Maintaining an LMA/SGA

Akulahawk

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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.
For an out of OR/Hospital situation, if you can't intubate and your SGA isn't working well, you should then proceed rapidly to another airway option. The reason being is that returning to baseline is going to return to the very condition that caused you to attempt intubation in the first place, and possibly in a worse position than what was started with.
 

Carlos Danger

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I am typically not a fan of SGAs because if I'm intubating, they probably needed a definitive airway anyway.
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.
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.
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.
For an out of OR/Hospital situation, if you can't intubate and your SGA isn't working well, you should then proceed rapidly to another airway option. The reason being is that returning to baseline is going to return to the very condition that caused you to attempt intubation in the first place, and possibly in a worse position than what was started with.
I'm gonna have to disagree with the idea that a patient should never be allowed to wake up after an intubation attempt. In theory, that makes perfect sense. In reality, I think it's a lot more nuanced.

Study after study has shown us that prehospital intubation rarely has a positive impact on outcomes. Despite that, for decades now paramedics have been trained to be extremely aggressive when it comes to airway management - probably much more aggressive, IMO, than what is often in the best interest of the patient. I've personally seen more than a few patients who were intubated in the field walk out of the hospital a day or two after admission with no serious injuries. What that basically adds up to is that we probably intubate a lot more folks in the field than really need to be intubated.

I know, I know - everyone else's experience is different than mine, and everybody else only intubates patients who really need it. If that's true - if you have a good protocol that is pretty conservative and your over triage rate for airway management is low, then good.

But things can get really messy really quickly when you start doing PPV through an SGA in a patient with a full stomach - especially one whom you've discovered is not easy to intubate - and a surgical cric really should always be the option of last resort. I would wager that in quite a few cases, if your patient was breathing effectively and saturating OK when you pushed your RSI drugs, and you aren't able to get a tube in a couple tries and they start to breath on their own, the best thing to do really is to just support them with oxygen and suction.

Clearly it's a judgment call, and I'm not saying that letting them wake up is always or even usually the right thing to do; I'm just saying that it is incorrect that letting them wake up is never the best option.
 

VFlutter

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I guess the caveat for me would be if they are being intubated for a primary airway or respiratory issue vs airway protection. The latter may have been breathing and saturating prior to RSI so allowing to resume spontaneous respirations may be a viable option while I do not see the former having that option.
 

Carlos Danger

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I guess the caveat for me would be if they are being intubated for a primary airway or respiratory issue vs airway protection. The latter may have been breathing and saturating prior to RSI so allowing to resume spontaneous respirations may be a viable option while I do not see the former having that option.
Throughout my HEMS career, most of the patients I intubated were for airway protection because their GCS was low following an MVC or fall and we presumed a head injury that was likely to worsen. Most of them were breathing and satting fine at the time; we were just being aggressive. That's still a very large percentage of prehospital intubations and it's mostly the scenario that I have in mind here.
 

Carlos Danger

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All that said, to get back to the original question, I don't think leaving a SGA in place in this scenario is necessarily a bad option. If you are able to get good chest rise with minimal pressure and are maintaining good Etco2 and Sp02 and the patient is overall tolerating it well, leave it.

I just disagree with the idea that "waking them up is never an option".
 

Akulahawk

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if your patient was breathing effectively and saturating OK when you pushed your RSI drugs, and you aren't able to get a tube in a couple tries and they start to breath on their own, the best thing to do really is to just support them with oxygen and suction.
In general, if my patient is breathing effectively and saturating OK, they're not likely going to be buying a tube from me. The ones that are going to get intubated are those that clearly need a secure airway because they can't protect their own airway and aren't breathing effectively. The ones that are breathing effectively and are saturating OK get the less invasive means of providing oxygenation and ventilation. I'm all for being and doing VERY aggressive care... when it is necessary.
 
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AusPara

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Interesting conversation.

I suppose the answer to my question depends a lot on what assumptions we’re making about the indications for ETI.

It’s probably worth me noting then that in our system intubation for airway protection in patients who are otherwise saturating well and ventilating fine is (or at least was until recently) quite normal.
 

Tigger

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I'm gonna have to disagree with the idea that a patient should never be allowed to wake up after an intubation attempt. In theory, that makes perfect sense. In reality, I think it's a lot more nuanced.
No doubt. I am a bit curious though to what degree we think the respiratory effort in a hemodynamically "less than stable" patient will return following a sedation and/or paralyzed. While I have seen patients wake up following an RSI gone wrong and have a perfectly adequate respiratory drive, I wonder how often this is going to be the case? Seems like having a barely breathing patient with a gag would be worse than throwing in an SGA while the patient is still sedated and then managing that.
 

