Maintaining an LMA/SGA

[AusPara]

You’ve encountered a difficult airway in RSI. The tube failed / wasn’t feasible in the first place. Next steps:

- BVM until paralysis (I’m assuming sux) wears off, continue to manage them with BVM or supplemental oxygen to hospital
OR
- Place an LMA/SGA (or whatever equivalent not-ETT you’ve got) and sedate / paralyse to maintain it as you would a tube.

Even more interested to know what the approach is if you’re doing inductions with roc.

My view has generally been that the patient was in a bit of trouble in the first place. You were RSIing for a reason. So they probably aren’t just going to wake up and be fine. There is some risk with a non-fasted patient and an LMA..but is it less than a BVM and a patient with who-knows-how-much propensity to vomit/obstruct etc.

Thoughts?

 

[NPO]

I think my answer depends on why the advanced airway failed. If the airway was doomed from the start, RSI should not have been performed.

Is it an unforseen anatomical issue? Is it poor preparation? Is it provider error? Is it equipment error?

My go to answer, without more information, would be to continue bagging with a mask, and have a second provider attempt the airway.

If the issue is anatomical or equipment, my prepared backup airway (King LTD at my service) would go in as soon as sats were satisfactory, that may be before bagging if they stayed adequate.

I am typically not a fan of SGAs because if I'm intubating, they probably needed a definitive airway anyway.

 

[AusPara]

Apologies, perhaps I should have provided a bit more.

So my assumption was that in reaching this stage of the plan, the airway wasn’t obviously going to fail from the start and the usual issues like position, etc. have be trouble shot. You have been able to ventilate with a BVM in between attempts (assuming that is part of your process). You’ve worked through what ever your approach is but you have had to move on to a not-a-tube permanent next step. So the question largely revolves around risk and efficacy of BVM in sick person you wanted to tube (perhaps with some agitation, perhaps with a varying degree of airway reflexes/spont vent) VS an admittedly substandard airway and sedation/paralysis, lower (but not lowest) risk of aspiration or ventilation issues.

I accept that there is some nuance and situationally dependant issues here and there won’t be a one size fits all approach. But your answer goes to my question...you were intubating for a reason..they need a definitive airway. Assuming there are no extenuating circumstances like you’re 3 feet from the ED, I tend agree.

Can I push you a little further and force a theoretical choice of BVM or SGA...

 

[VentMonkey]

Sounds like you’re wanting reassurance.

SGA, and continue paralysis with a longer acting agent until ED arrival, i.e., Rocuronium until you reach definitive care/ management (i.e., the hospital). Easy peasy.

 

[DesertMedic66]

SGA. It is hard enough to maintain a good BVM seal in a non moving environment with plenty of hands. If I am going to RSI a patient then there is a very high likelihood or it has already been proven that the patient can not maintain their own airway.

There has been a huge push recently to leave a SGA in place if you are getting a foot EtCO2 waveform and SpO2. I believe it was FOAMFrat who created a nice little flowchart on when to pull a SGA and attempt intubation or keep rolling with the SGA.

 

[AusPara]

It is an interesting point of difference between views in different parts of the world and it's a question that has come up again in my area. Always good to open the floor to people from outside the local culture.

It has a curious characteristic. The docs want sedation and paralysis in these patients and the paramedics do not. It is not often the case that paramedics push back against expanding their own skill set.

The only other thing I've seen go similarly is finger thoracostomy. Quite a bit of enthusiasm from the docs...not so much from the paramedics (and myself I might add - no a great idea to introduce it at that time in my view). I expect it will probably have to happen at some stage but we shall see.

Sounds like you’re wanting reassurance.

SGA, and continue paralysis with a longer acting agent until ED arrival, i.e., Rocuronium until you reach definitive care/ management (i.e., the hospital). Easy peasy.

Why is that?

 

[GMCmedic]

It is an interesting point of difference between views in different parts of the world and it's a question that has come up again in my area. Always good to open the floor to people from outside the local culture.

It has a curious characteristic. The docs want sedation and paralysis in these patients and the paramedics do not. It is not often the case that paramedics push back against expanding their own skill set.

The only other thing I've seen go similarly is finger thoracostomy. Quite a bit of enthusiasm from the docs...not so much from the paramedics (and myself I might add - no a great idea to introduce it at that time in my view). I expect it will probably have to happen at some stage but we shall see.



