Regional Training Day

12th October 2011

Airway & Sedation

Scenarios & OSCE’s

1. Post Cardiac Arrest 1
Right Bronchus Intubation & Post-Resus Care
Clinical knowledge, technical skills and team work

2. Post Cardiac Arrest 2
Unrecognised oesophageal intubation & failed intubation
Clinical knowledge, technical skills and team work

3. Paediatric Sedation
Gain parental consent for ketamine sedation to facilitate wound closure.
Communication and clinical knowledge

4. Airway Assessment for Sedation
Clinical knowledge and teaching

Each scenario should run for 15 minutes followed by 10 minute debrief.
A further 10-minute discussion of relevant learning points can be included.
A mark sheet is included to facilitate structured feedback

 

Scenario 1
Post Cardiac Arrest 1 (Right Bronchus Intubation & Post-Resus Care)

Scenario
58 year old male witnessed collapse whilst in pub. Cardiac arrest, BLS undertaken.
On arrival ambulance,
VF shocked x3 then PEA
Adrenaline 1mg
Intubated
RoSC after 15 minutes.
Now spontaneously breathing

Instructor Briefing
High fidelity mannekin
A: Mannekin intubated 8.0 ETT to 26cm,
B: right main stem bronchus intubation with no expansion, air entry on left. O2 sats 94% decreasing to 88% unless tube repositioned. RR 28, ETCO2 3.7
C; Pulse 72, no radial, BP 85/40
D: Extensor posturing biting on tube

ABG, pH 7.10, pO2 9.0 kPa, pCO2 7.8 kPa, BE –10, lactate 8.4, glucose 23.4, K+ 5.8

ECG: anterolateral STEMI

Options
Consider run of VT requiring DC cardioversion and amiodarone loading in view protracted VF.
If aggressive sedation hypotensive episode progressing to profound low output state, PEA with low ETCO2

Candidate Expectations
Prepare team, allocating tasks.
Prepare equipment including ETCO2
Take adequate handover

Recognition of right main stem bronchus intubation, reposition under direct vision. Re-examination and CXR

Post Resuscitation Care

• Inotropic support 1 in 100.000 adrenaline cautiously to improve BP
• Paralysis: suitable long acting paralysis
• Ventilation, suitable ventilation profile 7ml/kg
• Cautious sedation, aliquots of midazolam or propofol infusion at low rate
• Cooling; cold 0.9%saline bolus, consider magnesium (VF and cooling)
• Insulin sliding scale
• NG tube for aspirin 300mg

Management of STEMI

• PCI preferred over thrombolysis
• Package for transfer to PCI
• Arrange escort

Candidate Briefing
You are the ED shop floor senior on in a DGH. The department has received a pre-alert from ambulance control. A 58-year-old male post VF cardiac arrest is 2 minutes away. They are intubated and have IV access.
You have an ST1 and nurse to assist you.
The nearest PCI facility is 30 minutes by road.

Clinical Knowledge 50%
Technical Skills 20%
Team Work 30%

Learning & Debrief Points
Recognition of right main stem bronchus intubation. Correction under direct vision, Discuss length at incisors 20-21cm.

Post Resuscitation Care
Role and requirements for paralysis and sedation after accurate GCS
Adequate oxygenation and ventilation
Use of ETCO2 as marker of cardiac output in steady ventilatory state
Cooling
Glycaemic control
PCI

Scenario 1
Post Cardiac Arrest 1 (Right Bronchus Intubation & Post-Resus Care)

Mark sheet

Candidate Name & Grade:
Key Point	Achieved	Not Achieved
Prepare team
Prepare Equipment
Take Handover
Attach ETCO2
Recognise right main stem bronchus intubation
Adjust ETT under direct vision
Length appropriate at incisors
Confirm correct placement, clinical & radiological
Interpret ABG
Interpret ECG
Post Resuscitation Care
Inotropic support
Suitable paralysis
Suitable sedation
NGT aspirin & clopidogrel
Glycaemic Control
Cooling
Aim for PCI
Package & arrange transfer
Resuscitate appropriately if VT occurs
Total

Overall                                                                                             PASS                            FAIL

Positive Aspects

Aspects in Need of Improvement

 

Scenario 2
Post cardiac Arrest 2 (unrecognised oesophageal intubation & failed intubation)

Scenario
Morbidly obese 60 year old male patient witnessed collapsed. BLS commenced by family.
Found by crew in VF with agonal gasps, shocked x3 with transient PEA, 1mg adrenaline and intubated.
Now RoSC with spontaneous breathing and gagging on ETT.

