If you have experience using the above captioned devices for cardiac arrest I have a couple of questions.

 

1.) Do you use a gastric tube in combination with the King LTS-D? If so, when and how do you insert it? Do you insert the tube up to the distal tip of the King prior to insertion of the King or just insert the King first and the gastric tube later? Do you attach it to suction right away or only if you suspect a problem? How long do you apply suction? Until no gastric contents are coming up the tube? Does it work well or does it get clogged?

 

2.) When you identify ROSC (thanks to waveform capnography) and the ETCO2 is above 45 do you hyperventilate the patient to bring down the ETCO2 below 45 or continue to ventilate the patient every 6-8 seconds (or when the light on the ResQPOD blinks)? Or would you expect the ETCO2 to come down below 45 on its own provided that ROSC persists.

 

3.) Do you bother with attempting IV access or go strait to IO or do you evaluate the patient's peripheral access and decide on a case-to-case basis?

 

4.) I'd like to know how many people are dispatched to a cardiac arrest in your system, particularly if your system is doing well with survival to hospital discharge. Include first responders and supervisors.

 

One of our emergency physicians has raised concerns about the effectiveness of the King and is quite adamant that it should be considered a rescue airway ONLY and never a primary airway, even for cardiac arrest. He feels that it does not adequately ventilate patients in comparison to tracheal intubation.

 

This is based on a case where EMS lost ROSC in the field several times (but identified it immediately because there was a significant change in ETCO2), chest compressions were continued, the ResQPOD was replaced, the patient was shocked, and ROSC was restored several times en route.

 

Apparently the patient's ABGs showed more CO2 than some of the ED physicians were hoping to see. The patient was intubated with a tracheal tube in the emergency department and apparently that rectified the problem.

 

I personally find it to be ironic that we are hearing complaints now that patients are surviving to hospital admission. I feel like patients could arrive pulseless with a tube in the right hole and no questions would be asked, but who knows.

 

We did have a problem with gastric contents inside the King and had to remove it, suction the patient, and replace the King (which is why I'm asking about the gastric tube).

 

My concern is that we will lose support for the King LTS-D before it's had a legitimate chance to work in the field. I don't think we ought to dictate to paramedics how they capture the airway because I think it should be based on a variety of factors including the patient's airway anatomy (predicted difficulty of intubation), circumstances on scene, experience level of the paramedic, and whether or not chest compressions will need to be interrupted (and how many times) for laryngoscopy.

 

So let's hear it! I'll be interested to hear what you guys have to say.

Tags: Arrest, Capnography, Cardiac, EZ-IO, King, LTS-D, ResQPOD, Waveform

Views: 1124

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I have no rebuttal other than Ive never had gastric contents leak into the trachea (that I could see) using the combitube.  Ive used it many times.  Ive used the king like 3 times and had negative experiences a couple of those times.  I cant think of any user error when I used the king but I wouldnt be so ignorant as to completely rule that aspect out.

dr-exmedic said:
Nathan said:

Will try and respond more later but personally I feel the Kind is far inferior to the combi tube as a backup airway

...

It says as a disclaimer on their web page "DOES NOT PROTECT THE TRACHEA FROM GASTRIC CONTENTS"!!!!!!!!!!!!!!!!!!!

Neither does the Combitube in the 90+% of times it hits the esophagus.
For those who go right to IO, do you place an IV afterward, if possible?  Even if no ROSC?

Hi Tom,

 

My view on this topic is:

 

1. I have had very good results using the King. I will put it in as early in the arrest as is possible after I am sure all the other tasks are covered. I will put the gastric tube in when time permits unless I think I have a large amount of air in the gut in which case I put it in and attach suction until I stop getting gastric contents returning. I have and not problems with gastric content leakage in the few dozen times I have used it. If I end up with ROSC or not terminating the resuscitation in the field I will consider changing out the King for an ET tube but don't do that routinely, there would have to be a good reason. My feeling is that if I am getting adequate air movement with good ETCO2 waveform and have a patent airway I'm going to stick with what is working unless there is a good reason to try something else.

