# King VS ET



## NPO (Jun 13, 2014)

On a recent cardiac arrest my partner (medic) and I (basic) were working in the back while a third EMT drove. Fire had swapped me out for compressions already so I was bagging. He was quite busy establishing access (failed IV to no fault of his, attempting manual IO). All I'm doing is squeezing a bag every few seconds. Thinking I can do more I offer to place a king as all the patient had was an OPA. The OPA was working, and there was very little resistance on respirations, but I thought he might like a secure airway when we roll into the er a few minutes away. He told me that when there is a medic on scene EMTs aren't supposed to place kings.

I understand wanting the more senior person (and higher level of care) to place the airway, but in the interest of time, I feel like it should be okay to delegate a task to someone who is capable of doing it within there scope. The policy seems to be because the ems dept prefers ET over King, since that is how the paramedic protocol reads. 

Now, me being a Basic, I don't have a lot of ET training outside of working with medics and a few intubations on dummy heads. Can someone explain the benefits of an ET over a King to me? Am I wrong in thinking it should be okay to delegate that task if the medic so chooses and the king is within the basic's scope, in which case it is for me.


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## kindofafireguy (Jun 14, 2014)

Theoretically, the ET tube protects against aspiration of emesis or secretions into the lungs, whereas a King does not actually guarantee that. 

That is, however, in a perfect world.


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## TRSpeed (Jun 14, 2014)

^ correct. Also it depends on which medic you work with.


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## Christopher (Jun 14, 2014)

NPO said:


> On a recent cardiac arrest my partner (medic) and I (basic) were working in the back while a third EMT drove. Fire had swapped me out for compressions already so I was bagging. He was quite busy establishing access (failed IV to no fault of his, attempting manual IO). All I'm doing is squeezing a bag every few seconds. Thinking I can do more I offer to place a king as all the patient had was an OPA. The OPA was working, and there was very little resistance on respirations, but I thought he might like a secure airway when we roll into the er a few minutes away. He told me that when there is a medic on scene EMTs aren't supposed to place kings.
> 
> I understand wanting the more senior person (and higher level of care) to place the airway, but in the interest of time, I feel like it should be okay to delegate a task to someone who is capable of doing it within there scope. The policy seems to be because the ems dept prefers ET over King, since that is how the paramedic protocol reads.
> 
> Now, me being a Basic, I don't have a lot of ET training outside of working with medics and a few intubations on dummy heads. Can someone explain the benefits of an ET over a King to me? Am I wrong in thinking it should be okay to delegate that task if the medic so chooses and the king is within the basic's scope, in which case it is for me.





kindofafireguy said:


> Theoretically, the ET tube protects against aspiration of emesis or secretions into the lungs, whereas a King does not actually guarantee that.
> 
> That is, however, in a perfect world.





TRSpeed said:


> ^ correct. Also it depends on which medic you work with.



Good news, in this case none of that mattered. Transporting a patient with ongoing CPR is far more likely to result in a bad outcome than the selection of your airway device!

The available retrospective research even shows that your OPA+BVM is the better choice over both ETT or a SGA. ETT's probably confer a minor benefit in patients who receive longer resuscitation, but that's not really known. As far as aspiration concerns...the vast majority of patients who aspirate during cardiac arrest do so prior to EMS arrival.

The really killer in cardiac arrest is inadequate chest compressions.

Fiddling with an airway? If it isn't a respiratory etiology that'll kill the patient if it gets in the way of chest compressions. My EMT's frequently place King's for me during cardiac arrests. I could care less what they do as long as somebody is pumping on the chest.

Moving the patient? If they don't have a pulse, the number of times this will need to happen should be countable on one hand (with one finger perhaps).

IV/IO? Who cares, the drugs don't seem to work anyways...just don't stop CPR 

Defibrillation? Very important. Mas importante. Be sure to do picture perfect chest compressions up until the point of defib, minimize the perishock pause (we're talking sub 10 seconds, sub 5 is preferable), and don't delay defibrillation for anything other than chest compressions.

tl;dr: the choice in airway is irrelevant if you do not work cardiac arrests on scene.


