King-LT vs. LTSD

[WarDance]

I am working on getting the mountain rescue team set up with kings but I realized there are two kinds. Is there a huge advantage with the LTSD? Is it worth the extra money? Do you guys think kings in general are worth the money for a crew of basics that would otherwise be using OPAs?

 

[Shishkabob]

Can you USE Kings as a basic at your service?

 

[gillysaurus]

^ It's new in Colorado protocol that basics can use Kings or Combitubes. At the discretion of each medical director, of course.

http://www.dora.state.co.us/medical/rules/500.pdf
Colorado Scope of Practice

 

[austinmedic77]

the main difference is the addition of the port for gastric tube insertion for suctioning and decompression as well as some medication administration depending on need and protocol. If you aren't going to drop og tubes then i would suggest not using the ltds secondary to the likely hood of creating a gastric content fountain during CPR additionally this may may a difference in price if you are going to order a lot as the style with the sump port are considerably more expensive. Also, the LTDS isn't available in the smaller sizes. As always either style can be used for easy retrograde intubation using a gum-elastic bougie and ETT at the ED or if needed when ALS arrives. Hope this helps.

 

[carpentw]

The major difference between the King LT and LTSD is the addition of a posterior tube which is used to decompress the stomach to help guard against aspiration. As a basic, I guess it wouldn't matter which one you got, but I would recommend the LTSD because that additional tube really makes it easy to decompress the stomach.

 

[VentMedic]

As always either style can be used for easy retrograde intubation using a gum-elastic bougie and ETT at the ED or if needed when ALS arrives.

Retrograde intubation?

Why?

 

[8jimi8]

In the case that bagging becomes ineffective, or in the case that the ER doc doesn't want anything except an ET.

 

[VentMedic]

In the case that bagging becomes ineffective, or in the case that the ER doc doesn't want anything except an ET.

But why retrograde intubation? An invasive procedure of this type is hardly necessary to replace an alternative airay.

 

[austinmedic77]

But why retrograde intubation? An invasive procedure of this type is hardly necessary to replace an alternative airay.

because in some cases this is placed secondary to a difficult airway or inability to visualize the airway. The king is not effective at preventing aspiration or protecting the airway when the patient is regurgitating either actively or secondary to gastric decompression. No one is advocating it as the only option but it is an option and not a bad one depending on the circumstances. If you had trouble the first time and need to replace the king with a ETT why take the unneeded risk of removing the tube only to be unable to place a new one. The practice of using the LT, bogie and an ETT is one that is good to have in your box. it is also being taught to MD's and RRT as well as CRNA's in Texas at all three of the hospitals attached to med schools here. You may not agree with it but I have had more then one RT in the field on HEMS be thankful they were taught this when they had an actively vomiting pt in the bird and the ease and speed with which they were able to pass the ETT using the bogie to replace that King that was no longer working. Not to mention the success that the medics docs and folks have had using this technique in Iraq and Afghanistan.

 

[VentMedic]

because in some cases this is placed secondary to a difficult airway or inability to visualize the airway. The king is not effective at preventing aspiration or protecting the airway when the patient is regurgitating either actively or secondary to gastric decompression. No one is advocating it as the only option but it is an option and not a bad one depending on the circumstances. If you had trouble the first time and need to replace the king with a ETT why take the unneeded risk of removing the tube only to be unable to place a new one. The practice of using the LT, bogie and an ETT is one that is good to have in your box. it is also being taught to MD's and RRT as well as CRNA's in Texas at all three of the hospitals attached to med schools here. You may not agree with it but I have had more then one RT in the field on HEMS be thankful they were taught this when they had an actively vomiting pt in the bird and the ease and speed with which they were able to pass the ETT using the bogie to replace that King that was no longer working. Not to mention the success that the medics docs and folks have had using this technique in Iraq and Afghanistan.

But why do you feel it necessary to cut someone's throat open?

If you are going to do that, you might as well do a perc trach.

This picture shows retrograde intubation. While you could probably use a bougie to pull the tube through, why? In all of my years (30+) as a Paramedic and RRT I have only done this 2 x in the field, both on kids, and assisted a handful of other times in the hospital. While I know how to do this procedure, I would NOT want to make it a habit to change an alternative airway either in the field or in the hospital. If I must cut someone's throat open, I use a trach.

 

[Akulahawk]

Retrograde Intubation and use of a Bougie to introduce an ETT are two different procedures that result in ETI. Retrograde Intubation requires that a catheter be introduced through the cricothyroid membrane and a guidewire be run through that catheter, between the vocal cords, into the pharynx and out the oropharynx. The guidewire is then passed through the lumen of the ETT and the ETT is advanced down the guidewire into the trachea. With a KT, the wire would come out of the opening of the KT... and you'd remove the KT and introduce the ETT in the usual manner for this technique.

