King LTS-D

[flyin dutch]

So what er "training" does the basic level receive in regards to a successful out come if they have to extubate ? That said: Thing is in most situations is basics are inserting these devices in cadavers, so really what's the harm?

The only training is: if the patient wakes up, DEFLATE and remove that puppy ASAP! I'm sure none of us would be too happy to awaken with that gob of PVC in our throat. On to the patient who survives, but doesn't wake up and does tolerate the Combi--what to do in hospital??? I think the onus of changing out an intermediate airway to a definitive airway falls to the OR/Anesthsia staff at the receiving hospital. I'm sure there will be an outcry for my saying this, but the fact remains . . . these Combitubes are out there and being inserted by FR's, EMT-B's, etc, and I don't think that will be changing anytime soon (especially in rural EMS). Let me defend that comment . . . I have seen an ER physican insist on changing out a working, adequately-ventilating Combi for an ETT in the ER only to fail to place the ETT and send the previously quite viable patient into full arrest :shock: :evil:

Good point on the cadavers, though--the majority of the time the Combi-tube is just one more thing the coroner gets to remove during the exam.

The King Lts-D is actually classified by the FDA as an OPA, putting them in every EMS provider's scope of practice.

I bet the first court case will change that error !

This a definitive "invasion" of the body so to speak, and with a blind inflation of cuff as well:

No IV access? (as in a trauma arrest?) so whats the point here ?

No IV meds?

No background in ETCO2 ..... its sounding kinda sketchy to me .

Ya . . . when I first started checking into the King tube, the FDA/OPA thing is what I was told. The State of Iowa has no protocol regarding the King tube and I haven't gotten a commitment on whether they're going to write one. And so, if the state requires "documentation of training" and "medical director's approval" to use the King tube, where do I get training that is adequate and accurate. All of the above pending that I find enough evidence to support replacing the Combi with the King? In the limited experience I have with them, I do think that the King tube is more "user-friendly" than the Combi and less barbaric to the patient.

I do have a question though . . . is there research out there showing that use of a Combi or some other intermediate airway has been detrimental to patient outcomes when there is no advanced airway management immediately available? That last part is the operative phrase . . . Because there is A LOT of rural EMS where they don't have any ALS available and in their cases, I do believe the Combi/King IS the next best thing. That being said . . . a BLS service with GOOD skills (oral, nasal airways and BVM) is far better than an ALS service with POOR skills (and I'm sorry, but it's very difficult to be good at ALS when you get 1 intubation a year!!!!!). I think there's quite a few rural EMS squad who have 1 or 2 ALS providers and see only a few runs a year--how do they keep up their skills? In those cases I'd rather see them dump in a Combi/King, etc than fail an intubation because they haven't done one for a year and a half. Anyway, that's just my $.02 on that.

Thanks for your help with the research . . .

[chbare]

It is a sad day when we look at patients as cadavers IMHO. Look, we have two kinds of arrest patients. Either we have somebody who we think is viable and may benefit from our care, or we have a dead person. If you are dead, then a King, ETT, or whatever simply will not help. If you are a potentially viable patient, then you should receive appropriate care. I do not understand the, "well the guy is already dead so this really will not hurt him anyway" argument. I can only assume it is simply about letting somebody perform a cool guy skill.

Are rescue airways appropriate care? Much depends on how you define appropriate. However, simply taking away the only option that is considered a true definitive airway and replacing it with a method that is not definitive sets a dangerous precedent IMHO. I understand many ALS providers may not do many field intubations. The company clinical coordinator should ensure that paramedics are getting tubes. I understand the difficulty with getting into the OR; however, companies must be much more proactive and advocate for their ALS provides. Otherwise, the company sucks.

Take care,

chbare.

[tniuqs]

It is a sad day when we look at patients as cadavers IMHO. Look, we have two kinds of arrest patients. Either we have somebody who we think is viable and may benefit from our care, or we have a dead person. If you are dead, then a King, ETT, or whatever simply will not help. If you are a potentially viable patient, then you should receive appropriate care. I do not understand the, "well the guy is already dead so this really will not hurt him anyway" argument. I can only assume it is simply about letting somebody perform a cool guy skill.

There was a small component of sarcasm in my origional comment, if one looks to the quite abismal outcomes ie OPALS study in out of Hospital arrests .... really the conclusions drawn boil down to the response times of the ALS (we knew this before) therefore in rural areas with only BLS providers available in lets say > 98 % of arrests were called DOA, so 98 % of the LT/Combi tubes WERE inserted in cadavaers .... if your following current stats in Out of Hospital cardiac arrests, the cool guy concept really does give false hope to the families in many situations and can endanger more lives .... those of your co-workers.

