King vs. Intubation

[VirginiaEMT]

If you were called to assist another squad with a working code and they had inserted a King airway before your arrival, what questions would you ask yourself to determine if you would remove the King and intubate the patient? I had this scenario not long ago and I left the King in because the airway was messy and I didn't want to take a chance of taking the King out and not being able to secure a patent airway again, but some others have told me they would have removed the King and intubated the patient. What would you do? And why?

 

[Christopher]

If you were called to assist another squad with a working code and they had inserted a King airway before your arrival, what questions would you ask yourself to determine if you would remove the King and intubate the patient? I had this scenario not long ago and I left the King in because the airway was messy and I didn't want to take a chance of taking the King out and not being able to secure a patent airway again, but some others have told me they would have removed the King and intubated the patient. What would you do? And why?

If auscultation and waveform capnography showed a patent and adequately managed airway any preexisting airway will remain in-place.

If we use post-arrest induce hypothermia, we may elect to swap out the King to save time in the ED. I likely would not.

 

[DrankTheKoolaid]

re

Depends on the way the resuscitation was going. If I felt it was viable patient with a good chance at ROSC then yes, I would swap it out. At this point in medicine every field code, make that every code in and out of hospital should be guided by EtCO2. While this I believe can be done with a King in place im not 100% sure on it's accuracy. Also if you read the latest literature and follow studies, King Airways have been shown to reduce neurological outcomes in patients. May have saved the heart but the brain to a hit in the process.

Google-Fu King airway Porcine studies for more info

So yes in most circumstances I would be swapping it to the definitive ETT.

 

[Christopher]

While this I believe can be done with a King in place im not 100% sure on it's accuracy.

There is no significant difference with EtCO2 readings from supraglottic airways and ETT, when an adequate bulb seal is present. I could pull some strips, but every time I've done/seen a swap the EtCO2 remains the "same" (probably +-3mmHg, not enough to notice).

The porcine studies have some interesting A&P questions related to the carotids, but are fundamentally sound. We likely should be evaluating the appropriate cuff inflation volumes when using King's.

Recently, Dr. Fowler has alluded to ROC data showing differences in discharge with ETT vs SGA, but focusing on just that comparison is a bit unfair. Simple BVM management showed a higher survival to discharge than both ETT and SGA. If you're going to use those studies, you shouldn't be placing an airway at all

 

[VirginiaEMT]

Depends on the way the resuscitation was going. If I felt it was viable patient with a good chance at ROSC then yes, I would swap it out. At this point in medicine every field code, make that every code in and out of hospital should be guided by EtCO2. While this I believe can be done with a King in place im not 100% sure on it's accuracy. Also if you read the latest literature and follow studies, King Airways have been shown to reduce neurological outcomes in patients. May have saved the heart but the brain to a hit in the process.

Google-Fu King airway Porcine studies for more info

So yes in most circumstances I would be swapping it to the definitive ETT.

I had great ETCO2 during the code so that is one of the reasons I decided not to remove it but the E.R doctor showed me an Xray and she definitely had vomitus in her lungs.

 

[Christopher]

I had great ETCO2 during the code so that is one of the reasons I decided not to remove it but the E.R doctor showed me an Xray and she definitely had vomitus in her lungs.

Likely this was present prior to your arrival and placement of the King.

 

[DrankTheKoolaid]

re

Very true Christopher. Will be interesting to see the final outcome of the French study. I personally wont use Kings until the dust has settled and final word is spoken on the studies. Just not worth risking a poor outcome if a ETT could have been placed just as fast. Im never in that much of a hurry that i cant take 45s to a minute to set up and intubate someone instead of putting them at risk with a King. Yes BVM is definately a viable option, but again offers no protection.

Thats the other downfall to the King VirginiaEMT. It does not offer the same airway protection that a ETT will.

 

[Aidey]

I've done both, it depends on the situation. If we have good ventilation and capnography numbers I will lave it. I did exchange on a few months ago on a code that we were planning on calling. It was a younger female and the airway turned into a bloody mess (literally, not the British slang type of bloody). We swapped out the king for an ET tube because we knew if we were going to call someone as young as that pt was we needed a 110% for sure airway before the doc would agree.

