# Kingtube info and experiences wanted for Australia



## FlightFon (Mar 19, 2011)

Good Morning.
I am a flight paramedic working out of Melbourne, Victoria in Australia.
Firstly, I’d like to apologise for this long winded post, but hopefully you’ll read on.
Our breakdown and hierarchy in the service begins with BLS Paramedic (No longer being trained, and the service is just waiting for the remaining to retire), ALS Paramedic, ALS Flight Paramedic,  MICA(Mobile Intensive Care Ambulance) Paramedic, and MICA Flight Paramedic.  Probably similar to that in the states, but with differing names.

Over time we are seeing a greater number of skills being provided, but airway management still leaves a lot to be desired.  As a result, other than RSI for MICA, ALS airway management has remained a bit stagnant.   ALS currently have OPs, NPs, and LMAs  With the area that Victoria covers, and the limited availability of MICA compared to the increase in workload, we have an increase in time that it takes MICA to attend a scene, and in country locations, you may be lucky to get them at all.

As a result I am putting a proposal forward regarding the King LTS-D™ to be used by ALS paramedics.  As with anything, change comes via evidence based practise, or clinical trials.  In this case, clinical trials are not required as the product is approved by our governing bodies, thus moving to evidence based practise.  The problem is, Australia can be in a bit of a black hole, just a large island away from USA and Europe, and gaining evidence from here is limited.

I have selected the King LTS-D™ over the Combitube™ for a number of reasons, more-so recently from many internet posts moving away from the Combitube™ moving towards the King, but also it’s ease of use.

What I am looking for is assorted information from varying Countries, States, Counties, Fire, EMS, etc. regarding their guidelines, protocols and their experiences.  This should include the LT, LT-D, LTS-II, and LTS-D.

I must stress that this is a project not to replace ETT, but to increase the level of options available to ALS.  ETT has it’s place as the gold standard, and will remain in use by MICA, especially now that the benefits of RSI have shown positive outcomes.

To be broken down I would love to receive the following:

-Written guidelines specifying where, when and who may use it
-Guidelines, or work instructions on how you use it
-Any visual aids or training videos
-Your experiences with it’s use
-How many have you done- Success VS Fail (Why do you believe they failed)
-How many were used following a failed intubation- Successfully VS Failed (Why do you believe they failed)
-Any anecodotal evidence heard back at station.

-Any responses whether in whole as above, or in part are much appreciated. They can be posted on this forum, or, depending on personal reasoning or copyrighting, may be sent to me via private posting or private emails.  I will also not use any, including published information, except with the permission of the original poster or organisation they are affiliated with.

Many thanks to all.
Rob


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## 8jimi8 (Mar 19, 2011)

Help a Brother out people...


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## Shishkabob (Mar 19, 2011)

I was held over late on shift, but when I get home I'll write my thoughts.


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## Shishkabob (Mar 19, 2011)

1-  At my agency, a King can be placed by an EMT-Basic, Intermediate and Paramedics.  Per protocols, it's to be used for difficult intubations or as a rescue airway.

2- Exactly how the pamphlet included with each King says to.  Insert, inflate, withdrawl till seated.

3-  [YOUTUBE]http://www.youtube.com/watch?v=ryyHWewl5ho[/YOUTUBE]

4-  It's built to succeed, and you really have to try to screw up its use.  Pop it in and you're done and can worry about something else for a bit until the need to intubate arises or compliance suffers.

5-  I've done a couple.  I had my EMT do his first yesterday during an arrest so he could have the practice.  I havent heard of anyone failing, except for choosing a size way too small or way too big for the patient.

6- I havent used one due to a failed intubation, but rather as a first line in someone that needed airway control but not quite ETT.

7-  I love them, and there's a reason why they allow EMTs to do them as well:  It does the job with little that could go wrong.  However, like any tool, it has it's place and just because you place one doesn't mean the airway is controlled.


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## MrBrown (Mar 19, 2011)

Rob

Over here our Technicians (vollies) and Paramedics run round with the LMA, Intensive Care has RSI and like you, are doing bloody fantastic at it.

Brown would be interested in seeing what you come up with as anecdotally Brown thinks the King isolates the trachea better than an LMA; although the LMA is cheap and effective for the most part.

Brown will be looking for you on next weeks "Medical Emergency" LOL!


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## medicRob (Mar 19, 2011)

MrBrown said:


> Brown thinks the King isolates the trachea better than an LMA; although the LMA is cheap and effective for the most part.



LMA stands for Let Me Aspirate, nuff' said.


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## FlightFon (Mar 19, 2011)

That's getting the ball rolling. Yes it will be used as a rescue device post failed tube, getting ride of the LMA which is rarely used, plus it's main use wound be for arrests by ALS not authorized to tube in the metro area. 
Just wondering about use in burns patients? Airway is a primary concern here. Can it be used initially then changed out with a bougie at a later time. In the past the airway will close without a tube and thus a surgical airway is required, Wichita can be done at hospital, or if MICA finally gets there. 
Many thanks to all thus far. 
Rob.


