The Emergency Surgical Airway: how can we learn & retain our skills?
Colin Graham
Outline The emergency surgical airway - how can we learn and retain our skills?
Colin A Graham
Professor, Emergency Medicine
Chinese University of Hong Kong
August 2010
Objectives
* Why is surgical airway training vital?
* Who does surgical airways?
* Who needs to be able to do them?
* How many, how often, how to train?
* Surgical airways in context
* Putting it all together
Why is surgical airway
training vital?
* Increasing requirement for definitive airway control in emergency care
- Prehospital care
- Emergency department
- Intensive care unit
- Operating room
* Not exclusively undertaken by anaesthetists
Why is surgical airway
training vital?
* Anaesthetists (anaesthesiologists) traditionally regarded as airway care
specialists - rightly so
* Now done by emergency physicians, intensivists, paramedics, combat medics,
flight nurses, prehospital physicians, etc...
Typical anaesthetist's patients
Bad day at the office....
Airway care goes wrong
Death during routine surgery
In summary, Elaine died as a direct result of clinical errors. Among the three
consultants (from two different specialties) there was a collective loss of
situational awareness, and failures in decision-making, prioritisation and
leadership during an emergency for which guidelines existed.
Among the four nurses there was an inability to communicate directly or
intervene (despite trying) despite a general awareness of what was actually
occurring and what should have been occurring.
Clinical human factors
* All necessary equipment present in theatre
* 2 anaesthetists and 1 ENT surgeon
* No clear leadership
* 'Lack of situational awareness'
* Lack of decision making
* Lack of perceived ability to speak up and voice concerns about patient's
condition
* Failure to follow guidelines
Who does surgical airways?
* Surgeons
- ENT surgeons
- Trauma surgeons
- General surgeons
- Maxillofacial surgeons
- Plastic surgeons
* Intensive care specialists
* Emergency physicians
* Anaesthetists
Who needs to be able
to do surgical airways?
= Who deals with the emergency airway?
* Emergency physicians & trauma surgeons
* Anaesthetists
* Intensivists
* Prehospital care providers
* Surgeons
How many?
* Walls et al (2010) - 31 North American EDs, 8937 intubation attempts, 67%
medical, 26% trauma, over 6 years
* 0.84% surgical airway rate, 1.7% for trauma
* 40 surgical airways in 31 hospitals in 6 years
How many?
* Phelan et al (2010) - Single North American ED, 224 intubation attempts over
21 months
* 1.34% surgical airway rate (3 patients)
* 6 patients required more than 3 attempts before successful intubation
How many?
* Wong and Ng (2008) - Single Singaporean ED, 2 343 intubation attempts over 7
years
* 93 difficult airways, 7 failed airways, 3 cricothyroidotomies, 4
tracheostomies
* Mean 3.6 intubation attempts in difficult group, surgical airway rate 0.3%
How many?
* Stephens et al: Level 1 Shock Trauma Center in urban Baltimore (2009)
- Anaesthesiology based airway service
- 6088 intubation attempts within first 24h in 10 years
* 21 surgical airways
- 17 cricothyroidotomies
- 4 tracheostomies
- 17 survivors (no airway related deaths)
- surgical airway rate 0.3%
The problem
* Most centres do 1-2 emergency surgical airway procedures per year
* In most centres:
- >30 ED physicians
- >60 anaesthetists
- >30 intensive care physicians
- >60 surgeons (all specialties)
How often?
* Chances of requiring to perform an emergency surgical airway procedure are no
more than 1 in 90 per year
* If manage airways for 30 years, you have a 1 in 3 chance of having to do a
surgical airway at one point in those 30 years
Minimum requirements
* Very little data
* Study of 102 anaesthesiologists in Canada
* Minimum number of practice cricothyroidotomies to be able to insert safely in
<40secs was 5 attempts
Methods of training
* Humans - difficult outside the United States
* Animals - anatomical differences may cause limited difficulties (pigs and
sheep)
- ATLS/EMST courses
- DSTC course
* Commercial manikins
Methods of training
* High fidelity human simulators
- Expensive - time and staff expertise
- Can be part of integrated training
- Can practice crew resource management
- Unlikely to be universal solution
* Plaster of Paris models
- Cheap, easy to make and portable
Putting it all together
* We need local training
* Inexpensive materials and training resources
* Time to teach
* Airway audit and feedback make a difference
Putting it all together
* Needs a total airway management package, not simply surgical airway in
isolation
* Participants should do at least 5 attempted cricothyroidotomies to gain
sufficient skills
* Monthly retraining periods may be better than 3 monthly - practical
implications?
Summary
* Emergency surgical airways are rare and becoming even more rare
* You'll be unlucky to have to do one in your career, but you need to be ready
* Local, regular, cheap training as part of an overall airway care strategy is
the key
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Ministry of Health
