CASE 1: Peri-arrest call to ward. Patient was vomiting and aspirating and was hypoxic on 15L via a non-rebreathing mask. Proceeded to VF Arrest. During the subsequent 2 shocks and ~6min CPR, continued to …vomit. It took > 5minutes to find a laryngoscope and endotracheal tube, which were not on the crash trolley. Cardiac Resynchronisation Therapy (CRT) bag was present, however CRT nurse assisting in CPR/shocks, took further time to open all the bag and find appropriate equipment. During this time delay patient further aspirated and took over 5 minutes to gain equipment to intubate.

CASE 2: Cardiac arrest call received for an inpatient. On arrival of the anaesthetic team, patient was agitated, short of breath with marked facial flushing. Already had a nasopharyngeal airway. Struggling to breathe. Medical on-call team present. Oxygen saturations were low, and Oxygen given via face mask. The patient had been admitted under ENT with supra/epiglottitis. The primary survey suggested upper airway obstruction. Medics sited IV cannula, took blood samples including blood gas. Patient was in extreme distress and holding throat struggling to breath. Also required multiple people to hold them to secure IV access. Although the anaesthetic team were aware of the need for immediate airway support, there was no front of neck access kit or scalpel for emergency tracheostomy available leading to delay. Patient lost cardiac output and chest compressions commenced immediately after which intubation was undertaken. ROSC achieved after 1 cycle + adrenaline. Patient transferred to ICU.

Background information:

Patient had been admitted to [emergency department] earlier that day where a diagnosis of? Laryngitis, ?supraglottic infection made. ENT team reviewed the patient who had refused fibreoptic nasendoscopy. CT scans of neck and thorax were reported as showing oedema of the supraglottic structures, with mild narrowing of the adjacent airways. Of note there was a significant time span between admission to A/E and the arrest call, during which continual assessments had been made.

Commentary:

Both these cases highlight the need to check emergency equipment before use.

In addition to daily and weekly checks, resuscitation trolleys should be checked after each use. There should also be regular training and reminders to staff about where the trolley is kept. Opening of drawers to allow familiarisation of kit is also to be encouraged. Consideration should be given to better use of dividers, signage labels and possibly use of pictures, to guide staff in emergent situations.

DAS recommends the following:

E-FONA kit: The location of eFONA equipment should be standardised and clearly sign posted in every area where airway management is undertaken, including wards where head and neck patients are cared for. The guideline gives suggestions for equipment and prompt cards to be included in eFONA packs.¹

Although both patients were successfully intubated, patients with upper airway pathology can be tricky to manage – it's an ever changing, dynamic situation.

This requires:

• Repeated and early MDT assessment (ENT, Anaesthesia) – ENT must be alerted early if they are normally off-site.
• Constant monitoring in an appropriate place e.g. HDU
• Planning in advance for emergency care should deterioration occur.
• Availability of equipment: e.g. Difficult Airway trolley (including eFONA kit, Fibreoptic scope) in apocopate areas

MDT training, which doesn't need to be high fidelity, is to be encouraged for critical events. This can be task specific or even delivered as talk-through simulation. The College has a flash cards team training resource, available on its website.²

1. Difficult Airway Society. Guidelines for management of unanticipated difficult intubation in adults, BJA, 2015 Dec; 115(6): 827-848
2. Royal College of Anaesthetists. Flash card team training