Scope of Practice(Combi Tubes)?

[usalsfyre]

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.

It's a gastric suction port. I suppose you could try to jam a French cath through the hole used for a tube changer, but it would have to be a small fr and you'd have to hope it stayed on course to go in to the trachea.

Another one I just thought of is decrease in airway resistance. I can't imagine trying to suck air through a King would go well...

 

[usalsfyre]

So on further research, I was wrong and you were right. The port your refering to IS considered a suction port. However, I still can't see how this would facilitate deep suctioning very well.

 

[18G]

hmmm... I was under the impression that the port on the side of the King was for an NG tube which obviously goes into the stomach. How are you going to perform deep suctioning of the trachea with an airway placed in the esophagus?

 

[jjesusfreak01]

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hmmm... I was under the impression that the port on the side of the King was for an NG tube which obviously goes into the stomach. How are you going to perform deep suctioning of the trachea with an airway placed in the esophagus?

You are correct. I don't believe there is any safe way to do deep suctioning through a King airway. It is possible to run a small catheter through the main tube (the ventilating tube, not the NG canal), I believe, but you would have no control over the catheter and no way to verify it was going where you wanted.

 

[usalsfyre]

hmmm... I was under the impression that the port on the side of the King was for an NG tube which obviously goes into the stomach. How are you going to perform deep suctioning of the trachea with an airway placed in the esophagus?

The LTS-D at least has a port that exits at the distal end of the main lumen of the airway (where the 15mm adapter is). I guess the idea is you would slip a small suction catheter through that. In practice I'm not sure it would make it into the trachea, go deep enough, or have a large enough diameter to acomplish much.

 

[Phlipper]

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.

I'm not talking about long-term, where ETT certainly makes sense. I'm talking purely field use when you need an airway asap and have a whole lot of other things going on.

If even a newbie like me can drop a king, inflate it, check compliance, and tape it off and be bagging without interrupting CPR that quickly I see it as a very very good tool. The King appears - based on everything I've ever read, including the recent Wake Co studies - to work very, very well for what it was designed to do. And in many cases, I just don't see a reason to automatically grab the tube kit automatically. Ask me again in a year when I finished medic class.

 

[usalsfyre]

I'm not talking about long-term, where ETT certainly makes sense. I'm talking purely field use when you need an airway asap and have a whole lot of other things going on. And suctioning thru the King tube does work. I've seen it done, but have not done it.

Outside of cardiac arrest (where airway period is pretty dubious), you should have time to place an airway. If you don't (a true can't intubate/can't ventilate scenario), you should probably be considering a cric anyway.

 

[Phlipper]

I've seen a clip on suctioning with the King and it appears to work ok for fluids. In the real world who knows? Maybe I'll get to find out in the next year or so, though, since I seem to be a black cloud. h34r:

 

[Phlipper]

Something else to consider, in my service we usually only have one medic on scene. And if we're on an arrest or shooting or whatever and the medic is drilling shin bones who's gonna tube the pt? I is. And I cain't do ET per NC guidelines. Heah come da King.

 

[TransportJockey]

Tubing should be done pretty much last during a code. Its not exactly a high priority.

Something else to consider, in my service we usually only have one medic on scene. And if we're on an arrest or shooting or whatever and the medic is drilling shin bones who's gonna tube the pt? I is. And I cain't do ET per NC guidelines. Heah come da King.

 

[Phlipper]

Tubing should be done pretty much last during a code. Its not exactly a high priority.

Really? I've always read/been taught A-B-C. Seems like an airway is pretty high up on the ladder. Even though C is usually prioritized for arrest, trauma, GSWs, etc. We'll have to agree to disagree on that one. My Medical Director will also disagree with you, and he makes the rules I play under.

 

[TransportJockey]

Really? I've always read/been taught A-B-C. Seems like an airway is pretty high up on the ladder. Even though C is usually prioritized for arrest, trauma, GSWs, etc.

For a code compressions take priority over everything.