CANMAN

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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.
This... there are no U-Turns in RSI prehospital. If there are you shouldn’t be RSI’ing in the first place. SGA that you’re able to oxygenate and ventilate with is a win and you do not have an airway emergency on your hands. Provide sedation and transport and hand off to someone who may be better experienced, or just having a better day then you are. Also be able to articulate why you failed (what you saw/didn’t see, anatomy issues, etc.) will help them be successful.
 

Carlos Danger

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No doubt. I am a bit curious though to what degree we think the respiratory effort in a hemodynamically "less than stable" patient will return following a sedation and/or paralyzed. While I have seen patients wake up following an RSI gone wrong and have a perfectly adequate respiratory drive, I wonder how often this is going to be the case? Seems like having a barely breathing patient with a gag would be worse than throwing in an SGA while the patient is still sedated and then managing that.
Assuming they were breathing well before the induction was started and assuming short-acting agents were used, then I'd expect it (the return of adequate breathing) to be the case the vast majority of the time.
 

CANMAN

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Why not? Why must it be completely and totally black and white in every scenario?
I saw your previous post. It’s black and white because the patient either needs their airway secured or they don’t.... This isn’t same day surgery where the patient is NPO and if you can’t get them tubed you just wake them up and everything is ok.

There is a difference in being aggressive and intubating people who are maintaining their airway on their own & ventilating and oxygenating without much/any assistance. Sure if you RSI that person and can’t get it wake um up, but that’s crappy practice.

The patient who’s drunk, will likely has a full stomach, who wrecks his motorcycle and has a GCS of 6 and facial trauma with bleeding is getting intubated all day long, and there isn’t a u-turn option in that scenario in my opinion, protocols, or medical directors opinion. You also don’t see trauma bay teams changing their mind mid procedure because they have encountered some difficulty. We have some adjuncts to assist in those scenarios.

Make smart decisions on who truly needs RSI vs. someone that can be managed with simple methods, have a bougie, rescue airway, and surgical option as a last resort for a true can’t ventilate can’t oxygenate situation (stupid rare) and manage the patient.
 

CANMAN

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OK, so we agree.
No I’m not sure that we do, but this is America so that’s ok. I’m saying if you’re inappropriately RSI’ing you shouldn’t be doing it in the first place, and those patients are the only ones that MAY be ok with being woken back up after a failed attempt. Both, those attempts should never be made in the first place, so I don’t think those situations should exist if it’s a quality system.

If you’re correctly intervening on patients that truly need RSI and an airway I stand by my statement of “there are no u-turns” at that point.
 

Carlos Danger

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No I’m not sure that we do, but this is America so that’s ok.
Not sure what that’s all about, but I’m just going to point out that nothing you’ve said contradicts anything that I have said. The only difference is that you keep stressing that elective intubations shouldn’t be happening in EMS, and while I completely agree with that, It’s kind of beside the point, because the fact of the matter is that they DO happen, and not at all infrequently. Its with that reality in mind that I made the comments that I’ve made here.
 

KingCountyMedic

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If the i-Gel is working then it's awesome. I'd leave it. You can also take your bougie, flip it upside down and lube it a little and run that down the iGel and have a good chance at feeling the rings. We have had several successful iGel/bougie assisted intubations here.
 

VentMonkey

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@Carlos Danger (lol, I almost instinctively typed @Remi), what if any advice would you offer yourself in your past HEMS career regarding airway management?

What advice would, or do you offer the local flight crews in your area now? I’m asking because you’ve been in these shoes, and part of the same culture.

And, what made you change your mind, if at all (might be misreading—I am a bit tired), on your stance with the level of “aggressiveness” you think is all too common in the HEMS world.

I mean let’s face it, we both know an elective intubation can commonly be a patient that’s a “safety concern” who may be passed the sedative bolus/ gtt threshold.

FWIW, I’m not poking the bear, just its mind.
 