 

2. I tend to always ventilate the patient using the ETCO2 after ROSC so I can be sure I am not hypo/hyperventilating them. The blinky light is fine if you have no other way of monitoring the patients actual respiratory status but for me capnography is king. Eventually the ETCO2 will probably come down below 45 on its own but it will take longer than if you are titrating ventilation with the ETCO2.

 

3. Now that we have a little time between the time we start CPR and the time that we need to give meds I will generally allow 15-20 secs to search for an IV site (provided I have people to spare) but is there is no obvious site or if I am short personnel I'll go straight to IO. This is probably my own dinosaur bias from the days when IO was limited to last ditch vascular access.

 

4. Generally we will respond with a Intermediate level ambulance (2-3 people), a non-transport solo paramedic, and an engine company (3 people) which may be staffed with a paramedic but usually is at the Intermediate level. For 2010 we had a 30% survival to discharge rate but that was unusually high since most of our cardiac arrests occurred in the core of the community and very few in the more rural areas. Usually we average about 8% primarily, I think, due to longer time between 911 activation and arrival of personnel in the rural portions of our district.

 

By and large I have not found many circumstances when I was not able to adequately ventilate with a King airway in place. I have seen patients brought into the ED with higher PCO2 levels on the ABG but my experience has been that these ROSC patients were not having their ventilation rate determined by the ETCO2 levels. This may not be true in the case your physician is referring to but it is one possibility. 

 

As much as I enjoy intubating I am rapidly becoming a firm supporter of using some of these alternative airways provided that adequate tidal volume can be achieved. Having discussed the topic of not intubating every cardiac arrest with an ED physician a few weeks ago I found that some physicians just have a bias against these alternative airways and until there is enough evidence to satisfy them that they are just as effective for most patients they would still prefer to see patients intubated since intubation is still the "Gold Standard" in their eyes.

 

Regards,

Harry

 

 

Harry with all due respect this is concerning "I will put it in as early in the arrest as is possible after I am sure all the other tasks are covered." Who taught you that this is acceptable?  What standard airway algorythm or protocol advocates this?  It takes me < 2 minutes to set up for intubation and perform the procedure appropriately and safely for the PT. And I by no means am an airway Guru... It barely takes longer to intubate a PT in regards to placing a King tube.  You still have to take it out of the package, lube it up generously, inflate the cuff to make sure it hasn't blown and then insert.  Yes, less time than a traditional intubation method, but not much.  And then you stated that if you get an ROSC that you will then take it out and place an ET tube.  You do realize that the King tube and Combi-tube do cause trauma almost every time leading to bleeding, swelling and decreasing your chances of a successful traditional direct laryngoscopy right?  So why not just take your time, since you have time(they're dead), and do what's right for the PT.  Plus, cardiac arrests are considered crash airways which lends to no gag reflex and to very very little muscle tone.  It's like the PT is paralized and you didn't have to push an NMBA and accept the responsibility of doing it yourself.  These are generally considered the easiest and best intubating conditions.  Do you not feel confident in your intubating skills or what?  Not trying to call you out, but this sounds lazy and rushed.  Cardiac arrests are no time to be rushed, just methodical and steady.  I'm sorry that your are the recipient of my soap box, but seeing this mentality from you and other providers on here is concerning and frustrating.  I have been in EMS long enough and know that this was never taught to be acceptable and is not currently the standard of care in airway maintainence.  If this is something because you don't get many chances to intubate or your EMS service provides little to no CEs(like Sim man practice intubations, OR rotations, or Airway seminars) then I understand your thinking.  But if not then I believe you have no excuse providing this type of care.  If it's the first option then your need a better, more dedicated medical director.  Airway is the cornerstone of our existance and yet we pay very little attention to it.  Again not a paragod or Guru.  Just my .02 worth...

