Pre-Hospital Anesthesia Handbook

147 Pages·2010·1.56 MB·English

by  Andrew Griffiths

Pre-Hospital
Anesthesia Handbook
Andrew Griffiths
Tim Lowes
Jeremy Henning
Pre-Hospital
Anesthesia Handbook
Lt Col Andrew Griffiths, MBBS Lt Col Jeremy Henning, MBBS
BMed Sci FRCA RAMC FRCA RAMC
Consultant in Anaesthesia Consultant in Anaesthesia & ICU
16 Close Support Medical Ministry of Defence Hospital
Regiment/ James Cook Unit Northallerton/ James Cook
University Hospital/GNAAS UK University Hospital
Clinical Director Great North
Lt Col Tim Lowes, MBBS Air Ambulance Service UK
FRCA Dip IMC.RCS(Ed) RAMC
Consultant in Anaesthesia & ICU
16 Close Support Medical
Regiment/ James Cook
University Hospital/GNAAS UK
ISBN: 978-1-84996-158-5 e-ISBN: 978-1-84996-159-2
DOI 10.1007/978-1-84996-159-2
Springer London Dordrecht Heidelberg New York
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Control Number: 2010928390
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Foreword
The dramatic changes in the management of critically ill or
injured patients in the pre-hospital environment that follow
the implementation of lessons learnt in austere distant zones
precede the publication of focused, evidence-based guides
and manuals. This manual is therefore a great step forwards
in training and assessment.
The commitment expressed in the Darzi report (High Quality
Care for All – NHS Next Stage Review Final Report 2008) to
provide the best care for all patients does mean that there will
be occasions when primary resuscitation of patients is followed
by a more prolonged transfer to definitive care. The opportuni-
ties to start and continue critical care of seriously ill patients by
skilled anesthetists should provide the same benefits for civilian
populations as has been demonstrated in hostile operations; a
clear message from the Healthcare Commission (2009).
The authors are all experts in both the practical clinical
application and the academic and research aspects of pre-
hospital care. This manual covers the most important aspects
of anesthesia and rightly concentrates on the safe and rapid
establishment of a secure airway as part of the ongoing care
of the patient. The techniques for rapid sequence induction of
anesthesia are discussed and just as importantly so are the
necessary subsequent anesthesia and sedation techniques.
This manual should be essential reading for all involved in
the pre-hospital arena from paramedical to medical staff. It is
a model for others to follow and it is a privilege to be asked
to write this foreword.
Prof. Chris Dodds
JCUH
v
Preface
Over the past few years in the United Kingdom there have
been many reports into trauma which have highlighted poor
pre-hospital care as a major cause of possibly preventable
deaths. Similar issues have been identified internationally.
Many pre-hospital systems have therefore developed stan-
dard operating procedures that involve inducing anesthesia
for airway control.
Many physician providers find it difficult to access training in
this area, and assisting anesthesia is outside most paramedics’
curriculum. This was a problem we faced at the Great North Air
Ambulance Service. To address this, we developed a two day
course to provide an introduction to pre-hospital anesthetic
practice. This book has evolved from the manual we wrote for
the course, which we continue to run three times a year.
It is clear that pre-hospital anesthesia remains a controver-
sial procedure, with many conflicting papers written about its
benefits and risks. For this reason, anyone undertaking it has a
duty to ensure they undertake it safely and within a well
governed system. A book cannot provide clinical experience,
however, we hope that it will give a good knowledge-base to
guide and develop practice. The available evidence is discussed,
relevant pharmacology is explained and a system to provide
pre-hospital anesthesia is presented.
We hope this book will prove to be an enjoyable read that
will encourage many to develop their pre-hospital anesthetic
practice. It has to be the hope of all working in this world that
no patient ever dies from having inadequate airway control
before their admission to hospital.
vii
viii Preface
The authors acknowledge the support that the Great
North Air Ambulance Service has given in the evolution of
the course, and are donating all of their royalties from the
sales of this book to the charity fund.
Middlesbrough, UK Andy Griffiths
Tim Lowes
Jeremy Henning
Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Pre-Hospital Anesthesia (PHA)............ 1
1.2 Rapid Sequence Intubation................ 2
1.2.1 Who Should Perform RSI? ......... 3
1.3 Pre-Hospital Rapid Sequence
Intubation (PRSI)........................ 5
1.3.1 The Pre-Hospital Environment...... 5
1.3.2 The Evidence for PRSI ............ 5
1.3.3 Who Should Perform PRSI?........ 7
1.4 Confidential Enquiry into Peri-Operative
Deaths (NCEPOD): Trauma – Who Cares? .. 9
References ................................... 10
