Airway Training WGH Simulation afternoon WGH 22/01/2016 Thomas Bloomfield ST4 Anaesthetics

Reasons for session Majority of ICU junior medical staff without formal airway training (ITU rotation from other specialties and ACCS) Anxiety of these staff about how to handle airway emergencies particularly overnight Opportunity to involve ICU nursing staff and ANP’s in airway simulation

Aims of session Familiarise staff with equipment that may be needed in an airway emergency Familiarity with NHS Lothian Airway Trolley Allow airway trained staff to practice with emergency equipment: Cricothyroidotomy equipment and airway exchange catheter

Aims of session Scenarios aimed at basic airway management manoeuvres What nursing staff and junior staff might be able to do in the absence of senior/expert help Familiarity with emergency tracheostomy management

How Session ran 4 practical stations: – Crocothyroidotomy – Use of AmbuScope and airway exchange catheter – Tracheostomy management – Lothian Airway trolley

How Session ran 2 Simulation Scenarios Management of displaced ETT in ITU patients Use of airway manoeuvres Use of simple airway adjuncts Measures to maintain oxygenation until help arrives

Equipment utilised Cricothryoidotomy station: Melker Cricothyroidotomy kit Seldinger and surgical technique demonstrated Larynx model with prosthetic skin coverage Several Cricothyroidotomy kits avaialable to use

Equipment utilised Airway exchange catheter: Ambu disposable scope I-Gel LMA Intubation model Aintree airway exchange catheter

Equipment Utilised Tracheostomy safety training: “Trache Tracy” model NHS Lothian tracheostomy bedsigns Algorithm for management of tracheostomy emergencies Different types of tracheostomy tubes and attachments

Equipment utilised

Simulation Scenario 1 ITU patient GCS 3. Intubated and ventilated with sedation running. ETT accidentally displaced during routine turn Medical/nursing staff asked to attend

Simulation Scenario 1 Invasive devices record indicating ETT site at lips Capnography disappeared on monitoring SpO2 beginning to fall

Scenario 1 Learning points of scenario: Identify displaced ETT Call for help. Help is delayed. Apply high flow oxygen. Airway trolley into room and use of airway trolley contents in an emergency. Simple airway manoeuvres; BMV, Gudel insertion. Sats begin to improve when LMA inserted. Allows temporary ventilation until patient can be re- intubated

Simulation Scenario 2 ITU patient being treated for pneumonia Breathing spontaneously with minimal support Pulls out own ETT Medical/nursing staff called to assess Sats begin to fall

Simulation Scenario 2 Learning points for scenario: Apply high flow oxygen Call for help Airway trolley into room Simple airway manoeuvres Sats improve Maintain oxygenation with face mask until help arrives

Simulation Equipment Low fidelity mannequin Mannequin could be ventilated and allows airway insertion Monitoring provided using I-Pad and app Demonstration of Sats, Capnography,, ECG and arterial line trace Simple airway adjuncts, Gudel, NP, LMA

Simulation Equipment Low fidelity mannequin and basic equipment. Purpose of scenarios to increase confidence of staff with equipment available in an emergency and temporising measures which can be performed by nursing and junior medical staff.

How did the session go? Attendees divided into groups and rotated around stations Generally well received with good feedback Nursing staff in particular responded very positively to opportunity to be involved in simulation scenarios More experienced staff found opportunity to use front of neck access and ILMA/scope useful

What could have gone better First time session was run Initially large (20) audience. Probably too many people. Difficult to give everyone chance to have role in simulation scenarios. Fewer attendees later in afternoon; allowed opportunity for more hands on experience

Plans for future Plan to run the session every 6 months to be timed after changeover of junior doctors. More structured session: Attendees allocated to timeslot in attempt to maintain small group size. Focus on giving every attendee opportunity to be involved in scenarios.

Plans for future Try to incorporate 2 new scenarios: – Tracheostomy Emergency in real time – Front of neck access in real time: access equipment from trolley and insert on a model Allow session to be tailored at wide audience: nursing staff, ANP’s, junior anaesthetists

Summary Simulation session utilising fairly low fidelity equipment which was well received and generated enthusiasm for future simulation teaching. Multi-disciplinary attendance was good. Plan to improve confidence of junior medical staff and nursing staff in dealing with airway6 emergencies.