ST2 ACCS gives 10mg vecuronium IV as candidate enters room.

There is unrecognised oesophageal intubation as no ETCO2 or Easicap is attached. If attached there will be no CO2.
Auscultation is equivocal over chest but confirms oesophageal intubation over stomach.

The patient is spontaneously breathing past the ETT with low sats.
Unless rapidly recognised the paralysis will result in rapid reduction in sO2.
Once oxygen sats have dropped below 70% bradycardia will ensue.
Unless ETT removed and adequate ventilation under taken a bradycardic PEA cardiac arrest will result.

Adequate ventilation can only be managed by

• 2-person BMV with adjuncts or
• Supraglottic airway device.
  If re-intubation is attempted this will be grade 4 view unless attempted with head up, BURP, bougie and McCoy blade resulting in Grade 3 view.

Instructor Briefing
High fidelity mannekin
A: 8.0 CoETT at 21cm, oesophageal intubation
B: initially spontaneously breathing RR 28 dropping to 0 over 3minutes as paralysis occurs, no return of spontaneous respirations
Bilateral air entry with spontaneous respirations. Equivocal expansion and a/e with bagging through ETT due to body habitus
Oxygen saturations will start 94% with spontaneous ventilation dropping to <40% unless ETT removed and adequate ventilation by alternative route.
Ensure realistic lag time with saturation response to intervention.
No ETCO2 if connected before oesophageal intubation recognised.
C: SR 88 with ischaemic changes, good radial, BP 150/85.
Will gradually deteriorate into bradycardia (25) if sO2 drops below 70%, PEA arrest if sO2 below 50%.
D: initially grimacing and gagging until paralysis occurs.
Attempts at reintubation will result in difficult intubation. Grade 4 unless attempted with head up, BURP, bougie and McCoy blade resulting in Grade 3 view.
Ventilation with 2-person BMV and adjuncts will be difficult but possible. Supraglottic device will achieve adequate oxygenation.

Options
If oesophageal intubation not recognised by ETCO2 in sufficient time, can alert candidate by stating gastric contents coming up ETT.

Candidate Expectations
Early connection of ETCO2.
Recognition of oesophageal intubation
Removal of ETT and institute adequate oxygenation
Attempt re-intubation having established plan and prepared equipment.
Only maximum 3 attempts at re-intubation, each must have a change of technique instituted.
Recognition of potential difficult intubation due to body habitus.
Call early for senior airway support.
Adequate resuscitation if arrest occurs
Senior airway support will not arrive until end of scenario; aim is for candidate to maintain adequate oxygenation by appropriate route until this arrives.
Ensure debrief, informing consultant and critical incident report.

Failure to intubate is not considered a failure of scenario,
Failure to recognise oesophageal intubation and maintain oxygenation is!

Candidate Briefing
You are the ED shop floor senior on in a DGH. You have been busy in the Obs Unit and are informed by the senior nurse that an obese 60-year-old male post VF cardiac arrest is in resus. They have RoSC and are intubated and have IV access. The nurse feels you are required as the patient is gagging on the ETT and she is concerned the ST2 is “out of their depth”.
You have an ST2 ACCS Anaesthetics and nurse is in attendance.

Clinical Knowledge 30%
Technical Skills 50%
Team Work 20%

Learning & Debrief Points
Recognitions of oesophageal intubation

• ETCO2 is essential as clinical examination can be unreliable
• “If in doubt take it out”

Dangers of long acting paralysis until tube position confirmed
Difficult airway and failed intubation drills
Oxygenation is paramount.

