Scope of Practice(Combi Tubes)?

[jjesusfreak01]

Never used the SALT, but a similar option does exist with the King LTS-D and the LMA, as long as you have a bougie available. Pass the bougie down the bore of the airway, it should emerge at the larynx. Pass the bougie as normal, remove the LMA/King and pass the tube. Confirm via standard methods, plus direct visualization if needed.

Don't get me wrong, its a cool concept, but that seems like a giant waste of time to me. If you think King isn't going to work well, intubate and save yourself the trouble of having to explain to your medical director why you needed to shove a tube down your patients mouth twice. We have Kings and ET tubes, and we try to avoid using either as much as possible. EMS based EMTs can place Kings in the field here.

 

[firemed17]

Here in Florida all we are allowed to use as Basics are: LMA's and Kingtube's.

 

[whizkid1]

Our service we do combi-tubes and now we are starting to use king airways.I am from Minnesota.

 

[yotam]

Here in the holy-land...

(Yea, the real one) combi's aren't even heard of, and the only kings we have here are dead. Then again, we don't even get nasal airways:glare:

 

[bigmoosewi]

Wisconsin still allows Combi-tube. We actually just tested out on it about a month and a half ago for class.

 

[18G]

In PA EMT-B's are not allowed to use supraglottic airway devices. ALS services have the option of using the Combitube or King. My service uses the King.

 

[EMTRyan232]

In SC, the basics are allowed to drop a King, in my area they don't even carry the combi on the truck anymore. but once ALS gets on scene they are going to pull it and intubate anyway

 

[jjesusfreak01]

In SC, the basics are allowed to drop a King, in my area they don't even carry the combi on the truck anymore. but once ALS gets on scene they are going to pull it and intubate anyway

No reason to pull a perfectly good airway to put in a much more invasive one if the first one's doing a good job.

 

[Shishkabob]

Don't get me wrong, its a cool concept, but that seems like a giant waste of time to me. If you think King isn't going to work well, intubate and save yourself the trouble of having to explain to your medical director why you needed to shove a tube down your patients mouth twice.

Several reasons, actually:

First, the basics at our company can do Kings, so they may drop a King right off the bat for some reason.

Second, the King may be working at first but something can change to where we will need an ET tube.

 

[18G]

No reason to pull a perfectly good airway to put in a much more invasive one if the first one's doing a good job.

That was my thought exactly... especially during an arrest. The mindset still exist that "we have to intubate". Airway management is just that... managing the airway with whatever technique achieves control and not necessarily inserting an ETT just because you can.

 

[Flight-LP]

No reason to pull a perfectly good airway to put in a much more invasive one if the first one's doing a good job.

Please define "doing a good job".

In an arrest, where there are obvious priorities that directly influence whether the patient will regain circulation and thus possibly improve neuro status, I could agree in some situations.

However, outside of that, if a patient lacks the ability to maintain the patency of their own airway, is not adequately ventilating to maintain appropriate perfusion, or their predicted clinical course includes potential long term airway management, then they need definitive airway management. Simplistic rescue devices and failed airway adjuncts do not meet definitive airway criteria. As such, I would intubate them and reserve the use of other devices only for the situation of a failed airway.

My personal belief is that this philosophy allows for the practice of quality medicine. Some agree, some don't. Fortunately, those involved in my collaborative practice of medicine (i.e. MD, QA and Clinical Department) agree with this philosophy and promotes it within our clinical practice.

 

[Sassafras]

CombiTube dropped from MD protocols.

Contains latex.

That would be why my hands started itching when we played with them in ALS assist class. That would be bad...very very bad if they shoved that down my throat.

 

[18G]

On an arrest I would not hesitate to insert a King airway after a single failed attempt at intubation. As long as the airway device is providing good tidal volume and giving some protection from aspiration I feel confident that is an airway "doing a good job". And if BLS has one inserted prior to ALS with good ventilations going on, why mess with it? Insert an NG tube and I say you have pretty good airway control. Is intubating going to provide any better outcome than the King or Combi-Tube in an arrest? of course not. The AHA is even recommending going with a supra-glottic device during arrests.

As for other clinical scenarios... obviously intubation needs to be attempted but don't prolong the decision to switch to a supra-glottic device. It doesn't mean your a crappy Medic because you "couldn't get the tube". Anyone who still thinks this needs re-educated. And I don't buy the standard "3 attempts" to intubate before switching to an alternative airway. Attempting to intubate up to three times in a head injured patient would be much worse then going with a supraglottic device after one ET attempt if you aren't feeling confident with being able to get the tube. The vagal response and risk of increasing ICP and inciting an episode of hypoxia in these patients is extremely detrimental. There is debate on the benefits of pre-hospital intubation of the head injured patient with much worse outcomes in several studies. So is intubation really the best medicine or is securing an airway as quickly as possible in adverse field conditions the best medicine?