Using a Bougie with a KT is fairly simple, but caution must be maintained because you don't want to lose the Bougie placement when you remove the KT. The ETT just slides into position over the Bougie...

See how the two procedures are a bit different?

Vent: that pic was the same one I was going to use...

 

[austinmedic77]

****Retrograde: to move in a direction contrary to the usual one****


This term is used to describe intubating a pt using a bougie to maintain the airway while removing the king LT (retrograde) and passing a ETT into the trachea over the bougie. I am glad you are able to make yourself feel better because I chose to use the term that is commonly used to describe the procedure of using a bougie to replace a King with an ETT so as to avoid confusion. People have decided to shorten the procedure to retrograde intubation when it is in fact called Retrograde Guidewire intubation and is another type of retrograde intubation but not the only type. Your both quick to point out others perceived mistakes but then make one yourself. Guidewire intubation is not the only type of retrograde intubation. I have included the definition of retrograde at the top for your reference. No one claimed they were the same procedure and I didn't reference a guidewire once during my post so I don't see how there could be any confusion between the two. And yes I see the difference between the two but dont see how using the term retrograde could cause you to confuse the two unless you are not familiar with the proper term for the procedure you are describing.

 

[VentMedic]

****Retrograde: to move in a direction contrary to the usual one****


This term is used to describe intubating a pt using a bougie to maintain the airway while removing the king LT (retrograde) and passing a ETT into the trachea over the bougie. I am glad you are able to make yourself feel better because I chose to use the term that is commonly used to describe the procedure of using a bougie to replace a King with an ETT so as to avoid confusion. People have decided to shorten the procedure to retrograde intubation when it is in fact called Retrograde Guidewire intubation and is another type of retrograde intubation but not the only type. Your both quick to point out others perceived mistakes but then make one yourself. Guidewire intubation is not the only type of retrograde intubation. I have included the definition of retrograde at the top for your reference. No one claimed they were the same procedure and I didn't reference a guidewire once during my post so I don't see how there could be any confusion between the two. And yes I see the difference between the two but dont see how using the term retrograde could cause you to confuse the two unless you are not familiar with the proper term for the procedure you are describing.

For those of us who can do both procedures as have been described in the recent posts, some of us prefer to use "retrograde intubation" in the usage as it has been known for several decades which is what Akulahawk and I have posted. If you are not familiar with the procedure it is easy to see your confusion.

The bougie and the King were already discussed in this thread.
http://www.emtlife.com/showthread.php?t=14703


Retrograde Guidewire intubation? You need to surf a little more for all the information as well as read my posts in their entirety.

Now, are you doing the retrograde intubation with the incision and "guidewire"? Have you ever done one?

We also use various devices when changing out ETTs. There is not always a special name since there are many different devices and techniques. However, in all of them, the ETT is still entering the same direction through the mouth and not coming in from the throat. The other tube (King, Combitube) is exiting the same way a tube should exit and NOT in the opposite direction. For it to be "retrograde" it would exit opposite of how it normally would leave. I believe that is the same definition you just quoted:

Retrograde: to move in a direction contrary to the usual one****

 

[austinmedic77]

first you are the one that posted a picture of a retrograde guidewire intubation are implied that that was a picture of retrograde intubation. Again this is a typr of retrograde intubation not the only type. Additionally if this isnt what you meant then you need to research better and post a picture of what you do mean. Furthermore:

ret·ro·grade (rtr-grd)
adj.
1. Moving or tending backward.
2. Opposite to the usual order; inverted or reversed.
3. Reverting to an earlier or inferior condition.
4. Astronomy
a. Of or relating to the orbital revolution or axial rotation of a planetary or other celestial body that moves clockwise from east to west, in the direction opposite to most celestial bodies.
b. Of or relating to the brief, regularly occurring, apparently backward movement of a planetary body in its orbit as viewed against the fixed stars, caused by the differing orbital velocities of Earth and the body observed.
5. Archaic Opposed; contrary.

As the definition clearly states removing a king LT would be retrograde (moving or tending backward, opposite to the usual order; inverted or reversed) to its stated normal intent of introduction into the esophagus to facilitate assisted or mechanical ventilation.

My original post was very clear and accurate and would only confuse someone that is looking for a way to try to make themselves look intelligent in the uninformed eyes by making an inaccurate statement and then trying to pass it off as fact. I never implied that my example was the only example of retrograde intubation however, you implied that your example was. Just another example of you trying to get people to believe that just because you say something on this post it is fact and god forbid someone disagree with you or show evidence to the contrary of your views, cause you could never be wrong.


Additionally, retrograde is never referring to the introduction of the ETT it is referring to the removal of the existing device or introduction of the guidewire inversely through the incision. Retrograde of an ETT would be commonly refered to as extubation.

