|“ICU is full and this patient is in asystole. And you want to fix their fracture?”|
- not always easy to pass the endotracheal tube into trachea
- removing the LMA whilst leaving the ETT in situ is fiddly and risks losing both
- overall success rate is 90% – so 1:10 will fail.
- drop in an AirQ II and ventilate
- pass the oesophageal blocker to decompress the tummy
- use a fibreoptic device to intubate through the iLMA, improving intubation rate
Needle Cricothyroidotomy technique
Bag 2 – Adult or Easy Anatomy
Bag 3 – Impossible Anatomy
When I was a young lad, one of the things that would excite me was stories of pirates and murderous ‘cut-throats’. At the age of ten, the idea of a ‘cut throat’ was somehow synonymous with a quick death. Fast wind forward a decade or so (ahem, well maybe more) and I’m reflecting on some of the more interesting cases of 2011.
One was a young man involved in a ‘glassing’ in the local pub. He presented to the ED via ambulance, maintaining his own airway but with an obvious zone 1 neck injury. Now, I teach in the animal lab on EMST courses and it amazes me how difficult it can be to identify the appropriate place to perform a tracheostomy. We aim for the cricothyroid membrane, but I’ve seen FACEMs bugger it up completely and transect the trachea (even once the oesophagus and damn near severe the vertebral column!)
Anyhow, this chap’s assailant had obviously either been on an EMST course or had performed percutaneous tracheostomies in the ICU – because with just a broken beer glass, he’d managed to make a perfect incision in the victim’s trachea, between 2nd and third tracheal rings. OK, not the cricothyroid membrane, but otherwise a damn near perfect tracheostomy!
So we took him upstairs and performed an awake fibreoptic intubation with a surgeon scrubbed and ready to perform a tracheostomy. And the patient did OK (had an injury to posterior tracheal wall with oesophageal perforation confirmed on oesophagoscopy, but no mediastinitis and injury healed over time in ICU).
So I’ve been thinking about these sort of injuries and how best to manage them with my (limited) kit back in the bush. Although reasonably rare, both blunt and penetrating laryngotracheal injuries present difficulties for the rural GP-anaesthetist…as the airway needs to be secured ASAP.
And this is not a hypothetical – such injuries are not uncommon in the bush – the classic is ‘clothes-line’ injury where a quad or trail-bike rider impacts a fencing wire at speed, sustaining tracheal injury. Add to that ‘robust’ sports, the usual gamut of farming and motor vehicle injuries..so the rural docs needs to have some form of game plan on how to manage these. And the ‘exam answer’ for ANZCA may not be applicable for the rural doctor, with limited equipment/backup.
The danger of course is that attempts at direct laryngoscopy may cause complete tracheal disruption, with subsequent passing of the ETT tube down a false passage, development of subcutaneous emphysema, failed ventilation and a spiral down into demise.
Every now and then, one hears of paramedics just popping a suitably sized ETT tube through the hole made in a traumatic tracheostomy – a fine strategy for the penetrating injury, but not available for blunt injury or small penetrating wounds.
How then to approach this? There isn’t a great deal in the literature and my FANZCA colleagues fall back on the ‘awake fibreoptic intubation’ answer…which is fine in the tertiary centre, but impractical in a small rural hospital.
So, what to do when faced with a patient with tracheal injury and needing emergent intubation (let’s assume they are becoming obtunded or failing to keep SpO2 up). My thoughts?
– direct laryngoscopy. May seem controversial, but this is what I am best at and the equipment is readily to hand (ETT/bougie). However DL risks disruption of the larynx/trachea and a false passage, making further attempts at intubation impossible.
– do a formal tracheostomy under local. Sounds fine, especially if can delegate to a surgeon. If I am in luck there may be an ENT surgeon visiting for a fishing trip, otherwise it’s going to be a messy scrabble with a patient who may refuse to lay flat/be combative. Nasty, but potentially do-able with equipment to hand (betadine-gloves-drape-local anaesthetic-scalpel-lots of gauze-retractors-ETT-lots of light-assistant)
– indirect laryngosocopy using videolaryngoscope. I like this idea, as intuitively seems to involve less mechanical distraction of the larynx…and the KingVision allows easy passage of a bougie, then railroad ETT over the top. Parker-tipped ETT to try and avoid any ‘hang up’ at the arytenoids…
– use an iLMA to maintain oxygenation – then intubate with ETT through this using either AmbuAscope or a malleable intubating stylet such as Bonfils or Levitan. To my mind the Ascope seems to offer an advantage here as could use iLMA as a conduit then follow down to carina…ensuring no false passage – then railroad ETT over the top. The shaped intubating-stylets allow one to visualise the laryngeal inlet..but not to insert down to carina, so potentially will intubate through the cords, but suffer false passage further down.