Carlos Danger

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And, what made you change your mind, if at all (might be misreading—I am a bit tired), on your stance with the level of “aggressiveness” you think is all too common in the HEMS world.
My thinking has definitely evolved over the years. As a macho young flight paramedic who worked for an agency that prided itself on being extremely clinically aggressive, I was brought up to think that if there was ever even a slight question, you were always better off intubating than not. This made sense at first but as I developed an interest in EMS research I realized I couldn't square our approach with what I read in the literature. Later I spent some time as the QI guy there, and saw all the reports on our scene call transports. It was clear that we were both flying and intubating a lot of patients who didn't benefit from either and it was then that I started to really question the "fly 'em all, tube 'em all, let the ED sort 'em out" approach that wasn't just the culture where I worked, but was a prevailing thought process in HEMS at the time. The evolution in my thinking continued throughout my tenure at another HEMS program which took a more cultivated and measured approach to patient management, through my anesthesia training and specifically my trauma rotations, and my first few years of practice as a CRNA where I did a lot of airway teaching in the OR. Throughout this whole time I stayed up on all the research related to EMS airway management, which over the years has been quite consistent in what it suggested and largely reflected what I saw in my own educational and clinical experiences. The net result of all this is that I have developed some ideas and opinions on what EMS airway management should look like, and it is quite different than how I was originally taught.

I have definitely seen some positive changes. I think we've gotten better in general at airway management. We certainly have better tools, and I think the uber aggressiveness that I described from back in the day is less common.

Also, it is almost infinitely easier to find current information and learn from smart, experienced people now than it was early in my HEMS career, when youtube and blogs didn't exist and textbooks and journals were pretty much the only sources of info. FOAMed and social media has generally been an amazing educational development for EMS but I see a real problem in some cases with the cult of personality that has developed with a few of the characters. These guys are really smart and generally put out great ideas and information but because of that and their charisma, almost nothing they say is ever even questioned. For instance, why were so many so quick to accept the concept of DSI - where you sedate a full-stomach patient with an unprotected airway - while simultaneously arguing that an LMA is inappropriate as anything other than a rescue device? Why did we abandon sux so quickly even though it's been used with such success for so long and clearly has some advantages over the alternatives? Why all the attention on ketamine as an analgesic all of a sudden when fentanyl works so well and has hemodynamic advantages? I'm not saying that DSI isn't a useful tool or that you can't make good arguments for using roc in RSI or that ketamine isn't useful as an analgesic, I'm just saying that the rapidity with which these new ideas were accepted appears to have a lot more to do with those who were promoting them than the ideas themselves, especially when you consider that in at least some cases these ideas contradicted other thing that we still hold on to, and that those who said "hold on, let's look at this idea a little more critically" were often roundly chastised for not mindlessly and obediently toeing the progressive line.

I'm clearly getting off on a tangent here. Sorry. But it kind of loops back around to my original comments on this thread: Why is it controversial at all to suggest that sometimes, the best way to manage a difficult airway might be to let the patient wake up? It is because we really just can't conceive of any scenario where that might be appropriate? Are we just too tunnel-visioned on always placing an advanced airway once we decide that's what we should do? If the right FOAMed personality were to make the same suggestion, would there be as much resistance to the idea?


@Carlos Danger (lol, I almost instinctively typed @Remi), what if any advice would you offer yourself in your past HEMS career regarding airway management?

What advice would, or do you offer the local flight crews in your area now? I’m asking because you’ve been in these shoes, and part of the same culture.
People like the early 2000's me often don't like to take advice from people like the me of 2020, unless the advice supports their existing ideas of how they like to do things, or unless it's some edgy new idea. "Slow down, be more measured, be more conservative, be flexible in your thinking, remember that in medicine nothing is black-and-white" isn't a very cool or sexy idea, but it pretty much summarizes my advice for all sorts of things, including airway management.

There's a saying in anesthesia that I think is relevant: "You can always give more, but once you give it, you can never take it back".
 
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silver

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My thinking has definitely evolved over the years. As a macho young flight paramedic who worked for an agency that prided itself on being extremely clinically aggressive, I was brought up to think that if there was ever even a slight question, you were always better off intubating than not. This made sense at first but as I developed an interest in EMS research I realized I couldn't square our approach with what I read in the literature. Later I spent some time as the QI guy there, and saw all the reports on our scene call transports. It was clear that we were both flying and intubating a lot of patients who didn't benefit from either and it was then that I started to really question the "fly 'em all, tube 'em all, let the ED sort 'em out" approach that wasn't just the culture where I worked, but was a prevailing thought process in HEMS at the time. The evolution in my thinking continued throughout my tenure at another HEMS program which took a more cultivated and measured approach to patient management, through my anesthesia training and specifically my trauma rotations, and my first few years of practice as a CRNA where I did a lot of airway teaching in the OR. Throughout this whole time I stayed up on all the research related to EMS airway management, which over the years has been quite consistent in what it suggested and largely reflected what I saw in my own educational and clinical experiences. The net result of all this is that I have developed some ideas and opinions on what EMS airway management should look like, and it is quite different than how I was originally taught.

