# combi/kingairway BLS or ALS?



## wildmed (Feb 20, 2010)

Does your service/ state have the insertion of combi/king airways as a BLS or an ALS measure? what do you think it should be? while it seems to be pretty much idiot-proof, however it is also far more invasive than an an OPA/NPA? Even further, I have heard that several states are making intubation a BLS skill? I don't know how I feel about that.


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## TransportJockey (Feb 20, 2010)

wildmed said:


> Does your service/ state have the insertion of combi/king airways as a BLS or an ALS measure? what do you think it should be? while it seems to be pretty much idiot-proof, however it is also far more invasive than an an OPA/NPA? Even further, I have heard that several states are making intubation a BLS skill? I don't know how I feel about that.



MLAs, EOA, and LMA is considered BLS here in NM. King is not yet approved for use AFAIK.


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## EchoMikeTango (Feb 20, 2010)

> MLAs, EOA, and LMA is considered BLS here in NM. King is not yet approved for use AFAIK.​


*im sorry... what? Im new ...*


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## TransportJockey (Feb 20, 2010)

rjrobinson said:


> *im sorry... what? Im new ...*



MLA= Multi-Lumen Airways. Eg. Combitube.
LMA= Laryngeal Mask Airway
EOA= Esophageal Obturator Airway


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## Veneficus (Feb 20, 2010)

jtpaintball70 said:


> MLA= Multi-Lumen Airways. Eg. Combitube.
> LMA= Laryngeal Mask Airway
> EOA= Esophageal Obturator Airway



EOAs are still in use somewhere?


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## TransportJockey (Feb 20, 2010)

Not sure about them being still in use. I know it was a device the state still has in scope of practice as an either/or for MLA. I did play with one a few times cause my old service had a few in the storeroom just laying around.


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## MSDeltaFlt (Feb 20, 2010)

Veneficus said:


> EOAs are still in use somewhere?


 
Sort of.  They've evolved into the King LT.


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## DarthMalachi (Feb 20, 2010)

NC considers MLAs to be a BLS skill, and protocol here is to insert one after the 2nd shock from a AED(after confirming pulselessness and apnea).  Henderson county(Hendersonville, where I live)uses the CombiTube, the next county over from me uses the King airway.  I don't know who might use the LMA around this area...


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## mississippimedic (Feb 20, 2010)

The last service I worked for still carried the Eoa, in the five years I was there I never heard of anybody using one. I think that service it was considered an als skill.


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## MusicMedic (Feb 20, 2010)

I honestly dont know much about the different advanced airways, i just wanted to know
Whats the difference between a King LT and Combitube?

the combitube just looks like a longer version of the King LT


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## TraprMike (Feb 20, 2010)

the two services I've been involved with both use the Combi tube. and have for 16+ years


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## VentMedic (Feb 20, 2010)

*King*







http://www.kingsystems.com/EDUCATION/FrequentlyAskedQuestions/KINGLTAirways/tabid/132/Default.aspx






*Combitube*


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## bravesfan160 (Feb 20, 2010)

My service uses combitube.  

Tennessee has been talking about creating a third teir emt called "EMT-Advanced" which will be able to set up and do some EKG reading, and ET tubes as well as IO.  

I am pretty sure that they are close to getting that underway because they are making BLS ambulances required to have the technology to send EKGs ahead to the hospital enroute.


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## Shishkabob (Feb 20, 2010)

The King is designed to always intubate the esophagus and ventilate through proximal holes, there by only needing one airway connection. 

The Combi can either be placed in the trachea or esophagus and as such has two ports, one for the distal port and one for the proximal ports.  Two different possible ventilation ports means it can take longer to find tge right one and possibly cause gastric distention if the wrong one is used.  


Also the Combi is made with latex while the King is not. 



Long explanation made short due to me being on my iPhone.


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## MusicMedic (Feb 20, 2010)

Thank you VentMedic and Linuss for the explanations!!


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## Seaglass (Feb 20, 2010)

I work at a couple places. One allows Combitubes for basics. The other uses Kings, which basics can't apply.


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## wildmed (Feb 20, 2010)

so we have established the difference between the different blind airways... But what do you think? ALS or BLS? Here in colorado it is dependent on the agency you work for. As far as the EMT-A, i have heard it will be similar to the I-85 level, so somewhere in-between EMT-B-IV and EMT-I. I have no idea what scope of practice it will entail though. There is nothing about it in rule 500 since the last time I looked.


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## wildmed (Feb 20, 2010)

I guess I should say what I think too. I think they should be a BLS skill if a basic receives extra training or certification in it.


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## TransportJockey (Feb 20, 2010)

wildmed said:


> I guess I should say what I think too. I think they should be a BLS skill if a basic receives extra training or certification in it.



Here they're BLS because they are included in the EMT-B curriculum.


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## skivail (Feb 20, 2010)

Most services in my area have the King tube as a BLS skill.


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## ExpatMedic0 (Feb 21, 2010)

They are BLS skill here, along with CBG testing. Some services carry the combi and some carry the king.