 

[usalsfyre]

Really? I've always read/been taught A-B-C. Seems like an airway is pretty high up on the ladder. Even though C is usually prioritized for arrest, trauma, GSWs, etc. We'll have to agree to disagree on that one. My Medical Director will also disagree with you, and he makes the rules I play under.

The AHA is going to disagree with you on this one too. In cardiac arrest good quality compressions and defib take precedence over anything else. The new CPR accronym is "CAB".

Serious trauma, including GSW should be treated the same way with regard to exangunating hemmorhage.

 

[Phlipper]

The AHA is going to disagree with you on this one too. In cardiac arrest good quality compressions and defib take precedence over anything else. The new CPR accronym is "CAB".

Serious trauma, including GSW should be treated the same way with regard to exangunating hemmorhage.

Since you didn't read the whole post here ... "Even though C is usually prioritized for arrest".

And CAB still puts A and B right up there in the top three. If A and B are that unimportant, why are you guys trying to justify RSI/ET above all else? Why not just wait till you get to the ER and let the docs do it? You're contradicting yourselves.

I know you like playing with your toys. But perhaps you should consider the possibility that Kings are becoming more and more accepted as a first line adjunct. If I understood correctly, already in Wake Co only the APPs are RSI'ing now. Since their review of data suggested King is the way to go more often than not, I'm betting more agencies are looking at it as well, if they haven't been already.

 

[reaper]

There is times when a secure airway is a must. An arrest is not one. You can push it down the line. A and B can be done with OPA and BVM.

 

[jjesusfreak01]

Really? I've always read/been taught A-B-C. Seems like an airway is pretty high up on the ladder. Even though C is usually prioritized for arrest, trauma, GSWs, etc. We'll have to agree to disagree on that one. My Medical Director will also disagree with you, and he makes the rules I play under.

ABCs are somewhat relative (ok, maybe completely relative). On anything other than a trauma or cardiac arrest, airway always comes first. If you come upon an arrest scene and the patient has not been getting compressions, thats obviously a top priority, as many body tissues use little oxygen when a patient is fully arrested, but if the blood isn't moving, they are getting no oxygen. If bystanders are doing compressions and you have a second person on your crew, one can secure the airway while the other sets up for electrical therapy.

Likewise, on a trauma scene, massive hemorrhage has to be treated first, since inadequate blood volume impedes your ability to restore adequate perfusion regardless of whether you can ventilate the patient or even get their heart restarted. Its a simple, "what is going to kill my patient first?" question. Well, actually, its even simpler than that. Hypoperfusion (shock) is probably what's going to kill a critical patient in the end, 90% of the time. All you have to do is determine the causes that currently (or will lead to) inadequate perfusion, and treat them.

 

[Phlipper]

If I can get done with the database I'm supposed to be working on (while I sit here playing on the web ) I'll see if I can re-find the info I dug up last month when we were discussing this at work (EMS work ... I still do both). Bottom line, there are states/counties/ERs looking into King Airways as first line for arrest and other kinds of events. NC and Vermont are two that I remember specifically, and there were two ERs who dropped Kings or Combis in the trauma rooms, also, rather than ETI.

There is something to it, whether we like it or not. And if, as some at my service and at my school have predicted, ETI is taken away from us in the field, just remember: it's the patient who should come first. Our egos and our toys are secondary, and justifying it ten ways to Sunday isn't going to change the trend if it is found to be valid wrt pt outcomes. Just like increased education requirements and national licensing, lots of changes are on the horizon for us that we may, or may not agree with. Keep an open mind and a stiff upper lip.

 

[usalsfyre]

If I can get done with the database I'm supposed to be working on (while I sit here playing on the web ) I'll see if I can re-find the info I dug up last month when we were discussing this at work (EMS work ... I still do both). Bottom line, there are states/counties/ERs looking into King Airways as first line for arrest and other kinds of events. NC and Vermont are two that I remember specifically, and there were two ERs who dropped Kings or Combis in the trauma rooms, also, rather than ETI.

