King LT--quick question

That's what I'm saying, Akula: When you need an ETT, do an ETT, but you won't always need an ETT for every patient who needs more than an NPA/OPA.

An ETT is always the gold standard, but that doesn't mean everyone needs one.
 
IMO, if you're the only medic onscene and only have one EMT with you and no one else, it would be better to quickly drop the king (quick, easy, reasonably effective), so you could watch the monitor, establish an IV/IO, so on and so forth. The pt should be adequately oxygenated, and your hands are free to continue with other interventions. You have the added benefit of not inflating the pt's abdomen as much as the prep time prior to ETT placement. It doesn't take much more time to place a king than it takes to place an OPA. Pop on an ETCO2 before you start bagging.

Also, if a supraglottic airway is adequate for the pt's oxygenation at the moment, replacing that with an ETT in the field (medevac notwithstanding) is foolish, unneccesary, and dangerous for the pt.

Now, if you have a pt that codes in front of you, or is in imminent resp arrest (APE, tight asthmatic, etc) the ETT is the only appropriate first line procedure.

With arrests, the AHA has gone away from ETT's if BVM vents are effective. I figure that if you drop a king, you're ahead of the game with a fairly decent airway. Just have the basic bag and do compressions for the few seconds it takes you to place the king. Done.

Now, if you have two or more medics, ETT ought to be placed instead of a king.
 
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All things considered, what are the advantages of an ETT over a King or combi?
 
When placed correctly, definitive airway past the epiglottis, and a direct route for drugs.
 
Linuss said:
That's what I'm saying, Akula: When you need an ETT, do an ETT, but you won't always need an ETT for every patient who needs more than an NPA/OPA.

An ETT is always the gold standard, but that doesn't mean everyone needs one.
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My standard has been that if someone needs an OPA, they need a tube. Not everyone needs an OPA... and not everyone needs to have an airway adjunct placed... but when they do, they DO. It's tempting to drop a rescue airway, but those don't address blocked airways, other than the tongue.

The other reason I choose ETI over a rescue airway is that I'd have both a secure airway and a route of drug admin (not great, but useful)... I'd prefer an IV for drug admin, but...
 
Brandon Oto said:
All things considered, what are the advantages of an ETT over a King or combi?
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You can put the patient on a ventilator with an ETT. You can not with a King or Combitube in the esophagus. It the Combitube does end up in the trachea, the patient can plan on damage to the vocal cords and probably a trach for awhile if not worse.
 
I'll play devils advocate here...

I think a rather large advantage to the "rescue" airways is the hypoxia factor associated with ETI. With a king or LMA you can quickly secure an airway and move on to other issues, like ventilating the patient! Additionally, if you have adult and pedi IO capabilities, you shouldn't need to be dumping medications down an ET tube. I think dumping medications down an ET tube is archaic (personal opinion). King airways and LMA supremes guard the airway extremely well against aspiration and allow easy access to decompress the stomach. Several places are making ETI the rescue airway and LMAs or Kings the primary airway. Overseas the JRCALC in England made a recommendation to make ETI the back up and LMAs primary. The service I currently work for has implemented RSA instead of RSI. We use an LMA supreme or King-LTSD as the primary choice for an airway and intubation as a backup. The "Gold standard" of intubation is fading away. Don't get me wrong though, I think intubation is still called for in certain circumstances and SHOULD NOT be removed as a skill, but do believe it should be a back up airway instead of a primary airway..
 
So, the advantages of intubation are:

-- Remains patent even in cases of laryngeal edema, laryngospasm, etc
-- Provides a little-used but available route for drugs
-- PT can be hooked to a ventilator upon reaching definitive care without switching airways

Anything else?
 
carpentw said:
...you shouldn't need to be dumping medications down an ET tube. I think dumping medications down an ET tube is archaic (personal opinion)....
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Meds down the tube present a few advantages, primaraly epi....where it dialates the airwayalmost imedatly upon exiting the tube, opening the airway from the airway intsead pf circulating though the blood....