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## Shishkabob (Mar 19, 2011)

Why even waste time with the king if you are concerned about airway compromise from burns?

Primary concern of King and other supraglottic devices is control of the oropharynyx, not the trachea, and minimal, if any, control of esophageal contents.


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## Miss EMT (Mar 20, 2011)

I have used the King airway some. Our EMT basics are allowed to use them. They can be a great tool especially when your trying to get an airway on someone with no teeth. I haven't had any trouble out of them yet. They are very simple and quick to use.


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## FlightFon (Mar 20, 2011)

Sorry Linus.  Had a bit of a back to front loss of the train of thought.
Regarding burns, over here MICA may RSI the patient.  Following a failed, they revert to the LMA or if that fails, Cric. My concern is if we replaced the LMA with a King, how easy, or hard would it be to then insert a bougie and do a changeover to an ETT.  For burns it would not be a first line of attack to use the King over the ETT, unless the Pt is GCS-3 and MICA was way too far away.  As you said we are dealing with orophanynx and trachea.  If the patient would be GCS 3 post burns, then you may well have already missed the boat, and the King may just cause more trauma, if in fact the Pt is now unconscious merely due to an obstructed airway.  Most of the airway burns patients I've been to have been as a result of trying to start a car by pouring petrol(gasolene) straight into the carby.  Woof, then big breath in due to the shock of the explosion, and well, you know the rest.
Rob.


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## FlightFon (Mar 20, 2011)

MrBrown said:


> Rob
> 
> Brown will be looking for you on next weeks "Medical Emergency" LOL!



Sorry Mr Brown.  You won't be seeing that.  I used to be a Copper in Sydney, and many years ago our station, Redfern, was the subject of this doco (called 'Cop it Sweet').  This left a bad taste in the mouth of many, and lead to much disciplanary action due to the media beatup, given that all filmed were given assurances that editing would be favourable.  Luckily I was on leave, but I have never trusted the media since.
Rob.


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## the_negro_puppy (Mar 21, 2011)

This should be an interesting study. I've often wondered why Aus ambulance sevices tend to use LMAs when other countries using different supraglottic airways and almost exclusively use LMAs for use in simple surgery etc


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## Shishkabob (Mar 21, 2011)

the_negro_puppy said:


> This should be an interesting study. I've often wondered why Aus ambulance sevices tend to use LMAs when other countries using different supraglottic airways and almost exclusively use LMAs for use in simple surgery etc



We have LMAs at my service...but the only time I can see using it instead of a King is to say I used an LMA in EMS.


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## MasterIntubator (Mar 30, 2011)

Well... I'll throw a wrench in the system for you, because that is what I like to do.

When the Kings came into field play for us, it was more of a price decision ( compared to the combi ).  And since the combitube was too complicated for some folks, that added to the fire.  I mean really.... what is easier than 1 tube, 1 syringe?   Its the ultimate in indirect intubations.... so what was told to us.

Im not a fan of indirect airways, but... they have thier place and have been used with great success.  I will always have them for those back-up moments, and won't hesitate - without delay - to use one when indicated. ( fine print over  )

Now, the actual field tests and useage... I still prefer the combitube ( and we carry the King as well ) over the King.  Out of the many shoved down the yap, all but 1 were properly placed.  Not bad... it was noticed very quick and replaced. ( mainly due to poor technique ).
Many times gastric contents have come up thru the side port, which was a bit messy.  There was question that if the balloon system developed a tear due to poor technique and over-zealousness, that the distal balloon ( being smaller ), would loose the seal and cause provider induced aspiration without noticing fast enough before damage happens.... or having a tear/trauma around the laryngopharynx causing the same results.  ( so far, just our theory ). Which could happen in the combitube as well.

Soooo, to recap...  the reason's I prefer the combitube is that you place it once, and use your skills to select the connector to hook to.  King does that most of the time, but you don't get the option if its wrong.
The gastric vent hole is not easy to plug in a King. 
The extra parts on a combitube do not slow you down much when you are efficient.
You can intubate with a King, by using a guide wire or bougie... but this is easier said than done.  Our success rate at this was not super. The distal tip of the bougie kept getting hemmed up in the laryngopharynx and it was tough to navigate at times. 

But, all in all... they are great tools in the right settings when your main options are limited.


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## JPINFV (Mar 30, 2011)

MasterIntubator said:


> The gastric vent hole is not easy to plug in a King.



Isn't the gastric vent hole there to facilitate placement of an oral gastric tube? Is there any reason short of protocol that you aren't decompressing the stomach?


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## MasterIntubator (Mar 30, 2011)

Don't have it in our protocols.  Which sucks...


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