 

[socalmedic]

Recently, Dr. Fowler has alluded to ROC data showing differences in discharge with ETT vs SGA, but focusing on just that comparison is a bit unfair. Simple BVM management showed a higher survival to discharge than both ETT and SGA. If you're going to use those studies, you shouldn't be placing an airway at all

which is why it is completely acceptable to work a code with a BLS airway up until the point when/if you are going to transport. I have been argueing here against KING tubes because my county was on of the ROC countys that first showed a 50% decrease in rosc patients with a CPS score greater that 3.

I discourage anyone from using a king first line. as response to the OP I would have asked why a king was used, was it a difficult airway? I would have either gone back to BLS with a BVM/OPA or would have switched to ETI.

 

[VirginiaEMT]

which is why it is completely acceptable to work a code with a BLS airway up until the point when/if you are going to transport. I have been argueing here against KING tubes because my county was on of the ROC countys that first showed a 50% decrease in rosc patients with a CPS score greater that 3.

I discourage anyone from using a king first line. as response to the OP I would have asked why a king was used, was it a difficult airway? I would have either gone back to BLS with a BVM/OPA or would have switched to ETI.

The King was used because the crew on scene was BLS only and that is part of our local protocol for EMT-Bs and EMT-Es. We were called to respond medic level to assist a completely different agency. It was me and a paramedic. We are in rural Virginia and paramedics and EMT-I/99s are not in abundance at most rural agencies in our area.

 

[jroyster06]

We have started using the king tube as front line in an arrest situation recently. Since then i have had more messed up traumatized airway was filled with blood vomitus and who knows what that are red and puffy swollen. I have also had to use a lot more suction and all around have had more complications since then. Im not sure if its just a coincidence or if the king airway is the culprit. Has anyone else noticed this?

 

[LearningByMistakes]

When dealing with the airway it should be about ventilation NOT intubation. If I arrive & the patient is being properly ventilated, there is NO need to change anything.

 

[usalsfyre]

Unless you are VERY comfortable with your airway management I would caution you about pulling a working airway. Ending up with a cric because you don't like supraglotic airways is poor form...

 

[DrankTheKoolaid]

When dealing with the airway it should be about ventilation NOT intubation. If I arrive & the patient is being properly ventilated, there is NO need to change anything.

While that is a true statement we always have to be proactive and thinking ahead. What good is a resus that dies of SIRS/Aspiration post code because a BLS airway was maintained and the airway was not protected. It's not, it is simply a drain on resources and a emotional roller coaster for the poor stiff's family.

Take a look at it from a in-hospital perspective. What is standard of care? I can tell ya in the 20 years ive been doing this I can count on 1 hand how many times I have been in on codes in the ED that were not intubated. Why do you think that is? Do you think a ICU would except a post-code resus and just leave a King in place, or a BLS airway to maintain itself?

Sure if you are not skilled enough to intubate through ventilations, then stick with a BLS/SGA as compressions are key. But if you can get the airway protected which in the end will hopefully prevent a early demise from post code complications then by all means get that airway protected.

 

[jwk]

Unless you are VERY comfortable with your airway management I would caution you about pulling a working airway. Ending up with a cric because you don't like supraglotic airways is poor form...

This!

 

[LearningByMistakes]

Well Corky, I will tell you that from the 32 years that I have been doing this, that I have seen far too many times that a providers "EGO" ruled in getting a patient intubated, at the cost of what is best for the patient. I have also seen far too many patients that aspirated from the intubation attempt (including in many ERs), which most likely wouldn't have happened without the intubation attempt.

And in Cardiac Arrest most studies have shown that intubation does little more than result in the stopping of CPR (many times for many minutes), when CPR is what IS important during the arrest (along with Defib, the ONLY 2 things that result in increased survival).

Other then the occasional arrest secondary from hypoxia, intubation is NOT what resuscitates cardiac arrest, high quality uninterrupted CPR & Defib IS.

Airway should be about ventilation NOT intubation.

Now, once we get to post resuscitation, that’s a WHOLE new story.