I have definitely seen some positive changes. I think we've gotten better in general at airway management. We certainly have better tools, and I think the uber aggressiveness that I described from back in the day is less common.

Also, it is almost infinitely easier to find current information and learn from smart, experienced people now than it was early in my HEMS career, when youtube and blogs didn't exist and textbooks and journals were pretty much the only sources of info. FOAMed and social media has generally been an amazing educational development for EMS but I see a real problem in some cases with the cult of personality that has developed with a few of the characters. These guys are really smart and generally put out great ideas and information but because of that and their charisma, almost nothing they say is ever even questioned. For instance, why were so many so quick to accept the concept of DSI - where you sedate a full-stomach patient with an unprotected airway - while simultaneously arguing that an LMA is inappropriate as anything other than a rescue device? Why did we abandon sux so quickly even though it's been used with such success for so long and clearly has some advantages over the alternatives? Why all the attention on ketamine as an analgesic all of a sudden when fentanyl works so well and has hemodynamic advantages? I'm not saying that DSI isn't a useful tool or that you can't make good arguments for using roc in RSI or that ketamine isn't useful as an analgesic, I'm just saying that the rapidity with which these new ideas were accepted appears to have a lot more to do with those who were promoting them than the ideas themselves, especially when you consider that in at least some cases these ideas contradicted other thing that we still hold on to, and that those who said "hold on, let's look at this idea a little more critically" were often roundly chastised for not mindlessly and obediently toeing the progressive line.

I'm clearly getting off on a tangent here. Sorry. But it kind of loops back around to my original comments on this thread: Why is it controversial at all to suggest that sometimes, the best way to manage a difficult airway might be to let the patient wake up? It is because we really just can't conceive of any scenario where that might be appropriate? Are we just too tunnel-visioned on always placing an advanced airway once we decide that's what we should do? If the right FOAMed personality were to make the same suggestion, would there be as much resistance to the idea?



People like the early 2000's me often don't like to take advice from people like the me of 2020, unless the advice supports their existing ideas of how they like to do things, or unless it's some edgy new idea. "Slow down, be more measured, be more conservative, be flexible in your thinking, remember that in medicine nothing is black-and-white" isn't a very cool or sexy idea, but it pretty much summarizes my advice for all sorts of things, including airway management.

There's a saying in anesthesia that I think is relevant: "You can always give more, but once you give it, you an never take it back".
As much as I agree with this, I took it the complete opposite in my comments. In an ideal world, only those who truly need an advanced airway will get RSIed to start with and gave my recommendations off that. Prehospital airway management remains so protocolized with variable education and training that it's challenging to know if these overly "aggressive" providers may take more liberties knowing they can just wake the patient up. With better advancement of education, I would tend to side more with you.

If patient is woken up, the provider should ask him/herself (or rather quality should) did that patient ultimately really need to be intubated at that given time?
 

VentMonkey

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If there's one thing about me, I do certainly welcome advice and opinions from other, more experienced clinicians. I'm certain that there are many of them on here who have decades more experience with airway management, not to mention actual requisite knowledge. As we all know, the average paramedics airway management education is definitely laughable.

I'd also wholly agree that with the advent of FOAMed there has been some stuff I, and many others, have had to learn to take with a grain of salt. With that, medicine is ever evolving, so to me, a realistic approach is inquiring about those who have gone before me and their experiences. I'm very big on going around the rocks, and boulders said person has already stumbled upon and alerted me to.

Sadly, ego will never, even in a field like this, and especially with topics such as airway management go away. I don't think anyone in this thread would ever argue against less education for paramedics who do in fact participate either frequently, or infrequently in a procedure as risky as an RSI.

FWIW, the sexiness of the procedure has long worn off so for me I look the clinical picture, of as an example, controlling said patient's presumed increase in ICP when they've lost the ability to do so intrinsically. Do I have EBM or data in front of me to back this up? No, but I do a fair amount of recaps and reflective learning in the event that there is, or was, a safer more effective alternative. That's why I joined this forum.
 

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