Pre-Hospital RSI Part I
Part I of a video run-through of pre-hospital care of patient requiring RSI
Hey, can I have some help? I think he’s on crutches. Hi. Hiya. Hi, how are we doing? Joe, can we just shut that car secure. I’m just going to check your hand, mate. OK, so what’s actually happened here? I think it’s someone reverse– OK I don’t know where the driver’s gone. OK, do you know the gentleman at all? No, not at all. OK, Joe, we’ve got a bit stuck in the airway here. Can we have some oxygen for me. So we first arrived on scene, it appeared that there was a relatively low mechanism of injury. However, the gentleman had hit the ground with some force, and it quickly became apparent he had sustained a significant head injury. He was unresponsive.
There was an element of airway compromise. Joe is the suction to hand please? Oh, yeah. OK, yeah, thanks. OK, can you hear me sir? Can you hear me? Open your eyes. It should be working. OK. He’s getting oxygen. Yeah, and if we got– I think an orange O2 would be probably OK, as well. Orange OP, OK, coming up. OK. Let’s try that one. Let’s just size it up, OK. Right, OK. Right, yeah, let’s pop some O2 on, and then we’ll crack on with the primary. Yes.
So once we’ve done a dynamic risk assessment to make sure it’s safe to approach and there was no catastrophic haemorrhage that I need to deal with, my immediate priorities were to manage his airway. And we did that using some basic techniques a jaw thrust, some suction, and the insertion of oropharyngeal airway. We also applied some oxygen with a non re breathe oxygen mask.
So having managed the airway, I would normally conduct a full primary survey. However, on this occasion, the HEMS team are on scene relatively quickly, and therefore I hand it over the care to them.
I’m Kat, and this is Laura. Hi, Joe and Al. Yeah. Could I give you a quick handover, Kat. Yeah, go on. So this guy I think he’s probably in his 40s. No one witnessed the incident. We believe this call is reversed into him. This lady just found him. The driver’s absconded. On our arrival, it was as you see. His airway was mildly compromised, which we’ve managed with a jaw thrust, a little bit of suction, an OP, and some oxygen. He’s got a reduced level of consciousness. I haven’t done a primary yet, cause we’ve not been on scene that long. I mean did you want to take it from here and we’ll also assist you as you need to?
Yeah, sounds like a plan. Laura, I’m just going to do a quick primary, and I’ll let you know what I find. Yeah, so we secured the car, and that’s safe, yes. What are you having to do for his airway? So we’ve got a dual thrust and an OP. Yep, see.
OK, looks like we’ve got symmetrical movement there feels symmetrical. Have a feel of the collarbones. A press, we’ve got no crepitus there. We’ve got a good radial pulse. Can I have a little feel of the tummy? Looks like you’ve kept him nice and warm pelvis feels symmetrical.
Trying to feel this long bone here. Can I have a feel of his head here?
I think I can feel a bit of a boggy hematoma there, yeah. We’ve got some blood. We arrived early on scene, and we received a clear handover. From a HEMS’ perspective, this appeared to be a relatively straightforward case of an adult with an isolated head injury requiring an RSI. OK, Laura, so this looks like an isolated head injury. He’s got a GCS of six, E1, V2, M3. He’s cardiovascularly stable, good radial pulse, nothing to find on the chest or in circulation. So I think this is going to be an RSI and a carry to King. However, this has the potential to be a life changing or life threatening injury.
And as a HEMS team, we’re in a unique position to be able to offer advanced secondary neuro protection and facilitate time critical transfer to an MTC. Right.
OK, in which case, Laura, if you’re happy to do the kit down, I’ll get access and monitoring. Fairly sunny, are you happy with DL? DL. Have DL on the back up. Sounds good to me. Yeah, awesome. 322 let’s work to 80 kilos. So I broke away in order to set up a kit dump for the RSI. I just needed to think about factors such as the light, direction of the sun, and make sure we’re in a safe space. And then I prepared my kit there. Then I requested some extra equipment from the ambulance crew and began to set my kit up. Concurrent activity is key.
While Laura was preparing the kit dump for RSI, Joe, Al, and myself are packaging the patient, securing IV access, and placing our monitoring. Other things we need to do at this stage include attaching IV fluids, checking a BM, and checking an INR. And so we would always prepare our circuits, and we would also make sure we had access to difficult and failed airway devices. So it’s really important for me to have situational awareness. And secondly, I need to be in visual and verbal contact with the whole team in case any emergencies occur or anything changes with our plan. I’m ready for a slip.
Ready, brace, and up.
In the next couple of steps we will bring together our learning so far using an RSI scenario video. In this first part we will see initial patient assessment and airway management by the first on scene paramedics, the arrival of the HEMS team and the RSI kit dump set up.
(Not all aspects of scene management and patient care are portrayed and a relatively simple scenario has been selected to emphasis the key learning points.)
Post-Video Exercise:
Watch the video first and then consider the following scenario reflections and challenges.
Reflections:
- How did the HEMS team and first on-scene paramedics communicate with each other?
- How was concurrent activity and time-efficiency achieved?
- Would you have approached the scenario differently – if so how?
Scenario Challenges:
How would you manage this scene differently if:
- It was night time and/or raining?
- The driver of the vehicle was drunk and aggressive to the clinical team?
- The vehicle was unstable or leaking fuel?
- The patient was trapped in or under the vehicle?
- There were multiple critically injured casualties?
How would you manage this patient differently if:
- They were GCS 10, combative and agitated?
- They had multiple limb injuries and suspected pelvic fracture?
- They were cardiovascularly unstable and urgently needed blood product resuscitation?
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