 

[usalsfyre]

While that is a true statement we always have to be proactive and thinking ahead. What good is a resus that dies of SIRS/Aspiration post code because a BLS airway was maintained and the airway was not protected. It's not, it is simply a drain on resources and a emotional roller coaster for the poor stiff's family.

Take a look at it from a in-hospital perspective. What is standard of care? I can tell ya in the 20 years ive been doing this I can count on 1 hand how many times I have been in on codes in the ED that were not intubated. Why do you think that is? Do you think a ICU would except a post-code resus and just leave a King in place, or a BLS airway to maintain itself?

Sure if you are not skilled enough to intubate through ventilations, then stick with a BLS/SGA as compressions are key. But if you can get the airway protected which in the end will hopefully prevent a early demise from post code complications then by all means get that airway protected.

Corky, it's a question of hands, light, devices and knowledge. Me pulling what is my rescue device to attempt a more difficult airway in relatively uncontrolled conditions with no back up is a questionable decision.

 

[DrankTheKoolaid]

re

Learning, you obviously did not read my whole post as I plainly stated if your not skilled enough to get the tube then stick with a BLS airway.

US, Yeah I get that. Obviously nobody in their right mind is going to pull a BLS airway that is working on someone with a airway nightmare.

I just dont like blanket statements that BLS/SGA is best for codes. They are temporizing measures until a definitive airway can be placed, assuming ROSC.

 

[Aidey]

I've done both, it depends on the situation. If we have good ventilation and capnography numbers I will lave it. I did exchange on a few months ago on a code that we were planning on calling. It was a younger female and the airway turned into a bloody mess (literally, not the British slang type of bloody). We swapped out the king for an ET tube because we knew if we were going to call someone as young as that pt was we needed a 110% for sure airway before the doc would agree.

US, Yeah I get that. Obviously nobody in their right mind is going to pull a BLS airway that is working on someone with a airway nightmare.

Careful there. If there is reason to believe that the BLS airway is causing the airway nightmare pulling it can be the right thing to do.

 

[Christopher]

What good is a resus that dies of SIRS/Aspiration post code because a BLS airway was maintained and the airway was not protected.

You're correct that pneumonia is a common problem in the post-cardiac arrest patient: "Pneumonia caused by aspiration or mechanical ventilation is probably the most important complication in comatose post-cardiac arrest patients, occurring in up to 50% of patients after out-of-hospital cardiac arrest." (PubMed)

But, I don't believe the literature supports the claim than an ETT decreases the incidence of aspiration pneumonia post-ROSC: "Where the patient was ventilated with the BVM alone or BVM followed by ETT the incidence of regurgitation during CPR was 12.4%...Where the patient was ventilated with the LMA alone or LMA followed by ETT the incidence of regurgitation during CPR was 3.5%." (PubMed)

If you'll allow me to point to patients being RSI'd, I think they represent a similar cohort for patients receiving prehospital airway management during cardiac arrest: i.e. NPO status questionable. I would understand if you take exception to this connection, as I can't show the two groups are truly matched.

From a cohort of patients being RSI'd: "The vast majority of aspiration events seem to occur before the arrival of prehospital personnel." (PubMed)

This probably means that even if we do tube them, we're not going to prevent aspiration, and studies concur: "Paramedic RSI did not seem to prevent aspiration pneumonia." (PubMed)

Worse still, it seems regurgitation and aspiration may be associated with ETI attempts themselves! Of patients being intubated in the ED who experienced cardiac arrest it was found that, "twenty-seven patients (45%) suffered gastric contents regurgitation with concomitant hypoxemia during the event, a finding that was considerably higher than the matched cohort and the entire database. Of the regurgitation cases, 72% were associated with multiple esophageal intubations. All but three regurgitation cases were associated with esophageal intubation." (PubMed)

The data from ROC shows that ETI is at best at equivalent w.r.t. "Airway and Pulmonary Complications" with an OR of 0.84[0.61-1.16] (PubMed).

The problem appears to be that a large number (power unknown) of our patients in cardiac arrest have already aspirated. Careful attention to proper airway management to prevent further aspiration is important. While there may be a theoretical advantaged to prehospital placement of at ETT to protect against aspiration, there is no data to support this claim.