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## BASICallyEMT (Jun 14, 2014)

NPO said:


> On a recent cardiac arrest my partner (medic) and I (basic) were working in the back while a third EMT drove. Fire had swapped me out for compressions already so I was bagging. He was quite busy establishing access (failed IV to no fault of his, attempting manual IO). All I'm doing is squeezing a bag every few seconds. Thinking I can do more I offer to place a king as all the patient had was an OPA. The OPA was working, and there was very little resistance on respirations, but I thought he might like a secure airway when we roll into the er a few minutes away. He told me that when there is a medic on scene EMTs aren't supposed to place kings.
> 
> I understand wanting the more senior person (and higher level of care) to place the airway, but in the interest of time, I feel like it should be okay to delegate a task to someone who is capable of doing it within there scope. The policy seems to be because the ems dept prefers ET over King, since that is how the paramedic protocol reads.
> 
> Now, me being a Basic, I don't have a lot of ET training outside of working with medics and a few intubations on dummy heads. Can someone explain the benefits of an ET over a King to me? Am I wrong in thinking it should be okay to delegate that task if the medic so chooses and the king is within the basic's scope, in which case it is for me.




If you don't mind me asking, what county do you work for? I thought my system was top notch in terms of SOP for basics. Placing an ET or King is out of scope and would definitely get you in hot water. Good conversational piece nonetheless.


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## NPO (Jun 14, 2014)

BASICallyEMT said:


> If you don't mind me asking, what county do you work for? I thought my system was top notch in terms of SOP for basics. Placing an ET or King is out of scope and would definitely get you in hot water. Good conversational piece nonetheless.



Kern County CA. We have an optional expanded scope to include King LT-D


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## DesertMedic66 (Jun 14, 2014)

BASICallyEMT said:


> If you don't mind me asking, what county do you work for? I thought my system was top notch in terms of SOP for basics. Placing an ET or King is out of scope and would definitely get you in hot water. Good conversational piece nonetheless.



In regards to EMS in SoCal, the words top notch and California are ones that should never go together..... Unless the word "not" is in there.


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## NPO (Jun 14, 2014)

There is room for improvement up here, but I have to say, Kern County is one of the best systems I've seen. Not just talking about protocols but hospital relations, fire relations, response times, etc. Im happy to work in this system as opposed to my old system in Los Angeles...


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## TRSpeed (Jun 14, 2014)

BASICallyEMT said:


> If you don't mind me asking, what county do you work for? I thought my system was top notch in terms of SOP for basics. Placing an ET or King is out of scope and would definitely get you in hot water. Good conversational piece nonetheless.






i worked Riv for a a couple of yrs, before coming over to Hall in Kern. I can say Riv is a good place too(especially compared to LA,OC) especially with the new med director but still far below kern co in more ways than I can count in 2 hands.

Just don't get complacent , as an emt and a employee I know moral sucks there right now. In Ric Co Bls units don't run 911 so they don't get much exp other than the occasional SNF to ER. And even those the hospitals will throw a fit if their is even a remote chance they could be ALS. 





NPO said:


> There is room for improvement up here, but I have to say, Kern County is one of the best systems I've seen. Not just talking about protocols but hospital relations, fire relations, response times, etc. Im happy to work in this system as opposed to my old system in Los Angeles...



Don't forget , bls fire, priority dispatching including bls ambulance response, scene control, etc


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## BASICallyEMT (Jun 14, 2014)

DesertEMT66 said:


> In regards to EMS in SoCal, the words top notch and California are ones that should never go together..... Unless the word "not" is in there.



That is a good point. But, referring to Socal I think we are pretty progressive.


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## BASICallyEMT (Jun 14, 2014)

TRSpeed said:


> i worked Riv for a a couple of yrs, before coming over to Hall in Kern. I can say Riv is a good place too(especially compared to LA,OC) especially with the new med director but still far below kern co in more ways than I can count in 2 hands.
> 
> Just don't get complacent , as an emt and a employee I know moral sucks there right now. Bls units don't run 911 so they don't get much exp other than the occasional SNF to ER. And even those the hospitals will throw a fit if their is even a remote chance they could be ALS.
> 
> ...



I currently work in Riv County and I completely agree with you.


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## TRSpeed (Jun 14, 2014)

Come over to Hall. If you want a career in EMS.


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## NPO (Jun 14, 2014)

TRSpeed said:


> Come over to Hall. If you want a career in EMS.



^ This. We run the show. Fire walks up and ask US what WE need. I'm not against fire helping out, and sometimes we definiately need it. But its a whole let better working WITH them rather than FOR them like I'm used to.


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## Quikclot (Jun 20, 2014)

Back to the original question, ET has the benefit of not putting possible pressure on arteries/vein in the neck in the event of swelling, whereas a King tube could cut off blood flow to the brain.


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## Carlos Danger (Jun 20, 2014)

Quikclot said:


> Back to the original question, ET has the benefit of not putting possible pressure on arteries/vein in the neck in the event of swelling, whereas a King tube could cut off blood flow to the brain.