I don't worry about upholding philosophies... I only worry about my patient at that exact moment and doing what needs to be done.

 

[Hellsbells]

Virginia allows EMT-B's to drop the "tube of shame," commonly known as the King. We got rid of combitubes, since they showed no benefit for out of hospital discharge. Nasals have always been in the EMT-B's scope. Whether or not each state chooses to adopt the new National Scope of Practice depends on many things, such as supply of medics, or supply of EMS in general for rural areas, for example.

I hate this attitude that its shamful to miss an intubation. There is no reason not to go right to a superglottic airway after a failed intubation attempt. It is critical to avoid hypoxia while wasting time on multiple attempts while trying to fulfill some heroic mentality that good medics always get the tube.

That said, I have my reservations about the combitube and LMA's. Combitubes are rather bulky and can cause significant trauma when used roughly. The problems with LMA's and aspiration have been detailed in this thread already. However, I think that the King tubes with the suction ports are a great primary device for basics and a good back up for paramedics.

 

[usalsfyre]

Please define "doing a good job".

In an arrest, where there are obvious priorities that directly influence whether the patient will regain circulation and thus possibly improve neuro status, I could agree in some situations.

However, outside of that, if a patient lacks the ability to maintain the patency of their own airway, is not adequately ventilating to maintain appropriate perfusion, or their predicted clinical course includes potential long term airway management, then they need definitive airway management. Simplistic rescue devices and failed airway adjuncts do not meet definitive airway criteria. As such, I would intubate them and reserve the use of other devices only for the situation of a failed airway.

My personal belief is that this philosophy allows for the practice of quality medicine. Some agree, some don't. Fortunately, those involved in my collaborative practice of medicine (i.e. MD, QA and Clinical Department) agree with this philosophy and promotes it within our clinical practice.

I agree to a point. That said I've also shown up when a King has been placed as a rescue device in a failed airway and opted to leave it be. I might try the tube changer trick, but I'm somewhat disinclined to go digging around in what has already proved itself to be a difficult airway (granted it may be the skill of the laryngoscipist), not to mention deal with the trauma probably caused during multiple ETT attempts. A King with an NG in place actually works fairly well for delivering mechanical ventilation. The receiving facility will most likely have full time anesthesia, fiber optics, ect to help get a tube placed.

That said if the King appears inadequate, we're going to pull it and place a better airway, even if that means a cric.

 

[Bosco836]

Here in Florida all we are allowed to use as Basics are: LMA's and Kingtube's.

Does this mean no OPAs/NPAs in FL?

 

[usafmedic45]

Virginia allows EMT-B's to drop the "tube of shame," commonly known as the King.

That's a really mature attitude. The only airway one should be ashamed to admit to is the one you don't maintain because you let your ego get in the way of good patient care.

We got rid of combitubes, since they showed no benefit for out of hospital discharge.

Last time I checked, neither did King Airway or ET tubes for that matter.

 

[Phlipper]

We use Kings in NC and I dropped one during my first month. Very easy, very effective (just didn't help in this case). I may feel differently when I finish medic school and have more experience, but for now it seems so easy and quick that I'm not sure RSI/intubation should always be first line. I don't quite grasp what ET does in most cases that can't be accomplished by a King. I still have lots to learn, though, and may change my mind later.

 

[usalsfyre]

We use Kings in NC and I dropped one during my first month. Very easy, very effective (just didn't help in this case). I may feel differently when I finish medic school and have more experience, but for now it seems so easy and quick that I'm not sure RSI/intubation should always be first line. I don't quite grasp what ET does in most cases that can't be accomplished by a King. I still have lots to learn, though, and may change my mind later.

Isolation of the trachea, ability to perform procedures such as broncoscopy, route for suctioning, the ability to provide long term ventilatory support including multiple modes of ventilation and effective PEEP, ability to keep the patient conscious without stimulating the gag reflex and prevention of stasis injuries to the upper airway are just some I came up with off the top of my head, I'm sure usafmedic45, Journey and Flight-LP can provide more. ETT placement may not appear more advantageous, but if it can be done skillfully and without complication it is far superior in the overall continum of care.

 

[TransportJockey]

The only one of those that you mentioned that is not quite right is suctioning. The newer King's have a suction port on them. Might not be able to do it as well as with ETT, but you can at least do it.