2 Indications and Decision Making ................ 13
2.1 Significance of Aspiration ................. 14
2.1.1 Incidence, Morbidity and
Mortality of Aspiration ............ 15
2.2 LMA vs. Endotracheal Tube ............... 16
2.3 Summary ............................... 17
2.4 Assessment of Need: Risk vs. Benefit........ 17
2.4.1 Factors to Consider
(The A B C D Approach) .......... 18
References ................................... 21
3 Pre-Hospital Rapid Sequence Intubation ......... 23
3.1 The Six P’s .............................. 23
3.2 Preoxygenation.......................... 24
ix
x Contents
3.3 Preparation ............................. 26
3.3.1 Preassessment .................... 27
3.3.2 Prepare Equipment and Drugs...... 36
3.3.3 Positioning....................... 39
3.3.4 Protection........................ 41
3.4 Premedication........................... 47
3.5 Paralyze and Sedate ...................... 47
3.6 Passage of Tube.......................... 49
3.6.1 Laryngoscope .................... 50
3.6.2 Bougie .......................... 50
3.6.3 Plan A and Plan B................. 54
3.6.4 Failed Intubation Drill (Appendix
“Failed Intubation Protocol”)....... 55
3.7 Post Intubation .......................... 55
3.7.1 Confirmation of Placement ......... 55
3.7.2 Capnography..................... 56
3.7.3 Colorimetric Capnometer .......... 56
References ................................... 57
4 Post-intubation Management.................... 61
4.1 A (and c-Spine) BCDE Approach .......... 62
4.1.1 Airway .......................... 62
4.1.2 Cervical Spine . . . . . . . . . . . . . . . . . . . . 64
4.1.3 Breathing........................ 65
4.1.4 Over Ventilation or
Fall in Cardiac Output ............. 66
4.1.5 Circulation....................... 68
4.1.6 Disability ........................ 70
4.1.7 Exposure and Packaging ........... 71
4.1.8 Handover and Documentation...... 72
References ................................... 73
5 Equipment and Minimum Monitoring Standards... 75
5.1 Monitoring.............................. 75
5.2 Equipment.............................. 76
5.3 Ventilators .............................. 77
5.3.1 How to set a ventilator............. 79
References ................................... 81
Contents xi
6 Drugs and Sedation............................ 83
6.1 Pre-Treatment........................... 83
6.1.1 Fentanyl ......................... 84
6.1.2 Alfentanil........................ 85
6.1.3 Atropine......................... 85
6.2 Induction Agents......................... 85
6.2.1 Etomidate ....................... 87
6.2.2 Ketamine ........................ 87
6.3 Muscle Relaxants ........................ 88
6.3.1 Suxamethonium .................. 89
6.3.2 Pancuronium..................... 90
6.3.3 Atracurium ...................... 90
6.3.4 Vecuronium...................... 91
6.3.5 Rocuronium...................... 91
6.4 Sedation................................ 91
6.4.1 Midazolam....................... 94
6.4.2 Morphine........................ 94
6.4.3 Propofol (2,6-Diisopropylphenol) ... 95
6.5 Analgesia............................... 96
6.5.1 Morphine........................ 96
6.5.2 Fentanyl ......................... 96
6.5.3 Entonox ......................... 96
6.5.4 Ketamine ........................ 97
6.5.5 Local Anesthesia (Appendix
“Local Anesthetic Blocks”)......... 97
6.6 Cardiovascular Support . . . . . . . . . . . . . . . . . . . 98
6.6.1 Adrenaline....................... 98
6.6.2 Ephedrine ....................... 99
References ................................... 99
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
7 Special Circumstances.......................... 101
7.1 Hypothermia............................ 101
7.2 Pediatrics ............................... 102
7.3 Obstetrics............................... 104
7.3.1 Airway .......................... 105
7.3.2 Breathing........................ 105
7.3.3 Circulation....................... 106
xii Contents
7.3.4 Disability ........................ 107
7.3.5 Obstetric Referral................. 107
7.4 Head Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
7.5 Transferring Ventilated Patients by Air . . . . . . 109
7.5.1 Altitude ......................... 109
7.5.2 Temperature ..................... 109
7.5.3 Acceleration/Deceleration ......... 109
7.5.4 Vibration ........................ 110
7.5.5 Noise............................ 111
References ................................... 111
8 Complications and Adverse Events............... 113
8.1 Complications ........................... 113
8.1.1 Immediate Complications .......... 113
8.1.2 Early Complications............... 114
8.1.3 Late Complications................ 115
8.2 Adverse Events.......................... 116
8.2.1 Hypoxia (Low SpO) .............. 116
2
8.2.2 Hypotension ..................... 118
References ................................... 119
Appendices...................................... 121
Index ........................................... 139