– topicalise the airway and perform an awake fibreoptic intubation. Preferred technique of my FANZCA colleagues, but it’s hard to do enough AFOIs to keep ‘current’. Now is not the best time for a relative novice to be trying!
What do other’s think?
– any thoughts on above?
– gas induction or classic RSI?
– what kit do you have available to assist you, either now..or planned.
Bring it on…
I’ve long struggled with the ideal contents of my prehospital pack. Time was that I carried enough gear in the back of the ute to perform an emergency laparotomy at the roadside…as time goes on I’ve slimmed things down…even more so on kayaking expeditions where weight and space are at a premium. Indeed, my minimalist approach to medical kit caused a small stir in the Australian sea-kayaking community, not least for the reliance on duct tape, superglue and suggesting the rectal route for treatment of dehydration and/or hypoglycaemia.
I’ve touched on thoughts for minimal standards for prehospital kit and a move towards similar standards in equipment and infusion protocols between small rural hospitals and retrieval services elsewhere in this blog. However, I was surprised to see the inclusion of a rubber chicken in Minh le Cong’s essential prehospital kit. You can read more over at Cliff Reid’s Resus.me site. But this of course raises the issue of what other ‘unique’ piece of kit that you feel you cannot function without.
|Choking the chicken – an essential prerequisite for retrievalists?|
For me, it’s always been a six-pack of Dr Tim Cooper’s Pale Ale (or Dr Tim’s) – I usually slip a six pack in the vac-mat for the retrieval team when they take away a sick patient – in thanks for their efforts and as a reward to enjoy back at base.
What weird extra kit do you carry in your prehospital or emergency bag?
I found this on the web, which is an extension of the surgical time out and involves introduction of team members, discussion of critical steps and anticipated problems. It’s from the WHO and I like it.
Checklists are all very well, but they are a form of strategy only…you’ve got to know how to implement actions in case of disaster. Scott Weingart has recently podcasted on the concept of logistics vs strategy, emphasising that knowledge of the former distinguishes a true expert from an amateur. It’s all very well to trot out the medical student answer that in the case of a massive bleed we would give packed cells, FFP and cryo (strategy)…but the true expert needs to know how to activate the massive transfusion protocol, troubleshoot the level one infuser, transduce the arterial line and mix up prothrombinex etc. This distinction of theory from practice is one which can be applied in whatever field of medicine one practices.
|Airplanes, unlike Sick Patients, are designed to fly|
If one more person tells me that giving an anaesthetic is like flying a plane, I will swing for them, I really will.
Look. The whole point of a plane is that it is designed to fly, and if it’s not working properly then you don’t take it off the ground. Human beings, in contrast, are not designed to be anaesthetised, and are often not working properly when the occasion arises. They are also rather poorly provided with back-up systems and spares, and frequently have long histories of inadequate servicing.
So if giving an anaesthetic is like flying a plane, then this must be what flying a plane is like:
Captain James Bigglesworth DSO stepped out into the thin sunlight, and took a deep breath of the damp air. It was good to be alive. He was taking up a new crate today, and he relished the little knot of mixed tension and anticipation that always formed at the pit of his stomach under such circumstances. He strode briskly towards the hangar.
The Junior Engineer was waiting next to the aeroplane. He handed Biggles a single sheet of paper, on which he had scrawled a haphazard note of his work on the craft. “Is this all?” asked Biggles. “Where is the service record?”
“It seems to be lost. The filing department say it’s maybe still at the previous airfield.”
“And the manual?” asked Biggles.
The Junior Engineer looked startled. “I don’t think there is one. We thought you knew how to fly a plane.”
A cloud drifted slowly across the sunny sky of Biggles’ mind. He began his walk-round. “Where’s this oil coming from?” The Junior Engineer frowned seriously. “I don’t know.”
Biggles sighed. But he too, long ago, had once been a Junior Engineer. “Where do you think it might be coming from?”
“The engine?” hazarded the youth.
“Of course. So what’s the oil level in the engine?”
“I don’t know.”
“Have you checked the oil level?”
Biggles could feel his voice becoming a little tight, a little cold. “So could you check it now, please?”
“But you’re just going to take off. The Chief Engineer wants you to take off right away.”
“Not without an oil level. And this undercarriage strut is broken. And the port aileron is jamming intermittently.”
At that moment, the Chief Engineer arrived. “Biggles, old chap! Ready to take her up? Good man.”