 

Respectfully,

 

Matt King

Harry Mueller said:

Hi Tom,

 

My view on this topic is:

 

1. I have had very good results using the King. I will put it in as early in the arrest as is possible after I am sure all the other tasks are covered. I will put the gastric tube in when time permits unless I think I have a large amount of air in the gut in which case I put it in and attach suction until I stop getting gastric contents returning. I have and not problems with gastric content leakage in the few dozen times I have used it. If I end up with ROSC or not terminating the resuscitation in the field I will consider changing out the King for an ET tube but don't do that routinely, there would have to be a good reason. My feeling is that if I am getting adequate air movement with good ETCO2 waveform and have a patent airway I'm going to stick with what is working unless there is a good reason to try something else.

 

2. I tend to always ventilate the patient using the ETCO2 after ROSC so I can be sure I am not hypo/hyperventilating them. The blinky light is fine if you have no other way of monitoring the patients actual respiratory status but for me capnography is king. Eventually the ETCO2 will probably come down below 45 on its own but it will take longer than if you are titrating ventilation with the ETCO2.

 

3. Now that we have a little time between the time we start CPR and the time that we need to give meds I will generally allow 15-20 secs to search for an IV site (provided I have people to spare) but is there is no obvious site or if I am short personnel I'll go straight to IO. This is probably my own dinosaur bias from the days when IO was limited to last ditch vascular access.

 

4. Generally we will respond with a Intermediate level ambulance (2-3 people), a non-transport solo paramedic, and an engine company (3 people) which may be staffed with a paramedic but usually is at the Intermediate level. For 2010 we had a 30% survival to discharge rate but that was unusually high since most of our cardiac arrests occurred in the core of the community and very few in the more rural areas. Usually we average about 8% primarily, I think, due to longer time between 911 activation and arrival of personnel in the rural portions of our district.

 

By and large I have not found many circumstances when I was not able to adequately ventilate with a King airway in place. I have seen patients brought into the ED with higher PCO2 levels on the ABG but my experience has been that these ROSC patients were not having their ventilation rate determined by the ETCO2 levels. This may not be true in the case your physician is referring to but it is one possibility. 

 

As much as I enjoy intubating I am rapidly becoming a firm supporter of using some of these alternative airways provided that adequate tidal volume can be achieved. Having discussed the topic of not intubating every cardiac arrest with an ED physician a few weeks ago I found that some physicians just have a bias against these alternative airways and until there is enough evidence to satisfy them that they are just as effective for most patients they would still prefer to see patients intubated since intubation is still the "Gold Standard" in their eyes.

 

Regards,

Harry

 

 

"Do you not feel confident in your intubating skills or what?"

 

You say this as if paramedics receive an appropriate level of education, training, and clinical experience so that "confidence in intubating skills" should be a given.

 

Is that what you believe?

 

Tom

I personally find it to be ironic that we are hearing complaints now that patients are surviving to hospital admission. I feel like patients could arrive pulseless with a tube in the right hole and no questions would be asked, but who knows.


If the patient doesn't survive to discharge, does it really matter whether the resuscitation ends prehospital, in the ED, or in the ICU?

Yes, because it's clear that post-resuscitation care matters and the hospital hasn't implemented hypothermia yet. As Brent Myers, M.D. said in a recent Sustain the Gain webinar, EMS has to take responsibility for their part and the hospital has to take responsibility for their part. So getting them there with a pulse (and viable enough to be admitted) is an improvement over death in the field. At the risk of oversimplifying, the more patients with ROSC, the more candidates for hypothermia, so it's a good thing that EMS is doing its part to figure out how to increase the number of patients with ROSC. The hospital can't get good with post resuscitation care if they don't take care of any post-resuscitation patients.

 

Tom

No Tom I do not feel that paramedics get enough of what you stated.  You are right.  My goal was to try to state this in my last post, but probably didn't make it known.  We don't get enough which is why we owe it to ourselves, patients, and co-workers to seek education elsewhere as well.  But I still believe this has never been to norm taught and is not the standard of care in regards to airway maintainence.  

 

Respectfully,

 

Matt

Tom Bouthillet said:

"Do you not feel confident in your intubating skills or what?"

 

You say this as if paramedics receive an appropriate level of education, training, and clinical experience so that "confidence in intubating skills" should be a given.