Why is that?

The Paramedics are wrong. It has long been proven that in the field, paralysis increases first pass success, however paralysis without appropriate sedation is bad. I avtually have less of an issue on the pushback of paralysis and more issue with sedation.

 

[VFlutter]

- BVM until paralysis (I’m assuming sux) wears off, continue to manage them with BVM or supplemental oxygen to hospital

So paralysis wears off, the patient resumes spontaneous breathing, and you are left with....the same airway issue that you were trying to fix in the first place with a patient that likely just had a significant episode of hypoxia and hypercapnia or airway trauma from attempts.

IMO that should never be an option or plan for RSI. Primary airway, rescue airway, surgical.

 

[silver]

It has a curious characteristic. The docs want sedation and paralysis in these patients and the paramedics do not. It is not often the case that paramedics push back against expanding their own skill set.

Sorry what is the alternative to sedation and paralysis?

Place the SGA 100% of the time. The risk of aspiration and difficulty ventilating is substantially less than a BVM.

 

[Tigger]

What is the downside of placing an SGA here?

 

[DesertMedic66]

It is an interesting point of difference between views in different parts of the world and it's a question that has come up again in my area. Always good to open the floor to people from outside the local culture.

It has a curious characteristic. The docs want sedation and paralysis in these patients and the paramedics do not. It is not often the case that paramedics push back against expanding their own skill set.

The only other thing I've seen go similarly is finger thoracostomy. Quite a bit of enthusiasm from the docs...not so much from the paramedics (and myself I might add - no a great idea to introduce it at that time in my view). I expect it will probably have to happen at some stage but we shall see.



Why is that?

This is completely opposite from the USA. Usually we are asking our medical directors for more medications or skills. We are not having our medical director say “here is a new skill for you guys” and we respond with “that’s cool and all but no thanks. You can keep that one”

 

[VentMonkey]

I feel like this algorithm is pretty universal and transcends several countries train of thought:

http://www.openanesthesia.org/wp-content/uploads/2015/02/algorithm_1.jpg

 

[Peak]

I think that one piece to add is that either with a SGA or bagging a NG/OG can substantially increase the efficiency of ventilation and decrease the risk of vomiting/aspiration.

 

[DesertMedic66]

Courtesy of FOAMFrat:

 

[AusPara]

The Paramedics are wrong. It has long been proven that in the field, paralysis increases first pass success, however paralysis without appropriate sedation is bad. I avtually have less of an issue on the pushback of paralysis and more issue with sedation.

I think there might be some miscommunication. We’re not talking about induction.

The drugs have gone in. The tube has been attempted. No joy. The usual trouble shooting has occurred. No joy.

Sorry what is the alternative to sedation and paralysis?

Place the SGA 100% of the time. The risk of aspiration and difficulty ventilating is substantially less than a BVM.

To this point other and other similar posts: The suggested alternative is to bag them until they “wake up a bit” and hopefully start protecting their airway / spontaneously ventilating to a degree that there is less risk than were you to place an SGA and maintain it with sedation / paralysis. This is a line of reason that has never really appealed to me.

This is completely opposite from the USA. Usually we are asking our medical directors for more medications or skills. We are not having our medical director say “here is a new skill for you guys” and we respond with “that’s cool and all but no thanks. You can keep that one”

It isn’t the norm here either. I’d like to think it reflects a certain maturity on the part of those rejecting the idea. These are paramedics involved in the governance process so they’re a little more concerned about the things that might go wrong than the average joe. I think the idea is just such a huge shift in mindset (people have been told for years that sedating + SGA = murder).

The foam frat stuff is interesting - thanks.

 

[VentMonkey]

With due respect, what exactly are you talking about?

Have you heard of the DASH-1A Study?

DASH -1A Emergency Airway Concepts with Dr Bill Hinckley

Hi folks, Dr Bill Hinckley, sent me an awesome audio powerpoint recording on DASH -1 A emergency airway concept

prehospitalmed.com

Is this the you’re point you’re trying to get across? I think I’m lost in translation.

 

[AusPara]

With due respect, what exactly are you talking about?

Have you heard of the DASH-1A Study?

