places have withdrawn 250 Ml Neonatal BVMs as they are always way too large for the required tidal volume of that group!
This assists in ensuring a controlled maximum tidal volume even in the most stressful scenarios and also saves on expense and volume of kit carried as a bonus. One day maybe #AirwayNerds (although we have been already waiting some years!) the adult BVM size manufactured will catch up with the clinical guidelines!
Something we preach on our Pre-Hospital Airway and Ventilation courses is why and how we should use mechanical ventilation over manual Bag Mask Ventilation (You all should know the reasons #AirwayNerds)
Most current ambulance fitted models are either too simple, inappropriate for the patients used on or antiquated! So if we are going to use a Ventilator what would be on our wish list for functions:
- Light and easy to carry (MOST important AND has a proper bag!)
- User friendly, Pre-Sets and instinctive to operate
- Ambulance Proof (That’s the level above Bomb Proof!)
- Pump driven so will operate if O2 runs out and uses minimal O2
- Therefore needs good battery technology
- Adjustable FIO2 from 1.0 down to 0.21
- CPAP (And BiPAP if possible)
- Multi Modes but not crazy complication
- Choice of Pressure or Volume Cycled (Or both at same time)
- Monitors Exhalation so closer determination of Ventilation
- CAN cope with CPR without alarms going mad or worse stopping ventilating!
- Proper mount for Stretcher and Ambulance
If only that utopia of Pre-Hospital Ventilation existed (Maybe it does?!)
Hope you had a good Xmas and a Happy New Year #AirwayNerds.
Thanks to one of our “The Difficult Airway Course EMS (TM)” Faculty Members for spotting some interesting thoughts on Social Media FOAMED streams recently for something we have to admit as #AirwayNerds we had not considered before! On our courses we look at 2 person TE grip as superior when done with good jaw thrust and head positioning and we talk about head manipulation to improve glottic view for Intubation BUT how about lateral head rotation for Difficult Bag Mask Ventilation (BMV) with a BVM?
Well it seems it may be an old school forgotten technique from when BMV was used more regularly and certainly in the non-trauma patient when you don’t have the benefit of a 2 person technique it maybe well worth a try rather than having to progress more quickly than desirable to a more advanced technique with the associated risks of being under prepared.
Original Article by the excellent VIKING ONE HERE
Articles referenced for interest are:
The effect of head rotation on efficiency of face mask ventilation in anaesthetised apnoeic adults: A randomised, crossover study
Effects of head and body position on two- and three-dimensional configurations of the upper airway.
As ever Enjoy!
So we are all very familiar with the Yankaeur Suction catheter but where did it come from?
“Invented circa 1907, the Yankauer suction tip remains the most commonly used piece of suction equipment in the world. Sidney Yankauer began work in the outpatient surgery department at Mount Sinai Hospital in New York in the late 1800’s, specialising in ENT. He invented many medical devices that greatly impacted the profession during that time, but he is best known for his rigid suction catheter, the Yankauer tip. It was originally designed to help clear the surgical field during a tonsillectomy. However, its use has expanded to include many surgical procedures, as well as in-hospital and Pre-hospital Oro-pharyngeal suctioning. Often made of plastic or stainless steel, the Yankauer catheter is characterised by small holes in a bulbous tip designed to remove fluid while minimising damage to the surrounding tissues. The catheter is curved, making it manoeuvrable and easy to grasp” (Thanks to SAM D SAY for the history lesson!)
SO this was a device by invention for small scale mostly capillary bleeding from surgery NOT an airway device although of course it does work for that purpose to a degree!
BUT if we want to suction volume (You are having a bad day #AirwayNerd!) then why do we want to use a device that is:
- Smaller than the tubing to it so limiting suction volume.
- Unable to suck up any decent “Lumps” (Carrots, Doner Kebab etc!)
- Has a small hole you have to find and put your thumb over to make it work.
Of course this does not sound ideal so we advocate change to the new designed and made for purpose devices such as the Ducanto Catheter you will get the try them in the SALAD session of our Airway Courses where you will be amazed and the volume and consistency they can shift because at times when a life saving intervention is required you want to spend a couple more pounds on something that works!
We also myth bust all the old Dogma technique such as “Only suction what you can see and for no more than 10 seconds” as I like to ask what if the airway is NOT CLEAR at the 10 second mark???????
P.S Look out for cheap suction tubing too, it can be narrow bore so strangling the suction machine and kinks easily while stored!