This has never been proven in humans, and I'm highly skeptical that it ever will be. Millions of patients a year undergo elective surgery with LMA's in place, and no increase in morbidity or mortality has ever been identified as a result. 

Unfortunately, the many people who still insist that "real paramedics intubate" use this purely hypothetical idea to support outdated practice.


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## STXmedic (Jun 20, 2014)

A local agency did a small study* using fresh cadavers to see if it truly does impede circulation. Many providers down here were (incorrectly so) taught to inflate the balloon until they got some back pressure. They found that there was impedance when the balloon was inflated in that manner (I forget what the average amount of air that came out to was- I believe it was around 100mL). However, they found no evidence of this when the balloon was inflated to the manufacturer's recommendations.

The LMA in the hospital argument is invalid, though. That's an entirely different device from the King tube, and nobody has ever said the LMA causes vascular occlusion.

*They used four different cadavers I believe, and I'm not sure if they are going to get it published since it was so small of a sample.


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## Carlos Danger (Jun 20, 2014)

STXmedic said:


> The LMA in the hospital argument is invalid, though. That's an entirely different device from the King tube, and *nobody has ever said the LMA causes vascular occlusion.*



Yes, they have. There has actually been a lot of discussion on it. 

Impairment of carotid artery blood flow by supraglottic airway use in a swine model of cardiac arrest.


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## STXmedic (Jun 20, 2014)

Remi said:


> Yes, they have. There has actually been a lot of discussion on it.
> 
> Impairment of carotid artery blood flow by supraglottic airway use in a swine model of cardiac arrest.
> 
> In fact, to my knowledge this is the only published study to address the issue.



I stand corrected  Thank you! Yeah, the Combi and the King make sense to me, but the LMA does not.


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## MSDeltaFlt (Jun 20, 2014)

NPO said:


> On a recent cardiac arrest my partner (medic) and I (basic) were working in the back while a third EMT drove. Fire had swapped me out for compressions already so I was bagging. He was quite busy establishing access (failed IV to no fault of his, attempting manual IO). All I'm doing is squeezing a bag every few seconds. Thinking I can do more I offer to place a king as all the patient had was an OPA. The OPA was working, and there was very little resistance on respirations, but I thought he might like a secure airway when we roll into the er a few minutes away. He told me that when there is a medic on scene EMTs aren't supposed to place kings.
> 
> I understand wanting the more senior person (and higher level of care) to place the airway, but in the interest of time, I feel like it should be okay to delegate a task to someone who is capable of doing it within there scope. The policy seems to be because the ems dept prefers ET over King, since that is how the paramedic protocol reads.
> 
> Now, me being a Basic, I don't have a lot of ET training outside of working with medics and a few intubations on dummy heads. Can someone explain the benefits of an ET over a King to me? Am I wrong in thinking it should be okay to delegate that task if the medic so chooses and the king is within the basic's scope, in which case it is for me.



Studies have shown that all you need is an airway.  That's it.  Nothing more.  OPA, SGA, ETT, it doesn't matter.  You can't kill a dead man.

Just treat chest compressions like Pringles: once you pop, you just can't stop.


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## NPO (Jun 20, 2014)

Thanks everyone. Lots of useful information


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## Quikclot (Jun 20, 2014)

LOL Delta ^ 

God that is so true.


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## VFlutter (Jun 21, 2014)

If you think that the arrest was precipitated by respiratory then in may be prudent to try harder for an ETT. Or if you can sink the tube during compressions or during a rhythm check then go for it. But compressions should not be stopped solely to place an ETT if your BLS airway techniques are working.


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## Carlos Danger (Jun 21, 2014)

STXmedic said:


> I stand corrected  Thank you! Yeah, the Combi and the King make sense to me, but the LMA does not.



What _does_ make any comparison here invalid is the fact that these studies were done in PIGS....who were in CARDIAC ARREST......any attempt to draw a parallel between the CBF of a dead pig receiving CPR and the CBF of a living human with a perfusing rhythm is simply beyond reason. 

FWIW, some of the LMA's are really great devices that should, IMO, be much more readily embraced by the EMS community. I never really liked the combitube (though it was a good backup before LMA's became common), and I've never placed a King in anything but a manikin. But I've used lots of different kinds of LMA's, and a good LMA is really where it's at.


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## TransportJockey (Jun 21, 2014)

Remi said:


> What _does_ make any comparison here invalid is the fact that these studies were done in PIGS....who were in CARDIAC ARREST......any attempt to draw a parallel between the CBF of a dead pig receiving CPR and the CBF of a living human with a perfusing rhythm is simply beyond reason.
> 
> FWIW, some of the LMA's are really great devices that should, IMO, be much more readily embraced by the EMS community. I never really liked the combitube (though it was a good backup before LMA's became common), and I've never placed a King in anything but a manikin. But I've used lots of different kinds of LMA's, and a good LMA is really where it's at.


