Airway question

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ajax

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I'm a basic who wants to know everything. I've been hearing a lot of conversation about holding off intubating in codes because the interruption in compressions is likely more damaging than the less-secure airway. Someone mentioned they tried an LMA in a recent code, which got me wondering about intubation. I've been looking but can't seem to find anything online that describes the methods, theories, pros and cons of different airway management decisions, RSI, LMA, king airway, etc - and I'm wondering if any of you have suggestions of places I can look.

Thanks!
 
i was wondering this myself...in new orleans i can only put in a combitube as a basic so i never really learned otherwise. But what/why would you intermediates and medics choose one method over another? (anyone who is involved in writing their local protocols feel free to put in your 2 cents).
 
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Current guidelines are if effectively able to ventilate with simple airway adjunct no need to intubate.

When would we decide to intubate? If unable to effectively ventilate. Even noting air was entering the esophagus would be a threat to effective ventilation's because in simple terms as air inflates the stomach it keeps lungs from properly inflating. Plus it makes the risk of aspirations greater because as air pressure increases in stomach at some point you will get the stomach contents coming out.

As to RSI. That is used when patient is still breathing on their own but their is a life threat to patient that could be better controlled if I take over control of their airway. So at that point I use medications to sedate and paralyze. Then I intubate. Much more involved but just quick overview.
 
ajax said:
I'm a basic who wants to know everything. I've been hearing a lot of conversation about holding off intubating in codes because the interruption in compressions is likely more damaging than the less-secure airway. Someone mentioned they tried an LMA in a recent code, which got me wondering about intubation. I've been looking but can't seem to find anything online that describes the methods, theories, pros and cons of different airway management decisions, RSI, LMA, king airway, etc - and I'm wondering if any of you have suggestions of places I can look.

Thanks!
Click to expand...

For intubating during codes, even with your less invasive backup airways, you do NOT stop chest compressions. If you cannot intubate during adequate chest compressions, then you don't intubate. You go with your backup airways including your BVM with OPA.

If you have an adequate airway then you should be able to adequately ventilate the pt, according to the AHA. The AHA wants an airway. Define "airway". An "airway" by any other term is this: an unobstructed pathway from your oxygen source (ambient air, compressed oxygen, etc) to your lungs. So what does that mean: airway? It means each and every single way to get an unobstructed pathway: spontaneous, head-tilt/chin-lift, jaw thrust, OPA, NPA, ETT, LMA, King, Combi-Tube, Needle cric, surgical cric, tracheostomy.
 
i can understand the need for a cric or trach but what determines whether you do ETT, LMA, king, or combi-tube. im assuming as a medic you would only carry ETTs and one other. Would i be correct? Im not wondering if you need to control the airway...im asking for example, why would you put an LMA in over an ETT?
 
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Intubating under direct laryngoscopy during chest compressions is easier said than done because the trachea, along with all the other landmarks, will be shaking up and down with the chest compressions. Which is why LMA, Kings, etc might, I repeat "might", be preferable to ETT.

All of this also depends on how much help you have on scene. My ground service part time you MIGHT have another truck help you. You might not. If you don't your only help is your partner who might be a Basic or an EMSD. Bystanders? Don't count on it. So what you can and cannot do on a code could very well be limited to say the least. But if you follow the evidence-based AHA guidelines, you can still work the code effectively with just you and your partner.

Once you start compressions, you don't stop until the AHA guidelines say you can. One reason would be to shock. Then you get your IV/IO line during chest compressions. Follow those protocols. Intubate when you can IF you can.
 
For my own information, how long would you honestly need to stop compressions to intubate? You can have the laryngoscope in the mouth and in position and the ET tube and stylus ready in the other hand, and they would probably only have to stop compressions for 5 seconds to get the tube to a stable point. Once its in position, hold it at the mouth and compressions can start back while you inflate the bulb and secure the tube.
 
Takes a slight bit more time than 5 seconds to intubate, especially a live person with vomitus and other things in the airway that accompany cardiac arrest.


As for the original question, a rescue airway (King/Combi/Etc) are good when A) You don't need an ETT, but need something more than an OPA, B ) you don't have time for an ETT, or C) you can't get the ETT for some reason.
 
Per the AHA and the Paramedic National Standard Curriculum, an intubation attempt should take no longer than 30 seconds. Easier said than done in some cases...
 
Also most people think they are of above average intelligence, can't be true. Likewise most medics, anesthesiologists, EM docs are convinced that they can intubate in a matter of seconds. But when you watch codes it often takes quite awhile longer. There was a recent article in Academic Emergency Medicine on how often there is a significant delay in prehospital chest compressions due to intubation.

As to why you'd use which one, intubation with an ET tube remains the gold standard, because you have the best protection from dislodgement and aspiration. Others like the KING have the advantage of speed and not having to do direct lyrangoscopy. LMA has the advantage that it's quick and easy, but it doesn't protect from aspiration.
 
No need to pee around trying to intubate a cardiac arrest; whip an LMA out, shove it down thier gob and blow up the cuff. Really is that simple.