“She’s not remotely airworthy. I need an oil level and some basic repairs.”
The Chief Engineer sighed. “What do you want an oil level for? You know it’s going to be low. We’ve got to get her into the air before we can control the leak. And that undercarriage and aileron aren’t going to get any better while we stand here. She needs to be in flight before I can properly assess them. Come on, old chap – the tower’s given us a slot in ten minutes’ time. If we don’t take off then, we’ll be waiting all day.” He eyed the plane despondently, and tapped a tyre with the toe of his boot. “And, frankly, I don’t think she’ll last much longer.”
Biggles rippled the muscles of his square jaw. The Bigglesworths had never balked at a challenge, but this … Well, there seemed to be no way out of it. He was going to have to take the old crate into the air, just as she stood. Deuced bad luck, of course, but no point in whining.
Twenty minutes later, they were aloft. The plane kept trying to fly in circles, and the engine temperature gauge was sitting firmly in the red. The Engineer was out on the cowling with a spanner.
“Just turn her off for a bit,” he bawled over the clattering roar of the sick engine.
Biggles was astonished. “What?”
“Turn off the engine. There’s nothing I can do about this leak until the engine’s stopped.”
Reluctantly, Biggles turned off the engine, and trimmed the aircraft for a shallow glide. The weight of the Engineer, out there on the nose, was not helping matters at all. Four minutes passed in eerie silence, as the treetops swam up to meet them. “I’m going to need power again soon.” There was no response from the Engineer. Another thirty seconds passed. “I need power.” No answer. “I’m turning on now.” The engine roared, and the Engineer recoiled, cursing, in a cloud of black smoke.
“What’s your game, Biggles, old man? I almost had the bally thing fixed, and now we’ll need to start all over again!”
Biggles bit back an angry retort, and concentrated on guiding the crippled plane upwards. This time, now that he knew what was going on, they would start their glide from a lot higher.
After another protracted glide, the Engineer clambered back into the cockpit, beaming. “All fixed!”
Biggles tapped the oil pressure gauge. “Pressure’s not coming up,” he said. “It will, it will,” said the Engineer breezily. “Don’t be such a fusspot. Now let’s get the aileron sorted.”
He crawled out onto the wing, and began to strike the recalcitrant aileron with a hammer. A minute later, the plane rolled violently to the right. Biggles struggled momentarily for control, his lips dry. By cracky, they’d almost lost it completely, there.
“Don’t do that!” he called hoarsely to the Engineer.
“Whatever you did, just then.”
“I wasn’t doing anything, old man.”
Almost at that moment the plane lurched again, more fiercely, and rolled through forty-five degrees. “That!” screamed Biggles, fighting the controls for his very life. “Don’t do that!”
“Fair enough,” said the Engineer, cheerily. A minute later he did it again, and the plane was inverted for ten long seconds before a sweating Biggles regained any vestige of control.
“Fixed! Undercarriage next!” called the Engineer, and clambered out of sight below the fuselage.
Ten minutes later, Biggles caught brief sight of a set of wheels dropping away earthwards. “Couldn’t save ’em,” said the Engineer when he regained the cockpit. “Better off without them, frankly.”
“I still have very little oil pressure,” said Biggles, worriedly.
The Engineer pursed his lips and tapped the pressure gauge reflectively. “Well, the leak’s fixed, old man. Must be something about the way you’re flying her.” He reached under his seat and pulled out a parachute. “Look, I’m most frightfully sorry about this, but the nice men from Sopwith are taking me out to dinner tonight, so I’ve got to dash. Be a brick, Biggles old fellow, and just put her down anywhere you like. I’ll cast an eye over her in the hangar tomorrow morning.”
And with that, he was gone.
Biggles thought longingly of his own parachute. But he couldn’t abandon the old girl now. It wasn’t her fault, after all. Black, oily smoke was already billowing out of the engine cowling, however – he needed to put her down soon. He began to peer around for a flat place to land and, almost immediately, he spotted a distant grassy field. He moved the controls a little so that he could take a closer look.
He flew around the field once, and it certainly looked flat enough. Oddly, someone had painted huge white letters across the level green grass – ICU, it read. He had no idea what that meant, but it seemed vaguely comforting, for some reason. The engine coughed once, and then stopped. He could see a fitful orange glow beneath the cowling. This rummy ICU field would just have to do, it seemed.
As he swung the ailing aircraft around to make his final approach, he realised that the field was just a little too short for comfort. He licked his lips, and prayed that there would be enough room…
Sounds familiar to my anaesthetic chums? Happy landings, colleagues!