There is a heated discussion going around my co workers and I on advisements from regional medical directors that is advising us to go directly to King LT Blind insertion Airways during the presence of Cardiac Arrest. I personally sit on the fence with this and am wondering the groups thoughts on this standard.

On one hand we are taught to intubate so do the skill,

On the other Kings take less time and have fairly impressive success rates lessening screw around time and limit interuptions.

So what are your guys thoughts on this topic. I look forward to your responses.

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Secondary Advance Airway devices are great to have. You always need a backup. There are many variables on why we would intubate a patient; more so use an advance airway device... I am not going to get into that because that is a differnet subject which can also get heated...

 

Since, we are in an age in healthcare where ET has been push to the side. That can be a major disadvantage, if the time comes and we haven't intubated since we have on a manikin during the last refresher or ACLS/PALS/ATLS/etc. class; that is a big problem... Having a secondary airway device is great but if you use it as a primary device because you don't have confidence in your ET skills; then will you ever get the confidence to ET intubate? What happens if the King LT/Comitube/LMA is not functioning because there is a leak?

I see no problem in intubating the cardiac arrest patient instead of using the secondary device; as long as hands off the chest time is no more than 10 seconds and there are multiple providers to perform CPR. Of course the basic airway adjunct and BVM with oxygen must be used first... Remember a cardiac arrest patient has no gag and will not fight you. Keeping this in mind, will make sure no time was wasted becuase you optioned to ET intubate.

 

Good luck...

In the UK intubation has all but been dumped as an EMS skill. LMA's and products like igel being used instead. Reducing time spent away from compressions and also skill degradation as it is performed few and far between.

On one hand we are taught to intubate so do the skill,

"Because I can" should never be a justification for anything. The question is: what's better for the pt? And right now, unless you're in a high-performing system where you get 15 tubes a year, evidence suggests that the King is better for the pt.

Of course, as already noted, how much of this is due to what airway you're using and how much is an artifact of long compression interruptions during ETI attempts is up for debate. It's probably completely reasonable to look, and if you don't immediately see cords during a 5-10 sec interruption, drop the King (or whatever blind-insertion device you have).

Great advice, Doc.  Thank you.

My services have used King LT/LTSD as the primary airway in cardiac arrest for the past 6 years.  I truly believe in the concept that supraglottic airways are faster and simpler than endotracheal intubation.  Providers can concentrate efforts on high quality chest compressions (autopulse in my case).  However, some new studies are implying that King/LMA/combitube are associated with slightly higher mortality.  It may have to do with increased pressure on the carotid complex.  In listening to a presentation on the research, there may be some study design flaws.  Nevertheless, it does raise some questions.  Stay tuned.

 

 

The biggest thing that we have to look at is the interruption of chest compressions during the intubation attempt.  I know that many of you are saying..."Well....I can do it while compressions are going on..."..but can you really?  After doing lots of call review and looking at the skill in depth, the average is...the intubation occurs on the second attempt, many stop compressions during the attempt, and the compressor is actually distracted.  I have reviewed hundreds of codes with recorded data....most of the time during the intubation the compressions are paused/stopped for 30 seconds or longer, and when they are not stopped, the depth of compressions changes for the time that the intubation is occurring.  Where I work we used this data and the evidence that a simple interruption in compressions of 20 seconds equals zero survivability to move to the recommendation of placing a BIAD as the primary airway during the cardiac arrest. 

 

In making this move we have noticed a significant increase in ROSC with cardiac arrest (primarily VF/VT) but other rhythms as well.  This has also let to an increase in patients being discharged neurologically intact.  Initially there was some push back from the staff, but once they started examining the recorded data and seeing that intubation was not helping the cardiac arrest patient everyone began to agree and peer pressure/gentle competition has set in to see who can improve their personal statistics with ROSC. 

 

Another thing to keep in mind is.....once the patient is intubated who do we pass off the tube to for management?  Often it is a Medical Responder, or someone who can not re-intubate if something goes wrong....someone who can fix the problem is the one who needs to manage the patient with strong post intubation management skills (not often taught in initial EMS classes).  In our system the Medical Responder can place a BIAD, and this allows the ALS personnel to focus on IV/IO/drugs, etc.  It is also important to point out that an airway has never saved a cardiac arrest patient, but high quality chest compressions and early electrical therapy has! 

 

I can go on....and on.....about the procedural process, the lack of optimizing chances for intubation on the first attempt, the physiology, and so on....but the important thing to remember is....it is all for the patient and doing what really works!

Faster insertion = less interruption of compressions = better patient outcomes.

What's the question?

After you get your ROSC and the patient has stabilized, if they still need ventilation, pass a bougie, insert an ETT tube over the bougie, and remove the King.

All for the good of the patient - not for the satisfaction of the provider.

Great point, Chief. Unfortunately, too many of us are married to the idea of the ETT, instead of using the most appropriate device.

Skip Kirkwood said:

Faster insertion = less interruption of compressions = better patient outcomes.

What's the question?

After you get your ROSC and the patient has stabilized, if they still need ventilation, pass a bougie, insert an ETT tube over the bougie, and remove the King.

All for the good of the patient - not for the satisfaction of the provider.

A minor problem: the science on this may evolve yet again. I'd read it last week, but couldn't find it again until today: there are already some suggestions that supraglottic devices may impair cerebral blood flow.

http://www.naemsp.org/documents/OralAbstract5.pdf

The improvements in OHCA survival rates may have reflected a longer apneic time while trying to insert an ETT as opposed to the rapid insertion of a BIAD. Now, we need to figure out whether putting in an ETT without stopping compressions is somewhat better than the BIAD. For right now, the supraglottic devices are better, and they may stay the standard of care. Just wanted to point out some newer thoughts on the matter.

Mr Waller....one last point: my internet connection shut me down in the middle of posting my reply to your posts on this board:

 

 I find it hard to believe , even with all your cool instructor certs you have so neatly listed on your profile, you have the huevos’ to argue with a world renowned anesthesiologist (which last time I checked, is essentially an airway physician) on what the gold standard airway management device is…….short sighted and disrespectful. Hilton Head must be proud.

What doc said!!!



dr-exmedic said:

On one hand we are taught to intubate so do the skill,

"Because I can" should never be a justification for anything. The question is: what's better for the pt? And right now, unless you're in a high-performing system where you get 15 tubes a year, evidence suggests that the King is better for the pt.

Of course, as already noted, how much of this is due to what airway you're using and how much is an artifact of long compression interruptions during ETI attempts is up for debate. It's probably completely reasonable to look, and if you don't immediately see cords during a 5-10 sec interruption, drop the King (or whatever blind-insertion device you have).

Mike, see my response in the other thread as well as this response.

 

There is plenty of evidence that ETI can interfere with CPRto the point that it is harmful.  That means that ETT is not always "the Gold Standard" no matter how you define it nor who makes that statement, nor what that person's credentials happen to be.

 

We're supposed to be basing our practice on the evidence.  I asked Dr. Grabinsky for evidence, and for a definition of a term he used.  He has provided neither.  Thus, legitimate questions will continue.

 

I certainly hope that my agency is proud of people that question accepted practice that isn't based on evidence, or that in fact, is contrary to the evidence. 

 

Our business should be about improving patient outcomes, not cults of personality.

 

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