"I know that probly didn't make much since....forgive me as I just finished the 50th hour of a 48 hour shift....."
 
ki4mus said:
Meds down the tube present a few advantages, primaraly epi....where it dialates the airwayalmost imedatly upon exiting the tube, opening the airway from the airway intsead pf circulating though the blood....
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Not necessarily. For effective dilation, particle size must be taken into consideration for the med to absorp. Thus, the reason we don't just dump albuteral down a tube in its liquid form.
 
VentMedic said:
Not necessarily. For effective dilation, particle size must be taken into consideration for the med to absorp. Thus, the reason we don't just dump albuteral down a tube in its liquid form.
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Which is also why after you "dump" meds down the tube, you give the bag a few small, sharp squeezes... you might aerosolize those meds a bit and get them to work better. Ideal? Not a chance. Aerosolizing the meds as you bag them into the lungs would probably work better, but... the connection from ETT to Bag is pretty short, and not exactly ideal for attaching a nebulizer, though it would be doable... and it takes a nebulizer a while to deliver the med...

The extremely small droplet size you do get from a nebulizer does allow those droplets to get much further down the respiratory tree than say, 10 ml of medicated fluid... that's "blown" in after being dumped down the tube...
 
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Akulahawk said:
Which is also why after you "dump" meds down the tube, you give the bag a few small, sharp squeezes... you might aerosolize those meds a bit and get them to work better. Ideal? Not a chance. Aerosolizing the meds as you bag them into the lungs would probably work better, but... the connection from ETT to Bag is pretty short, and not exactly ideal for attaching a nebulizer, though it would be doable... and it takes a nebulizer a while to deliver the med...

The extremely small droplet size you do get from a nebulizer does allow those droplets to get much further down the respiratory tree than say, 10 ml of medicated fluid... that's "blown" in after being dumped down the tube...
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We have in-line neb setups to give albuterol/atrovent to a pt that's on CPAP or one that's intubated, if needed. I don't know about nebulized arrest meds though.
 
46Young said:
We have in-line neb setups to give albuterol/atrovent to a pt that's on CPAP or one that's intubated, if needed. I don't know about nebulized arrest meds though.
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I've known about in-line nebs for a while... I just don't think that you can deliver code meds in-line fast enough for them to be useful in that situation. Perhaps in a pre-arrest situation...
 
In line nebs have been common for ventilator patients for decades although now the preferred is the MDI but the new HFA propellant has been creating some issues (thank you Canadians :glare:). Bagging a treatment in is acceptable except one must remember the increased flow will increase the VT on kids and babies. For vents and bagging, we may run a nebulizer designed for 2 L of flow. Don't try this low flow with a standard acorn neb or you will get particles that are too large if any at all.

We may also use the nebs capable of being powered by 2 L/M inline with a CPAP/BiPAP machine. Giving nebs by BiPAP/CPAP has been controversial as the turbulent flow hampers deposition of the particles. If there are vents on the face mask present, that also causes flow disturbance and much of the med to be lost as does an inline whisper valve. Adding flow to the circuit from a neb also presents with a flow disturbance.

However, the little prehospital "CPAP" devices rarely have an issue of too much flow but there is not that much data to determine how effective nebs are through these devices.

Code meds would not absorb systemically fast enough if given through the lungs which is why they are no longer advocated in ACLS. As well, the meds given by nebulization are meant to have an effect on specific receptors within the lungs to reduce side effects. Over 30 years ago when research was being done for the ACLS meds, each was trialed through the pulmonary system. Few proved effective. NaHCO2 was also trialed and although it was not proven effective for its intended purpose, it was found to have "snot busting" properties. It is an active ingredient in some nasal sprays and I also carry it diluted on Neo/Pedi transports to unplug a clogged ETT quickly without the need to pull the tube. I don't recommend that since it is off label unless your M.D. approves. It can cause bronchospasm and damage to the tissue of the lungs if not used correctly.
 
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