As you know when we need to use suction in Pre-Hospital Care it is normally because things are going very badly! We carry hand powered suctions units but they generally provide poor suction, require a very odd technique or are often damaged in the bag and fail to work at all. As long as we are being good clinicians (That’s us #AirwayNerds) and take the electric powered suction to the patient where indicated then what concerns should we have?
A 2013 study showed a 2.4% failure rate of suction units when tested, this may not sound too bad but your average UK EMS service with approx 500 clinical vehicles means that on any given day somewhere out there approx 12-13 units may fail to work when required! See the Pre-Hospital study HERE.
Further to that many units are working but not ready for use, i.e tubing and catheter are still in sealed packets to satisfy IPC or are not with machine. See the Hospital based study HERE.
So what can we do:
- Buy quality electric powered suction units and service them as required.
- Accept hand powered suction units are usually no more than ornamental so deploy electric powered suction unit in to the scene more often.
- Always check and prepare suction units at start of every shift.
- If in a Suction critical situation such as SALAD then request a second vehicle so you have a standby suction unit as some will not run for long either due to type or battery age.
Next in part TWO we are going to look at suction catheters……………….
And finally in 2018 we saw the release of the United Kingdom’s AIRWAYS 2 trial which compared in OOHCA Paramedic led Intubation Vs Paramedic Led iGel placement (Most common EGD in UK EMS use)
So now you have the background to initiate some good discussion with colleagues and those who influence clinical practice! Our prediction we will (Hopefully) soon see a BMV (Bag Mask Ventilation) by BVM Vs EGD (iGel or Laryngeal Tube) trial in OOHCA to complete the data set!
OK So we follow PART ONE with the next in the 2018 timeline the Pragmatic Airway Resuscitation Trial (ROC-PART) from the USA which compared, in OOHCA the use of Paramedic led Intubation with a King Airway (VBM Laryngeal Tube In Europe) a device not often seen in the UK but widely used in USA and European EMS as a primary airway device.
Follow with PART THREE…………
As I am sure you are aware there has been a number of key publications in the last year that are highly relevant to #AirwayNerds.
Should you wish to be having any evidence based Airway discussions you need to understand these International published studies beyond the well known headlines, our interest has often been not the primary study point but the data the study has collected into success and complication rates of different airway techniques and devices.
Many other sites (Obviously we recommend the Resus Room as James is an #AirwayNerd) has discussed these papers but we would like you to read and digest them all in your own time.
So we start in order of publication with the SAMU trial ran across France and Belgium that compared outcomes in OOHCA from Intubation by Doctors Vs BMV (Bag Mask Ventilation) by BVM by ambulance crews trained only in Essential skills. Enjoy!
FOLLOW WITH PART TWO…………………
(Part Three of an evidence review by Jamie Todd)
The recommended procedure in many other guides and systems is for a surgical approach to establishing an airway in these can’t ventilate, can’t oxygenate scenarios (Difficult Airway Society, 2018) where a surgical incision is made to the cricothyroid membrane and culminating through various intermediate taught techniques and slightly varying equipment with a cuffed endotracheal tube being placed into the trachea. (Bosanko, 2018)
The known advantages of this technique are; Cost, as in its simplest form the only expense is a Size 10 disposable scalpel as the other equipment is already in Pre-Hospital Care Endo-Tracheal Intubation kits; Familiarity, the simplest form of this procedure is often advocated (Difficult Airway Society, 2018) as there is no complex technique or equipment to remember, in my anecdotal experience once someone has the principles of the technique the skill fade although present is far less than other complex techniques; Speed, in probably an already hypoxic patient the time taken OR time taken to convert a failed other technique into a surgically performed airway may be significant in patient outcomes (Crewdson & Lockey, 2013); Safety, in its simplest technique when well done the scalpel is contained in a relative safe zone, almost no force is required and the use of the bougie can prevent the false positive insertion feel of the short tube trochar devices; Effectiveness, obviously the placement of a reasonable size (Usually 6mm Internal Diameter) Endo-tracheal tube allows for near to normal ventilation with relatively low ventilation pressures and reduces the need for further procedures to exchange the device based tubes for something larger.