• Patients die from failed oxygenation not failed intubation.
• Desaturation can be tolerated until bradycardia ensues then arrest imminent

Intubation attempts must be planned and each time something must be changed.
No more than 3 attempts, acceptable to “bale out” after 1 optimal attempt.
“O HELP”
O Oxygenation
H Head Elevation
E External manipulation of larynx
L Laryngoscope blade
P Pal

Oxygenation is paramount, can be achieved by good BMV or SAD. Discuss role of cricoid pressure in this situation.
Head position is critical in the obese for intubation and BMV. Tragus of ear in line with sternal notch.
External laryngeal manipulation BURP
Laryngoscope blade, consider McCoy and gum elastic bougie.
Discuss techniques of using bougie
Need senior airway practitioner as soon as possible, call early.

Scenario 2
Post Cardiac Arrest 2 (Unrecognised oesophageal intubation & failed intubation)

Mark sheet

Candidate Name & Grade:
Key Point	Achieved	Not Achieved
Take Handover
Attach ETCO2
Recognise oesophageal intubation
Recognise prolonged paralysing dug given
Immediate extubation
BMV with adjunct
Maintain adequate oxygenation
Prevent bradycardia
Plan reintubation
Recognise potential difficult intubation
Difficult-Failed Intubation
Senior airway support if not already called
Pre-oxygenate before all attempts
No more than 3 attempts
Change factor for each attempt
Head position
BURP
Bougie
Blade change
Bale out at appropriate stage
Consider SAD
Maintain oxygenation throughout
Debrief, report to consultant and critical incident
Total

Overall                                                                                                PASS                            FAIL

Positive Aspects

Aspects in Need of Improvement

 

Scenario 3
Paediatric Sedation
Gain parental consent for ketamine sedation to facilitate wound closure.

A 3-year-old male patient has presented to the ED of a DGH with a facial laceration that requires closure. The laceration is complex and will be closed by the maxillofacial team. However to achieve a good cosmetic result is proposed that sedation is used. The child is fit, healthy and fasted.
There is no paediatric anaesthetic support on site. If GA is required this will require transfer to tertiary paediatric facility 40 minutes away.
The candidate is competent in paediatric sedation using ketamine and there is a departmental protocol.
An ED junior has informed the parent that sedation under ketamine is proposed. The parent has concerns regarding the safety and acceptability of this drug as they have seen several recent news items regarding abuse of ketamine.
These involve
Is it safe?
Street drug, will it harm child, make them mad or addict
It’s a horse tranquiliser
They go mad after it’s given
Causes abdominal pain and urinary problems.

The candidate is expected to address the parental concerns and obtain informed consent for wound closure under ketamine sedation. 

Instructor Briefing
No mannekin requirement. Brief parental role player.

Parental Role Player Briefing
You are the single parent of a 3-year-old boy. He has sustained a facial laceration by falling into barbed wire. You appreciate this wound will be disfiguring unless closed appropriately.
The child is fit, healthy, fully immunised and has no significant PMH. The child has had no food for 4 hours and only sips of squash 2 hours ago.
You have seen recent news reports about ketamine abuse.
You are of the opinion it is
Unsafe for humans
Addictive street drug
Animal tranquiliser
Makes people go mad after they have had it.
Causes problems with bladder function

You have an elder brother who took large quantities of ecstasy and cannabis in the 90’s and was subsequently diagnosed with schizophrenia.

You will be convinced to consent to sedation with ketamine if all your fears are allayed sufficiently.