RSI is quite a useful tool if it is correctly applied. The boys in the orange jumpsuits (HEMS) have convinced me it is just not for medical patients and can be quite handy in severe trauma too.

Selected Intensive Care Paramedics have the ability to heavily sedate, paralyse and intubate here and we are showing nearly 98% success consistently for the last three years. It is quite controversial however selecting who gets it and who does not but those that do have strong support from our Regional Medical Advisors and the national Medical Director.

Use of Intensive Care Paramedic RSI here is restricted to patients with a GCS of 10 or less so its not as avaliable as it is to the HEMS Reg ... but then agian its his bum and not mine! :D

I am however a true proponent of prehospital RSI if the right conditions are met.
 
In the service I currently work for ETI is still considered the "gold standard", and the program I attended put a HUGE emphasis on being able to intubate in any situation at any time. That being said, interruptions in CPR are uncalled for. It can be VERY difficult to intubate during compressions, someone mentioned that it should only take "5 seconds" to correctly place your ETT...Well I'd be very happy with that. I agree that if you're able to insert your laryngoscope, locate the trachea and maintain visualization during compressions then yeah, if you've got your tube lubed 'n ready then it shouldn't take long to place it. Easier said than done (as was said earlier).

On the other hand, several pretty progressive services across the country, Wake County, NC in particular, who still have the option of ETI or the KING LT, have gone to simply cramming a KING LT in during codes, for the simple fact that:

A) No pause in compressions

B) No chance of a misplaced tube

C) With the insertion of an NG/OG tube into the provided port and suctioning, the risk of aspiration is reduced by a huge percentage.

I personally believe that if an ETT can be placed without a break in compressions, by a properly trained medic able to absolutely confirm placement and secure it...Do it :)
 
^^^ Did you miss the memo of the King LTDs all being recalled because the FDA hadn't approved it for prehospital use?
 
Actually from what I understand, the maker got a slap on the wrist for claiming the King was good for prehospital use when it wasn't cleared by the FDA for that. Itwas technically only tested and cleared for surgical environments.

They can still sell it to EMS, it's just an off label use, which is perfectly allowed.
 
The letter doesn't say the problem is that it is being used prehospital, it's that it was approved for anesthesia in patients who are low risk of aspiration rather than emergent situations.

On a related note, do products need to be specifically cleared for prehospital use? I would expect that it would be pretty burdensome if each BVM, IV cath, saline bag etc. not only had to get general FDA approval but also be approved for prehospital use.
 
I don't see why everything needs to be approved specifically for prehospital use. A King is pretty much just a combitube minus the unnecessary second tube (unless you are really talented enough to get a combitube into the larynx). The LMA doesn't protect against aspiration of regurgitated material, so I wouldn't think it's as useful prehospital. Just teach everyone ETI and King LTD and we're golden.
 
I know my agency pulled the LT-Ds because of the liability concerns.
 
Ok, so alot of what I am going to say is repetitive but I have read all of the post for this thread and the one thing I have seen mention of but not really discussed is BVM Ventilations, everything eventually ends up reverting back to ALS equip. As stated before if you have effective BVM ventilations no Intubation needs to be performed or at the least can be withheld. I think that BVM ventilations are not discussed because it is never really taught how to ventilate effectively with a BVM it is discussed in AHA videos to give a "concept" and then it is changed by the individual for their comfort. The biggest problem with BVM ventilations is gastric distension. Which can be decreased by delivering proper volume (enough to allow for chest rise) and proper rate. I did a "study" mainly out of curiosity in which I had 20 EMTs at all levels just come in and bag our airway mannequin with a BVM at the appropriate rate for 10 minutes. For the first 5 minutes I said nothing to them and paid attention to their technique and their rate, which varied anywhere from 24 times a minute to 36 times a minutes and they squeezed the bag almost everytime to make thier fingers touch. The second time I added distractions, talking to them calling their cell phone to make it ring and the results were somewhat funny but a little sad. Some ventilated two times in a minute and as much as 50 times a minute. So lately I have been focusing the training here on BVM ventilations. Paramedics are only as good as their basic skills... If the world falls apart and you don't have a laryngscope blade or batteries or a bulb, or your cuff won't inflate on you BIAD and you broke your cric. You still have your basic airway adjuncts and a BVM. So primary focus for all training programs when talking about airway should be BVM ventilations. Now some things that make you want to start to advance from that are as previously mentioned. Difficulty in ventilating, obstruction, decreased SPO2 readings even with 00% O2 and for EMS services with long transport times. ( The one that i'm in we have that as one of our criteria, because even if you do ventilate extremely well with a BVM eventually will are going to over the pressure of the cardiac sphincter and cause gastric distension, the #1 side effect of BVM ventilations) In cardiac arrest situations key points are minimizing compressions and providing adequate VENTILATIONS so go for what works. If its a BVM good, if its a BIAD good, if its ETI even better. The "Gold Standard" for airway control, now I think that its effective ventilations. Oh yeah, and lets not forget about suction.....
 
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