 

Is that what you believe?

 

Tom

Joe I am not understanding your question.  And to one up you, it only matters if the PT comes out of the hospital close to neurologically the same way they were prior to going into caridac arrest right?

 

Respectfully,

 

Matt

Joe Paczkowski said:

I personally find it to be ironic that we are hearing complaints now that patients are surviving to hospital admission. I feel like patients could arrive pulseless with a tube in the right hole and no questions would be asked, but who knows.


If the patient doesn't survive to discharge, does it really matter whether the resuscitation ends prehospital, in the ED, or in the ICU?


Tom Bouthillet said:

Yes, because it's clear that post-resuscitation care matters and the hospital hasn't implemented hypothermia yet. As Brent Myers, M.D. said in a recent Sustain the Gain webinar, EMS has to take responsibility for their part and the hospital has to take responsibility for their part. So getting them there with a pulse (and viable enough to be admitted) is an improvement over death in the field. At the risk of oversimplifying, the more patients with ROSC, the more candidates for hypothermia, so it's a good thing that EMS is doing its part to figure out how to increase the number of patients with ROSC. The hospital can't get good with post resuscitation care if they don't take care of any post-resuscitation patients.

 

Tom

 


While, true, there is plenty that can happen in and/or because of hospital care that isn't related to EMS, the anecdote provided was to the effect that, for what ever reason, the prehospital airway wasn't working properly (be it manufacturing defect, less than optimal placement, less than optimal use after placement, who knows? My intent is not to slam the crew with this statement) and could have contributed to the final outcome of this case. True, if getting more survival to admission improves hospital care of post arrest patients, it's good. However, just because the patient survived to admissions doesn't mean that the threshold hadn't already been passed with the outcome being inevitable regardless of the care received in the hospital. Of course the issue with the airway could have had absolutely no negative effect anyways.

Yes, the claim is that the prehospital airway wasn't adequate, and that tracheal intubation would have been superior. For the record, the patient was an obese female with an estimated Mallampati score of 4. However, the ED physician claims it was an easy intubation. In addition, the claim was made that had the patient been intubated, the EMS crew wouldn't have lost ROSC several times, because once the patient was intubated, ROSC was sustained. 

 

So, rather than throw the King LTS-D in the garbage, I'm trying to determine whether or not adding a gastric tube and suctioning the stomach might improve the overall effectiveness of the airway. My previous comment about how EMS could arrive in the ED with a tracheal tube in the right place (but a dead patient) had more to do with previous resuscitations I've witnessed where chest compressions were interrupted while 3 or 4 attempts were made, or there was an unwitnessed esophageal intubation.

 

Clearly waveform capnography will tell us if there is an esophageal intubation, but I don't think it's clear that tracheal intubation by inexperienced providers is superior to surpaglottic airways for cardiac arrest patients. That's the crux of the argument, and because paramedics are sensitive about their airway skills (or lack thereof) I don't think comments like "what's wrong aren't you confident?" are helpful (sorry, Matt -- I don't mean to direct that specifically at you because a lot of people feel that way). Step 1: Admit you have a problem. Or, prove you don't.

 

Tom



Tom Bouthillet said:
My previous comment about how EMS could arrive in the ED with a tracheal tube in the right place (but a dead patient) had more to do with previous resuscitations I've witnessed where chest compressions were interrupted while 3 or 4 attempts were made, or there was an unwitnessed esophageal intubation.

Ah, ok, I see where you're going at now. My issue (in general, not directed specifically at you) is that too many people at all levels shy away from mistakes. No one will ever provide 100% perfect care 100% of the time, albeit that doesn't mean that we shouldn't strive for it. While true, there is an area past optimal care that falls into "good enough," but the further you (generic "you") get from optimal, the more likely someone should speak up. Mistakes are not a problem. We all make them, even if we chock one every once in a while to a brain fart. However repeated mistakes, or worse, unrecognized mistakes (you can't fix something you don't know is broken) is a problem. We all fail at something every day. The issue isn't failing, but what we do to rectify it.

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