 
Candidate Expectations
Introduce self and establish relationship of parent.
Explain rationale for procedural sedation
Emphasise need for appropriate wound closure in timely manner
Retain empathy and rapport with parent.
Listen and address all concerns
Risk benefit of ketamine
Safety profile of ketamine
No risk of long-term sequelae
Discuss potential side effects and what can be achieved to mitigate these.
Emergence phenomena, nystagmus, ataxia, drooling, nausea and vomiting etc
Discuss other options; GA, alternative sedation
Post sedation care required
Post wound closure care
Gain informed consent to proceed with sedation

Learning & Debrief Points
Role of ketamine in paediatric sedation.
Increase in recreational ketamine abuse can cause issues with patient acceptance.

Ketamine
Pros

• Wide therapeutic range
• Rapidly effective IM
• Titratable IV
• Profound analgesic
• Minimal respiratory depression, bronchodilator
• Cardiovascular stability
• Amnesia, less than benzodiazepine

Cons
Emergence, excitatory phenomena

• Less common in children though do occur
• Consider pre-treatment with benzodiazepine, debatable in paediatric group.
• Minimal stimulation environment

Increased secretions

• Pharyngeal and bronchial,
• Consider glycopyrolate or atropine

 

• Enhanced laryngeal reflexes, bronchospasm
• Ataxia
• Nystagmus
• Increased sympathetic tone >HR, >BP. Less relevant in children
• Nausea & vomiting. More common in high doses

Dose
IV 0.25-0.5 mg/kg can be repeated
IM 2-4mg/kg

Caution
Three strengths available 10mg/ml, 50mg/ml, 100mg/ml
Ensure correct vial

Scenario 3
Paediatric Sedation (Gain parental consent for ketamine sedation to facilitate wound closure.

Mark sheet

Candidate Name & Grade:
Key Point	Achieved	Not Achieved
Introduce self
Explain rationale for sedation
Maintain rapport with parent
Explore parental understanding of situation
Address all parental concerns
Long term sequelae
Bladder
Horse tranquiliser
Addictive Street drug
Offer to answer any other concerns
Ketamine Knowledge
Safety
Benefits (analgesia, amnesia)
Side effects
Emergence phenomena
Methods to reduce this
Salivation
Ataxia & nystagmus
Nausea & vomiting
Describe appropriate technique
Post sedation care
Discuss other options
Gain consent
Total

Overall                                                                                                PASS                         FAIL

Positive Aspects

Aspects in Need of Improvement

 

Scenario 4
Airway Assessment prior to Sedation (Teaching)

An ST1 ACCS approaches the candidate to teach them a method of airway assessment prior to procedural sedation.
One other group member should be the ST1 doctor and another can be the patient to allow demonstration of assessment.
The patient is fit, healthy and no predicted airway problems. They have an anterior shoulder dislocation and are suitable for sedation with propofol and fentanyl.

The aim is for the candidate to teach a structured approach to airway assessment focussing on anatomical features.
The proposed procedure is a short sedation rather than RSI and intubation so the assessment should be relevant to predicted ability to BMV rather than predicted intubation difficulty. However a full airway assessment including predicted difficulty with BMV, laryngoscopy, intubation, SAD insertion and surgical airway is acceptable.

Instructor Briefing
No mannekin or airway equipment required
Whiteboard and pens or similar for candidate to use
Brief role players.

AACS Role Player
You are an ACCS ST1 in Emergency Medicine. You have no previous experience in sedation or anaesthetics. You are keen, enthusiastic and have read guidance on sedation. You have examined the patients cardiovascular and respiratory system and found no abnormality.

Patient Role Player
You are a fit, healthy patient with no significant medical problems. You have had a GA for appendicectomy when 8 years old with no problems. You are on no medication and have no allergies. You have no caps, crowns or loose teeth. (You do snore if asked).
You will comply with any instructions given.

Candidate Expectations
Demonstrate and teach a structured approach to airway assessment.
Focus on

• Anatomical factors
• Factors relevant to procedural sedation with propofol and fentanyl
• Predicted difficulty with BMV.

Factors relevant to predicting difficulty in BMV
This should be considered contra-indication to sedation in this circumstance.
Five independent predictors of difficult BMV

• Age >55 years
• Obesity, BMI >26kg/m2
• Beard
• Edentulous
• History of snoring or sleep apnoea

Adequate BMV can be difficult due to following factors
1.Difficult mask seal

• Beard, no dentition, dysmorphic face, cachexia, trauma (bony injury or laceration to cheek).