There is something to it, whether we like it or not. And if, as some at my service and at my school have predicted, ETI is taken away from us in the field, just remember: it's the patient who should come first. Our egos and our toys are secondary, and justifying it ten ways to Sunday isn't going to change the trend if it is found to be valid wrt pt outcomes. Just like increased education requirements and national licensing, lots of changes are on the horizon for us that we may, or may not agree with. Keep an open mind and a stiff upper lip.

Your trying to equate airway control in cardiac arrest (which is pretty effing pointless in most cases anyway) with other situations in which you might place an advanced airway. They're MASSIVELY different, as such your argument is incredibely flawed.

Your lack of knowledge of RSI is hugely apparent. If I'm using drugs to facilitate intubation, then a King was not an option at the outset. Otherwise I wouldn't need sedation and paralysis to stick a Miller blade down thier gob. If I'm going to that level of trouble then why am I not trying to place a more protective airway with better long-term options? Unless you can find me an intensivist who says a King is acceptable for ICU care (hint, you won't).

The reason RSI and ETI is going away is that medics are showing to be hugely inadaquate at performing it without complication. Which thanks to strong QA, oversight and education has not been a problem at my agency.

 

[Flight-LP]

I'm not talking about long-term, where ETT certainly makes sense. I'm talking purely field use when you need an airway asap and have a whole lot of other things going on.

If even a newbie like me can drop a king, inflate it, check compliance, and tape it off and be bagging without interrupting CPR that quickly I see it as a very very good tool. The King appears - based on everything I've ever read, including the recent Wake Co studies - to work very, very well for what it was designed to do. And in many cases, I just don't see a reason to automatically grab the tube kit automatically. Ask me again in a year when I finished medic class.

That statement is contradictory. How many folks out there who need an immediate airway in the field are going to be short term ventilatory patients? The answer is very few, with the majority of them being non-surviving arrest patients. Even if an adjunct is placed, is it not going to be replaced upon arrival to the ER? If you have the capabilities and the resources to provide definitive care, why wouldn't you knowing it is beneficial to the patient and possibly detrimental to their outcome?

In a code, the airway is still first. But intubation is no longer a huge priority PROVIDING you are adequately ventilating your patient through an alternative method. If I deem a code viable and choose to work them, then I will still intubate them as I know it will provide a more definitively secured airway, even if I am the only ALS provider on scene. That's just me, individual mileage will vary. You have 3-5 minutes between medications, that is more than plenty of time to perform the laryngoscopy. In addition, it is a reasonable expectation to accomplish the laryngoscopy without interrupting CPR.

Does the King have a place in EMS? Yes, absolutely, however it was designed and received FDA approval as an oropharyngeal adjunct for a controlled ventilated patient. In an arrest with non-compliant ventilation, or placement by a BLS provider for airway management versus none at all, it could work well. However, I am hearing other ALS providers make statements that they would use it as a frontline airway in the patients that clearly need endotracheal intubation (outside of an arrest). Folks, this is not a substitute for maintaining proficiency in one of the few skills that can actually sustain a life and provide a positive outcome.

I also don't buy the "whole lot of other things going on". This is so simple, the airway is first, period. The rest will wait. Didn't every single provider in this forum learn that at one point or another?

Sorry, but I see this trend of moving to airway adjuncts and completely half-a$$ed and a dilution of the medicine that we clearly can provide. If they need intubating, then put an endotracheal tube where it belongs.

As always, just my humble opinion. Take it as you will..........................................

 

[Flight-LP]

The reason RSI and ETI is going away is that medics are showing to be hugely inadaquate at performing it without complication. Which thanks to strong QA, oversight and education has not been a problem at my agency.

DING*DING*DING

We have a winner.

This says it all! The prime reason some peanut counting researchers make the blanket "Paramedics can't intubate" statement is because they evaluate substandard EMS systems with limited QA and questionable educational oversight. Wong's study and the San Diego study are both prime examples. Both provide on paper some statistical facts, there is no doubt, but what neither study addresses is the underlying deficiencies of the agency as a whole in their lacking oversight and education.