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## MrBrown (Feb 21, 2010)

laryngeal mask here is a Technician skill ("BLS")


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## mct601 (Feb 21, 2010)

jtpaintball70 said:


> Here they're BLS because *they are included in the EMT-B curriculum*.



This.

https://www.nremt.org/nremt/about/exam_coord_man.asp#BSkillSheets


Advanced airway is supposed to be included on BLS skill practicals, but I was actually not tested on it. Reason being, many states don't allow basics to perform advanced airway procedures.


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## Aprz (Feb 21, 2010)

I was introduced to Combi about two weeks ago. It seems to be stupid proof. I like it and I think it should be BLS with what I have learned about it so far. In my area, it's an ALS skill, and it doesn't seem like anybody likes it so maybe I am missing something here.


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## TransportJockey (Feb 21, 2010)

Aprz said:


> I was introduced to Combi about two weeks ago. It seems to be stupid proof. I like it and I think it should be BLS with what I have learned about it so far. In my area, it's an ALS skill, and it doesn't seem like anybody likes it so maybe I am missing something here.



For a lot of medics it's a pride thing. They feel they have to get that ETT. Some of the best medics I worked with would take one look and if they didn't think they could get it in 1 or two attempts would just drop an MLA and go from there.


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## VentMedic (Feb 21, 2010)

Aprz said:


> I was introduced to Combi about two weeks ago. It seems to be stupid proof. I like it and I think it should be BLS with what I have learned about it so far. In my area, it's an ALS skill, and it doesn't seem like anybody likes it so maybe I am missing something here.


 
Because some believe the Combitube is "stupid proof", it has higher incidence of complications which has had some bad consequences for  patients. Just the design alone can cause problems due to its size. Then, in the hands of those who feel it is "stupid proof", it becomes deadly.


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## EMSLaw (Feb 21, 2010)

VentMedic said:


> Because some believe the Combitube is "stupid proof", it has higher incidence of complications which has had some bad consequences for  patients. Just the design alone can cause problems due to its size. Then, in the hands of those who feel it is "stupid proof", it becomes deadly.



If you make something idiot proof, someone WILL build a better idiot.


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## EmtTravis (Feb 21, 2010)

In my class we were taught the use of several different tubes.  We practiced with the combitube but not the kind.  The service that I will be working at has them on the trucks but we only have ALS trucks but it's still a bls skill but has never been used I don't think.


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## VentMedic (Feb 21, 2010)

EmtTravis said:


> In my class we were taught the use of several different tubes. We practiced with the combitube but not the kind. The service that I will be working at has them on the trucks but we only have ALS trucks but it's still a bls skill but has never been used I don't think.


 
Establishing airways should not be viewed in terms of "BLS skill".  The King and Combitube are both advanced airways meaning they are more than the NPA or OPA and should be treated as such regardless of the level of the provider. By no means should it be thought of as a lesser skill because of some BLS label.  If you can not think in terms of "advanced" vs BLS and ALS, then this airway device and skill is probably more than one should be attempting.


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## Veneficus (Feb 21, 2010)

EMSLaw said:


> If you make something idiot proof, someone WILL build a better idiot.



Sometimes it seems that rather than building a new piece of stupid proof technology, wouldn't it be easier to just build a better provider?

Of course then I couldn't market my giant reflective star of life in Gals so all the new people could buy one and make me insanely wealthy. (No idea what the thing would do, but who cares as long as it sells right?)


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## Aprz (Feb 21, 2010)

Why not have the goal of having better providers and better stupid proof technology?  It's not like (most) of the instructors are the ones designing these utilities so we aren't taking away from the production of better technology or better providers.

VentMedic, can you provide us with examples of where the combi tube can fail? I can only think of somebody not paying attention to gastric distention (so they continue to use the wrong lumen), maybe too forcefully put it in causing damage to the pt. airway instead, don't have a good seal with the balloons, maybe one of the balloons block both the trachea and esophgas..? Just trying to think of what could go wrong the combi tube.


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## VentMedic (Feb 21, 2010)

Aprz said:


> VentMedic, can you provide us with examples of where the combi tube can fail? I can only think of somebody not paying attention to gastric distention (so they continue to use the wrong lumen), maybe too forcefully put it in causing damage to the pt. airway instead, don't have a good seal with the balloons, maybe one of the balloons block both the trachea and esophgas..? Just trying to think of what could go wrong the combi tube.


 
Look at the pictures I posted earlier. The size of the tube by diameter and the 85 ml cuff can do some damage.

Also, if you (not you specifically but in general) are using the Combitube, the potential complications should have been thoroughly discussed or your training was very inadequate.

Esophageal tears

Serious cord damage - the Combitube is much larger than any ETT you will commonly use.

Hematoma

Ischemia-reperfusion injury or compression of glossal blood vessels including the lingual veins which can cause the tongue to become engorged - this may require a tracheotomy as will some of the other complications.