We use iGels as our backup out here with some 37fr combis still left over. we are debating adding King LTDs as a second backup to replace the few MLAs we have left. The iGel so far works rather well, but too much secretions and it does start to have problems.


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## Summit (Jun 21, 2014)

If a BVM+OPA is working, I'd focus on compressions and reversing the cause of the arrest over placing a SGA or ETT. If the cause was respiratory, an ETT would be nice. SGA can be placed without interupting compressions, but so can an ETT if you have the right tools/provider.

Now if you have someone with a pulse who needs airway maintenance, I'd absolutely want a SGA or ETT, especially if I have to move them any significant distance (stairs, trail, rock, snow, ice). OPA+BVM is a nice solution if you are in a comfy ambulance.


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## OnceAnEMT (Jun 21, 2014)

From an ED perspective, I'll say our Respiratory Therapists will remove EMS-placed Kings and, assuming the Pt is still in respiratory arrest, replace it with an ET. For cardiac arrest, I will be honest and say I can't recall what they do. I believe all of the codes I've been in at this hospital the Pt arrived with an ET already in place, which we just worked, obviously. All trucks that hit our doors are either Medic-Medic or Medic-EMT (and that EMT can place a King), so we always have an advanced airway present on arrival, and I assume they choose ET. I can't seem to find their generic cardiac arrest algorithm which would state what is placed, and by who. I'll have to ask, I'm curious if they have a specific rule, or if anyone can place any airway in their scope. I'll ask RT what they'd do if a cardiac arrest Pt came in with a King. 

Just a thought, but what about placing an ET while the monitor is analyzing or Doc is checking pulse or any other mandatory pauses like that?


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## VFlutter (Jun 22, 2014)

Grimes said:


> Just a thought, but what about placing an ET while the monitor is analyzing or Doc is checking pulse or any other mandatory pauses like that?



If they can get the tube during a rhythm check then that is great. However most of the time we will check pulse, analyze rhythm, and shock in ~ 10sec. Not always enough time. 

In our hospital it is very MD dependent. Some MDs will want to intubate almost immediately. Others will wait it out. One does not like to intubate unless we get ROSC or BLS techniques are not working.


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## Carlos Danger (Jun 22, 2014)

Grimes said:


> Just a thought, but what about placing an ET while the monitor is analyzing or Doc is checking pulse or any other mandatory pauses like that?



Well, that was always the goal in the past (before the really BIG push towards not interrupting compressions that started a few years ago), and it just didn't work. It very often takes a lot longer than a few seconds to place an ETT, and we know now that maintaining perfusion pressure is much more important.

An ETT can sometimes be placed with compressions ongoing, but there's simply no reason for it, since it doesn't contribute to improved outcome. It's normally much easier to just slide in a SGA, and you can later exchange the SGA for an ETT if you get ROSC.


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## NomadicMedic (Jun 22, 2014)

Many services still place ego over outcome. "What do you mean you can't intubate while compressions are ongoing? Obviously you're not high-speed, low drag."


It's just our own ego getting in the way when we refuse to recognize that the only thing making a difference is fast, effective, un interrupted compressions and electricity.

If you really have to have an airway, use an SGA or a BVM and OPA. If you really have to have an IV, drill an IO. 

I often also hear the argument, "we practice these skills on patients in cardiac arrest, so we can perform them effectively on live patients." That certainly is a valid reason, but there is a difference between a truly viable sudden cardiac arrest patient and the run-of-the-mill arrest which we've all run.


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## Tigger (Jun 22, 2014)

We had some demo VividTrac video laryngoscopes come through recently. 75 dollars each (plus software) and you plug it into your tablet. The videos provided showed them in use with compression in progress with no difficulty.

Unfortunately I doubt we will get them. Too much provider pride here, I guess. Apparently not missing tubes for a year means you'll never face a challenging intubation ever.


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## OnceAnEMT (Jun 22, 2014)

Thanks for the replies guys, answered my questions. I asked one of the RTs today about King vs ET, and she, surprisingly attimently, said that she personally loves SGAs and as long as she confirms that it is correctly placed an the airway is secure, it doesn't need to be replaced by an ET. That said, most of the times one of the first things the MD orders is to get an ET in. We ended the conversation agreeing that an airway was an airway. 

 Out of the blue she also mentioned hating LMAs.


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