2. Difficult to maintain open airway (without ETT or SAD)

• Immobile neck, bony facial trauma, obesity, large tongue, upper airway obstruction.

3. Difficult to ventilate lungs

• Abdominal distension or diaphragmatic splinting, obesity, poor lung compliance and lower airway obstruction.

Should utilise mnemonic to aid learning
HAV NOT or MOANS

HAV NOT
H History of previous anaesthetic or airway problems
A Anatomy; facial features, mouth, dentition
V Visual clues; age, facial hair, obesity, posture
N Neck mobility, range or movement, pre-existing neck pathology, MILS
O Opening of mouth. Three fingers allow insertion adjunct
T Trauma, face, neck, chest

MOANS
M Mask seal, beard, trauma
O Obesity & obstruction
A Age, >55 years
N No teeth
S Stiff lungs, snoring, sleep apnoea

Good interaction should be maintained between candidate and ST1.
Introduction including relevance should be rapidly achieved.
Appraisal of ST1 knowledge base.
Techniques should be demonstrated
Suitable closure and questions achieved

Learning & Debrief Points
Facilitate could shop floor educational event.
Introduction, relevance, questions and closure
Demonstrate assessment technique
Use of mnemonic

Reinforce role of BMV as important in short acting sedation techniques.

Option to discuss
Predictors of

• Difficult laryngoscopy and intubation
• Difficult SAD insertion and function
• Difficult surgical airway

Difficult Laryngoscopy and Intubation

• Previous difficult airway
• Body morphology
• Facial features
• Neck mobility
• Mallampati score
• 3,3,2 Rule
• Trauma or tumours
• Infection

Difficult SAD Insertion and Function

• Restricted mouth opening
• Restricted neck movement
• Poor pulmonary compliance
• Obesity
• Upper airway obstruction
• Distorted airway, tumour, surgery

Difficult surgical cricothyroidotomy

• Short immobile neck
• Obesity
• Previous surgery
• Tumours, trauma and radiotherapy

Mnemonics
HAV NOT covers all above.

Difficult Laryngoscopy & Intubation LEMON
L Look externally
E Evaluate 3,3,2 Rule
M Mallampati score
O Obesity and Obstruction
N Neck mobility

Difficult SAD Insertion & Function RODS
R Restricted mouth opening
O Obesity and Obstruction
D Distortion or disruption of airway
S Stiff lungs or cervical spine

Difficult Surgical Airway SHORT
S Surgery or trauma to neck
H Haematoma or mass in neck
O Obesity, limited access to neck
R Radiotherapy
T Tumour or trauma

Candidate Briefing
You are the ED shop floor senior. You are about to supervise an ST1 reduce an anterior shoulder dislocation in a young, fit, healthy adult patient. You intend to sedate the patient with propofol and fentanyl.
The ST1 who has no anaesthetic training asks you to teach them how you assess an airway prior to sedation.
You are expected to teach the ST1 a structured approach to airway assessment. Focus on anatomical considerations required to assess an airway prior to a short sedation.

Clinical Knowledge 60%
Teaching Skills 40%

Scenario 4
Airway Assessment prior to Sedation (Teaching)

Mark sheet

Candidate Name & Grade:
Key Point	Achieved	Not Achieved
Introduce self
Explain relevance & importance
Examine pre-existing knowledge
Highlight key factors
Use suitable mnemonic
Summarise
Allow questions
Closure
Airway Assessment Knowledge
Key Role of BMV
Fators predicting difficult BMV
Age
Obesity
Facial features
Dentition
Mouth opening
Neck movement
Mask seal
Lung compliance
Trauma
Obstruction
Snoring, sleep apnoea
Total

Overall                                                                                                  PASS                     FAIL

Positive Aspects

Aspects in Need of Improvement

 

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