DASH -1A Emergency Airway Concepts with Dr Bill Hinckley

Hi folks, Dr Bill Hinckley, sent me an awesome audio powerpoint recording on DASH -1 A emergency airway concept

prehospitalmed.com

Is this the you’re point you’re trying to get across? I think I’m lost in translation.

Well, I’m not actually trying to make a point, so perhaps we both are!

DASH-1A: I haven’t heard of the study. Perhaps I missed it but I didn’t see that the link to Minh’s blog referenced any study, just the idea. I had a brief google and only came across a 2019 study on predictors of things going well. Powell et al., is that the one? In any case, none of it seems to be related, so I’m a bit lost I’m afraid.

With your flowchart in mind, what I’m talking about is analogous to:

We anaesthetised the patient and then found we couldn’t intubate them. Should we, 1) Call the operation quits and BVM/SGA until they wake up; or 2) Insert an SGA and continuing the anaesthesia/operation.

This is a bit of an oversimplification but basically the current practice here is essentially option 1 (in most cases). The reason for reviewing this is a little complicated but essentially option 2 is being considered. The docs have no problem with option 2 but some of the medics do.

I thought it would be interesting to get the views of a bunch of people who have absolutely nothing to do with our system.

 

[GMCmedic]

Well, I’m not actually trying to make a point, so perhaps we both are!

DASH-1A: I haven’t heard of the study. Perhaps I missed it but I didn’t see that the link to Minh’s blog referenced any study, just the idea. I had a brief google and only came across a 2019 study on predictors of things going well. Powell et al., is that the one? In any case, none of it seems to be related, so I’m a bit lost I’m afraid.

With your flowchart in mind, what I’m talking about is analogous to:

We anaesthetised the patient and then found we couldn’t intubate them. Should we, 1) Call the operation quits and BVM/SGA until they wake up; or 2) Insert an SGA and continuing the anaesthesia/operation.

This is a bit of an oversimplification but basically the current practice here is essentially option 1 (in most cases). The reason for reviewing this is a little complicated but essentially option 2 is being considered. The docs have no problem with option 2 but some of the medics do.

I thought it would be interesting to get the views of a bunch of people who have absolutely nothing to do with our system.

Ok, I think see what youre going with now.

So referencing Option 1: you sedate and paralyze, can't get and ETT so you BVM till the sedation and paralytics wear off.

You're now still in the same position you were in before you attempted the initial intubation, nothing was accomplished.

Or you drop in an SGA, patients becoming alert with an SGA in place never ends well.

On that note Ive never seen and awake patient tolerate a BVM for more than a few breaths.

Option 2: Maybe it's cultural differences but I just don't understand the diversion to this one
Intubation fails, you take 30 seconds (if youre intubating, you should have a backup aireay nearby) pop in an SGA and keep them sedated. Youve now got a working airway and ability to monitor capno and a decreased risk of aspiration.

Either way I would argue that weve escalated to induction, regardless of how we determine to manage the airway after the failed intubation, it should include some type of sedation.

 

[Peak]

Where are options 3, 4...

Surgical, trans-tracheal jet, bougie, et cetera?

If a SGA hasn't failed and bagging isn't adequate then returning to baseline isn't going to likely be that beneficial.

 

[silver]

Ok, I think see what youre going with now.

So referencing Option 1: you sedate and paralyze, can't get and ETT so you BVM till the sedation and paralytics wear off.

You're now still in the same position you were in before you attempted the initial intubation, nothing was accomplished.

Or you drop in an SGA, patients becoming alert with an SGA in place never ends well.

On that note Ive never seen and awake patient tolerate a BVM for more than a few breaths.

Option 2: Maybe it's cultural differences but I just don't understand the diversion to this one
Intubation fails, you take 30 seconds (if youre intubating, you should have a backup aireay nearby) pop in an SGA and keep them sedated. Youve now got a working airway and ability to monitor capno and a decreased risk of aspiration.

Either way I would argue that weve escalated to induction, regardless of how we determine to manage the airway after the failed intubation, it should include some type of sedation.

100% this.


Outside the OR, I can't imagine a situation where one was RSIing and attempting to return to where you started should be an option (maybe thats why almost everyone gets roc from me). The journey back to baseline as sedation/paralysis wears off could put the patient in a substantially worse position, especially with mask ventilation, and should be a well thought out decision.