No abstract

No abstract

The role of algorithms in guiding emergency airway management Stangoe et al. describe the successful management of a rare cause of tracheostomy tube 'ball-valve' obstruction [1]. The authors followed the widely used emergency management algorithms developed by the National Tracheostomy Safety Project (NTSP)[2] and have correctly highlighted that such algorithms may not account for every possible scenario.The NTSP took a transparent approach to guideline development, detailing the methodologies [2], testing and evaluation and measuring the impact of implementation [3]. The algorithms were designed to address the commonest scenarios identified from forensic analysis of reported incidents [4]. The Working Parties agreed that the benefits of a single generic algorithm focused on common and easily reversible emergency situations was preferable to multiple algorithms addressing problemspecific, patient-specific or location-specific approaches. Adopting a generic approach simplifies and standardises teaching and training while addressing the vast majority of the causes of tracheostomy emergencies. Accepting that special circumstance would inevitably be encountered, adherence to critical airway management principles is still likely to benefit the patient, as in the case described. Even if a suction catheter can be passed, the responder is guided to "consider partial airway obstruction" while continuing to assess the airway. Appropriate next steps when faced with an inability to ventilate a patient who has a tracheostomy in situ are cuff deflation; endoscopic evaluation if the clinical situation allows; removal of the tracheostomy tube; all followed by re-assessment and increasingly invasive attempts to oxygenate by either airway. We commend Dr Stangoe and colleagues for their effective management of this highly challenging airway emergency. We encourage readers to always consider any emergency algorithm in conjunction with the supporting information, full manuscript and educational resources.

Surgical services have been hugely disrupted by COVID-19 and have had to evolve rapidly in response. The best practice for consent mandates that risks associated with surgical treatment during a pandemic be discussed. This study aimed to assess whether patients undergoing orthopaedic operations were being consented for the risk of contacting COVID-19 and ITU care. All orthopaedic consent forms from four-week periods in March, June and July were reviewed. Measures such as staff education were implemented after the second cycle. Of consent forms for 37 operations performed in March, only 1 mentioned the risk of contracting COVID-19 and zero mentioned ITU. During June, 89 consent forms were reviewed, 32 mentioned COVID-19 and 10 discussed ITU admission. Following educational measures, the third cycle showed a significant improvement as of 100 consent form records available for review, 73 included risk of COVID-19 whilst 26 mentioned ITU. The results show that earlier in the pandemic, surgeons at our centre were not counselling patients regarding COVID-19. This improved slightly between the first and second cycles, likely reflecting increased awareness of the nosocomial transmission of COVID-19. Educational measures contributed to a significant improvement in the third cycle. Planned interventions include use of electronic consent forms which incorporate COVID-19 infection and associated risks.