Cliff Reid of Resus.Me fame put out an incredible post on NAP4, the audit done on all of the airway complications in Great Britain. It was such a phenomenal post that I got in touch with Cliff and asked if he wanted to come on the podcast to speak about it. He did me one better and got an interview with one of the authors of the Emergency and Critical Care Section.
So in this podcast, we interview Dr. Jonathan Benger, professor of Emergency Medicine with a particular interest in the management of the airway.
Points that came out of the show
- Mortality is higher in the ED and ICU compared to the operating room. Our patients are sicker, so we must be more diligent in planning
- Quantitative wave-form ETCO2 should be the standard of care for EVERY ED and ICU intubation
- Needle cricothyrotomy seems to fail more often than surgical cricothyrotomy
- Awake intubation was not used when it was indicated
- Junior resident anesthesiologists were often responding to the ED and ICU
- There was a failure to plan for failure
- Obesity figured into a large percentage of the airway disasters
- Airway operators were not prepared or just did not properly progress to surgical airway
For more from the NAP4
Full Report (Skip to the EM/ICU Chapter)
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Scott Weingart
An ED Intensivist from NY.
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Hi, my name is Scott Weingart.
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20 Comments on "EMCrit Podcast 47 – Failure to Plan for Failure: A Discussion of Airway Disasters and the NAP4 Study"
Minh,
Some fantastic points. I would respond, but even more fun would be to tape a show where we debate the issue. Are you game? If not, then I will give written reply. I cannot comment on the peds issue. I never speak about peds, b/c I do not feel I am an expert on the issue. Any readers want to comment on that portion?
scott
Hi Ram
I know what you are trying to say. Perhaps in response I’d ask you review the following paper at
http://www.scribd.com/doc/23508447/algorithm-for-cant-intubate-cant-ventilate
This is published airway research and in Australia is the general approach that the anaesthetic community is increasingly adopting. IN fact it is as a result of similar airway related deaths mentioned in NAP4, within Australia that has led to such airway research and training within my country.
You must have a simple strategy that gives you small range of options using simple gear and technique.
Its true that if you have never trained to do a needle cric or trachie then an emergency is not the setting to practice for the first time. The advantage is that you can have multiple attempts with the needle in a short timeframe and using a 14G cannula deliver 200ml/s of oxygen using simple tubing and a 15L/min flow meter…that’s 1L of oxygen in 5 seconds.
do not live the myth that you can ventilate with the needle airway, its goal is to rescue oxygenate when the SaO2 is 70% as outlined in the research paper.
read the paper and that might answer some of your questions..if not then let me know what you think afterwards
Minh,
Fantastic paper, but I read the conclusion very differently. We can discuss this during our debate, but it seems this paper is a ringing endorsement of bougie guided cricothyrotomy.
[…] Scott becomes a fly on the wall as Cliff Reid interviews Jonathan Benger one of the authors on the NAP4 Guidelines and discusses the finer points of the review in a podcast on Failure to Plan for Failure: A Discussion of Airway Disasters. […]
Hi all
I would say that every doc who does any sort of anesthesia – ED or OT should be drilled in a simple, reliable technique for surgical airway. Imagine a pilot who never trained to land off the normal runway!
My bias, based on many brown-trouser situations is: scalpel, bougie then a smallish (6 – 6.5) cuffed tube. Use the equipment you know, keep it simple stupid ( the least neurons required the better)
As for kids – very rare in “normal” kids – the anatomy is the same. Usually less fat. I would not change or have a separate technique for such a rare event. Too much to think about in a moment of crisis. – use the kit you have there. The biggest time delay is in looking for the kit, not using it!
Casey
Hi Scott et al
I have managed to track down dr Heard and he is happy to answer some written Qs. I will post it at Broome Docs when I can.
I’ll let you know if he is up for an interview.
Interestingly he is a bit critical of some of the recommendations to come out of NAP4. Should make for a lively debate
Casey
great comments! especially regarding the absolute necessity of continuing waveform monitoring so long as the patient has the ET tube in.
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