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## Aprz (Feb 21, 2010)

Eh, that's what I was guessing was that the size and being too wreckless with it could cause damage as I mentioned earlier (I mentioned being too forceful). In my area, I was only introduced to the combi tube on how to use a BVM on it (along with other ALS airway), not how to insert or the whole thing behind it. Our instructors briefly described how it worked (about a 15 minute total lecture for every ALS airway), which is where I got the idea that it was stupid proof, but that's it. I also heard rumor in Santa Clara County and Alameda County (around the Bay Area), they tried letting EMT-b using it, but it was a disaster and they stopped it so I was curious with what was so wrong with it. Thank-you very much for the explanation.


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## CAOX3 (Feb 22, 2010)

wildmed said:


> Does your service/ state have the insertion of combi/king airways as a BLS or an ALS measure? what do you think it should be? while it seems to be pretty much idiot-proof, however it is also far more invasive than an an OPA/NPA? Even further, I have heard that several states are making intubation a BLS skill? I don't know how I feel about that.



I would say ALS.

Im assuming the BLS crew would be using it in a caridiac arrest?

Im more then happy to drop an OPA, ventilate and transport if ALS isnt available rather then risking a injury to the airway and complicating matters by intruducing blood and swelling.  

If you do ROSC the patient the ER can place and advanced airway in their nice controlled enviorment when you arrive.

If I had a crystal ball and could predict future I would say the treatment for cardiac arrest patients is headed towards passive ventilation even at the ALS level.


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## EMTinNEPA (Feb 22, 2010)

wildmed said:


> Does your service/ state have the insertion of combi/king airways as a BLS or an ALS measure? what do you think it should be? while it seems to be pretty much idiot-proof, however it is also far more invasive than an an OPA/NPA? Even further, I have heard that several states are making intubation a BLS skill? I don't know how I feel about that.



Careful... as soon as something is declared "idiot-proof", they build a better idiot.

I advocate the King LT as a BLS skill.  The combi-tube, while amazing in its simplicity, can be confusing to new providers simply because it has two ports to connect the BVM.

As for BLS providers performing endotracheal intubation, absolutely not.  BLS providers do not get nearly enough education on airway anatomy and physiology to be performing such an invasive, and potentially life-threatening if performed incorrectly, procedure.

Besides, everybody from EMT-B up to emergency physician should be able to manage an airway without an endotracheal tube.


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## swindlman (Mar 29, 2010)

EMTinNEPA said:


> I advocate the King LT as a BLS skill.  The combi-tube, while amazing in its simplicity, can be confusing to new providers simply because it has two ports to connect the BVM.



Truly what is confusing about the Combi? If you connect the BVM on Port 1 and you see no chest rise and negative lung sounds switch to the other port. If the problem continues, pull it and use an OPA and BVM.


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## feldy (Mar 29, 2010)

Combitube is ALS in MA so i was not taught it in my course. When i took the Louisiana practicals it is a BLS skill which i had been verbally walked through the week before but never actually performed it until i was tested. It was quite simple.


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## MTEMTB (Mar 30, 2010)

Just completed an air training and got to see a King for the first time. Each person has a different opinion on it.
Was first trained to use a combi tube.


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## joeshmoe (Mar 30, 2010)

EMT-B's can use the combitube here.


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## AngelEyes (Mar 30, 2010)

*Combitube/King   ALS vs. BLS*

In Oregon we are able to do it as a BLS skill.


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## Bloom-IUEMT (Mar 30, 2010)

Wow I wasn't even aware medics used LMAs.  I saw one once in the OR and the anesthesiologist told me it can cause patients to aspirate but they use it frequently with surgery patients because they've fasted before the operation. Seems like it would be dangerous for a paramedic to use. AM I mistaken? Help me out.


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## FLEMTP (Mar 30, 2010)

Bloom-IUEMT said:


> Wow I wasn't even aware medics used LMAs.  I saw one once in the OR and the anesthesiologist told me it can cause patients to aspirate but they use it frequently with surgery patients because they've fasted before the operation. Seems like it would be dangerous for a paramedic to use. AM I mistaken? Help me out.



We were using the LMA... we now use the LMA supreme...it has a port for an NG tube on it and a nice built in bite block...they can allow for aspiration.. but if you paralyze someone and cannot get an ETT then they are a great rescue airway..IMHO


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## subliminal1284 (Mar 30, 2010)

Here in WI the combitube is a BLS skill. If youre dumb enough to mess up a combitube after you have been properly trained on it you really have no business whatsoever in EMS.


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## Bloom-IUEMT (Mar 30, 2010)

FLEMTP said:


> We were using the LMA... we now use the LMA supreme...it has a port for an NG tube on it and a nice built in bite block...they can allow for aspiration.. but if you paralyze someone and cannot get an ETT then they are a great rescue airway..IMHO



I still don't get it---if it doesn't protect against aspiration why use it?  Does it require RSI?


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## Shishkabob (Mar 30, 2010)

Bloom-IUEMT said:


> I still don't get it---if it doesn't protect against aspiration why use it?  Does it require RSI?



Because it still keeps the airway open from the tongue, just like NPAs/OPAs, and it frees someone from having to hold a BVM mask seal.  No, it does not require RSI.


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## adamjh3 (Mar 30, 2010)

San Diego county considers both the king and combitube airways a BLS skill. We have to get certified through the county for it, though.


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