Establishing success rates of the procedure can like the others be difficult to determine due to a variety of operators, techniques and situations reported in studies again with very low numbers. Many papers though suggest an average success rate in excess of 90% although this does often not translate into patient survival as these patients are often in extremis with severe injuries. (Davies, 2018) (Langvad, 2018) Of particular interest given the situation and the fact that mostly Paramedic level or none specialist physicians were involved is the reported data from 8 years of the British Forces medical personnel in Afghanistan obviously working in a more than harsh clinical environment under intense stress. Under these arduous conditions using a simple surgical technique a success rate of 92% was reported (Tony Kyle, 2016). Another recent UK paper involving UK Critical Care Paramedics reviewed the number of Surgical Airways performed in a UK ambulance service in a four-year period. Initially this paper raised a few eyebrows due to the numbers of procedures reported seemed high compared to no real data but to people’s expectations from routine anaesthesia (MacDougall-Davis, 2018) and I admit that included myself but on reflection may this be more that this cohort were recognising and managing airway issues a known cause of death particularly in trauma (NCEPOD, 2018). The data from this paper shows a success rate defined as ventilation through a surgically inserted Endo-Tracheal tube for this group of clinicians as very favourable 97% (Bell, 2017) with insertion times averaging 1 minute.
Complication for a surgical approach through the cricothyroid membrane appear low with low failure rates and controllable by compression site of incision bleeding being reported as the main issues (Davies, 2018) (Langvad, 2018)
(Part Two of an evidence review by Jamie Todd)
A small number of UK pre-Hospital Care Providers have trialled or used custom made devices in order to perform a large Needle, trochar or seldinger wire guided placement of a small diameter short cuffed tube through the Cricothyroid membrane. This skill was available to ALL paramedics in those regions although one service has recently with drawn these devices (Anecdotal report due to high cost and reported failures).
Most common is the Quicktrach II (VBM, 2018) and this represents a group of similar tube over large bore needle or trochar devices. Numerous studies including (Tomas Henlin, 2017) demonstrate these devices have a longer procedure time, more complications, an increased number of attempts and in some reports very high failure rates particularly in the obese. This means often the technique has to be modified and in one UK ambulance service and also in my anecdotal experience a surgical incision often has to be made to allow passage of the device at all and certainly to prevent excess force being used to penetrate the cricothyroid membrane which has the risk of puncturing the rear wall of the Larynx. (Henderson, 2018) There is also the risk with short tube devices of the tube entering the tissue layers in a laminar fashion (Again especially when a lot of force has to be used to insert) thus leading the operator to believe they have a successful placement until ventilation takes place with the result of tissue inflation and surgical emphysema.
A systematic review of multiple such devices concluded that there was little current evidence as to the superiority or success rates for each device given that the numbers reported in many papers are so small. (Langvad, 2018) Time taken to perform (Oft reported as 120-180 seconds) may also be critical in determining patient outcome where the patient was likely to have been hypoxic at the start of the procedure and may have been since the initial call to the pre-hospital emergency services.
Anecdotally in paramedic use in the emergency Pre-hospital can’t ventilate can’t oxygenate type scenario, a highly stressed situation for the clinicians involved I have heard of reported success rates from 0-50% for various devices although the numbers of procedures performed are incredibly small. This may also be partly explained by equipment familiarity, given the rarity of this procedure we are asking a clinician likely at their most stressed to use a piece of equipment that they may not have opened or used in training for some time.
(Part One of an evidence review by Jamie Todd)
Starting with the skill in the UK national paramedic guidelines (AACE, 2016) all baseline UK HCPC paramedics as far as I am aware in the event of a can’t ventilate situation are guided to perform the skill of needle cricothyrotomy. This skill usually utilises various pieces of non-purposed clinical equipment that often have to be scavenged from various bags in the ambulance and in my experience as an airway educator there is a general lack of faith in its ability to do anything other than a short period of possible enhanced oxygenation without ventilation.
Certainly, its reported procedural success rate in a meta-analysis of approximately 65% (Crewdson & Lockey, 2013) is of concern especially where other studies see success rates around 37% and a review of USA morbidity cases showed an 89% complication rate with no positive patient outcomes. Various publication define it as a sub-optimal procedure (Resuscitation Council (UK), 2018) so its inclusion as a guided skill is somewhat puzzling to those with an evidence-based medicine approach.
There is some support for this procedure from our colleagues in Anaesthetics where it may be used not only as a rescue technique but also for some specific elective surgical procedures, but their experience is generally of using larger custom-made catheters and specific jet insufflators or ventilators so this is not the same circumstances as seen in the emergency situations in Pre-Hospital Care and so we see very different rates of failures and complications. (Griesdale, 2016)