 

[VentMedic]

Look at the photo I posted. Do you see the direction the tube in the retrograde intubation is going? That is "opposite" or contrary to the way a tube or intubation initiation usually goes.

Let me see if I can make this simple for you.

When you intubate someone you go through the mouth, through the cords and into the trachea. That is the normal process. For retrograde, you start the procedure from below the cords through the trachea, through the cords and out the mouth. This is not the normal route thus it is "retrograde" or contrary to the usual. Your guidewire could be the bougie.

To extubate or remove a tube, you move that tube away from the cords out the oral route. That is the normal process. There is nothing contrary or abnormal when you remove an alternative airway in that direction. That is the preferred route.

When you insert the King, you are doing the normal direction as you would for intubation except the goal is into the esophagus. When you remove or extubate the King, again, it is coming out the direction expected. If it was to be "retrograde", we would go opposite of the expected. We do not extubate through the belly if we can avoid it or unless someone really screwed up with their "retrograde" intubation or extubation.

 

[VentMedic]

Additionally, retrograde is never referring to the introduction of the ETT it is referring to the removal of the existing device or introduction of the guidewire inversely through the incision. Retrograde of an ETT would be commonly refered to as extubation.

Please, READ and LOOK at the pictures:

http://www.google.com/search?hl=en&source=hp&q=retrograde+intubation&aq=f&oq=&aqi=g4

Yes, the guidewire (or whatever device) goes through to guide the ETT down but the "intubation" part is initiated below the cords. Extubation does not go through the cords down the trachea and out the chest some place.

I can see what you are saying since the ETT is traveling the only way it can. But, from the point of intubation initiation, the procedure is still considered "retrograde". The guidewire is your intubation tool from the trachea just like the bougie is your intubation tool orally.

Again, have you ever done a true retrograde intubation? Do you call that "extubation" if you are placing a tube?

 

[VentMedic]

Do you see the direction the tube in the retrograde intubation is going? That is "opposite" or contrary to the way a tube or intubation initiation usually goes.

Correction: guidewire

This is the intubation tool from the opposite direction. Thus the point of intubation is initiated opposite or contrary to the usual just as the definition provided by austin.

 

[austinmedic77]

the picture you posted shows the guidewire passing through the incision in the neck into the oropharynx where typically forceps are used to retrieve the wire out of the mouth at which time the tube is passed over the guide into the mouth and through the cords into the trachea then the wire is removed as it is no longer needed. The introduction of the guide is the retrograde portion of the picture YOU posted so maybe you need to look at your own picture. Also, you refer to my post incorrectly. Intubation of the trachea by introducing the ETT into the trachea by any means is anterograde: moving forward (into the trachea) and extubation of any airway is by definition retrograde: reversed, inverted, tending backward (out of the trachea) this is the opposite of their intent you don't walk around with an ETT in your throat all the time therefore the atnterograde procedure would be placing the tube by whatever means and the retrograde would be moving it in the opposite direction whether it be removal repositioning ect.. In the picture you show the retrograde portion is the guidewire that is moving in the opposite retrograde direction from the cricothyroid membrane to the ortopharynx. I will apologize if I am coming across as as confrontational but this is one case where you are wrong. I will admit that usually you are correct in what you say and I agree with much if not most of what you post on here especially your views on education but I can't abide the misinformation here.

 

[VentMedic]

Okay let's start at the beginning about retrograde intubation.

It is a procedure done when the oral route is consider difficult for some reason which could be trauma, congenital or surgical. The procedure has largely gone to the wayside due to improved cric kits, trachs and fiberoptics.

Instead of trying to find the trachea from the oral route. A guidewire (in the kit) or some device is inserted through an incision in the trachea. It is then maneuvered up through the cords and out the mouth. Thus, the patient is intubated in reverse with a guidewire or bougie type/tube introducer device. The ETT can then be passed over the guidewire through the mouth and through the cords. So "that" part is normal but the intubation procedure itself is still considered retrograde because it was initiated in reverse.

When a patient is extubated, the preferred and NORMAL or USUAL route is opposite of the way the tube went in. Thus, if an ETT, King or Combitube goes through the mouth, it should come out in the opposite direction but that is the usual or normal route so it is not "contrary". Even in the case of retrograde intubation, the normal or preferred route of extubation would be out the mouth so that also is not contrary to the preferred.

 

[VentMedic]

(into the trachea) and extubation of any airway is by definition retrograde: reversed, inverted, tending backward (out of the trachea)

So why are you using the term "retrograde intubation" if you are referring to the tube that is being removed?

The bougie/ETT are still going forward in a normal manner and not opposite regardless of what the King is doing. That is the "intubation" part.