Are rescue airways appropriate care? Much depends on how you define appropriate. However, simply taking away the only option that is considered a true definitive airway and replacing it with a method that is not definitive sets a dangerous precedent IMHO. I understand many ALS providers may not do many field intubations. The company clinical coordinator should ensure that paramedics are getting tubes. I understand the difficulty with getting into the OR; however, companies must be much more proactive and advocate for their ALS providers

Good points all, but we need evidence based medical studies to prove or disprove your query.

The only training is: if the patient wakes up, DEFLATE and remove that puppy ASAP! I'm sure none of us would be too happy to awaken with that gob of PVC in our throat. On to the patient who survives, but doesn't wake up and does tolerate the Combi--what to do in hospital??? I think the onus of changing out an intermediate airway to a definitive airway falls to the OR/Anesthsia staff at the receiving hospital. I'm sure there will be an outcry for my saying this, but the fact remains . . . these Combitubes are out there and being inserted by FR's, EMT-B's, etc, and I don't think that will be changing anytime soon (especially in rural EMS). Let me defend that comment . . . I have seen an ER physican insist on changing out a working, adequately-ventilating Combi for an ETT in the ER only to fail to place the ETT and send the previously quite viable patient into full arrest

Good point on the cadavers, though--the majority of the time the Combi-tube is just one more thing the coroner gets to remove during the exam.

We AGREE these Airways have ONLY been looked at the "insertion" criteria, my reasoning in all this comes from more of a historical perspective with the use of the EOA ... which was a great idea at the time (pre ALS in Edmonton Alberta) but the post insertions complications became such huge contraversy within the medical community and they were pulled off the cars, never to return ..... well until the advent of the Combi .... wierd that history repeats itself ? Just my crystal ball working overtime but this may become the fate of the use of the Combi/King LT as a primary airway. Quite odd because one can remove the Mask component with the EOA, the HOLE is still Obturated hence only one other choice for the ETT to go ?

In the King and Combi there is a even a greater possibillity of Aspiration .. so best get that SUPER DUPER peas and carrots sucking Portable Suction Device "RIGHT HANDY" :oops: :shock: Having another system comprimised ie "Pulmonary" (in the resusitation period) and rule of thumb = another 20 % AGAINST discharge to door and that's the just the ICU perspective.

I personally @ the BLS level ans shot an EOA, did have one patient survive from asystole with no neurological deficits and walked out of the hospital ! whoo hoo.

BUT VERY, VERY RARE ! just as an anecdote in passing. :roll:

cheers

[chbare]

I agree with your first statement. However, why put a King in a dead person? I simply do not agree with the whole "well it can't hurt so let's do it" concept. Even the AHA is deemphasizing the whole airway management concept for good chest compressions.

I think I understand your point as such: the only situation where BLS providers will place a rescue airway is in an unresponsive patient without a gag reflex. I would agree that most patients who meet this criteria without chemical intervention will not have a pulse. Perhaps I am incorrect in my thinking? I still cannot see how the King used as the sole airway for these patients will help, if in fact good CPR seems to be much more important to the outcome in the arrest patient.

I like the fact that you want evidence to backup claims; however, some things are quite obvious. For example, you see a pile of steaming hot poop on the floor. The smell causes you to gag and looking at it causes your stomach to churn. A research grant followed by a study is really not needed to prove that it will taste bad. However, I would not be surprised if such a study exists.

This concept is my point. There are patients who simply cannot be managed with supraglottic airway devices. Look at an asthma patient with peak pressures of 50 or more, or perhaps a liver failure patient who is 18 months pregnant with fluid and has the highest portal pressures you have ever seen. Then notice the massive amounts of blood that they are spewing from their mouth. This is why I think simply taking intubation and RSI out of the ALS providers scope and substituting "alternative airways" would set a dangerous precedent.

Take care,

chbare.

[flyin dutch]

Taking RSI/ALS away is not at all what I was suggesting, not sure about anyone else :oops: Rather, I was emphasizing that in some places, the best care available is an intermediate level, and why shouldn't they be able to use a Combi/King. I personally had never had any dealings with the EOA, it was gone long I started in EMS. Until later . . .

[Dustdevil]

I was emphasizing that in some places, the best care available is an intermediate level, and why shouldn't they be able to use a Combi/King.

I'll do you one better.

Why shouldn't they just get paramedics?

And don't say they can't afford them, or you're banned.

[tniuqs]

I'll do you one better.

Why shouldn't they just get paramedics?

And don't say they can't afford them, or you're banned.

I was wondering, when dustdevil would put in his 4 cents, AGREED !

[Spock]

Lots of good comments here and I have been on record as being a huge fan of the King. I've been using it in the OR for two years now as a primary airway (instead of an LMA) with minimal problems. I have had a few patients that I couldn't get the King placed but that is also true of the LMA. No device is 100% fool proof.

Flyin dutch makes a good point about evidence based literature and what is currently available is limited and biased because of manufacturer support. I do know of several studies that will soon be published that demonstrated subjects with minimal medical training can quickly place the King in a mannequin. Also, the latest edition of Prehospital Emergency Care is supposed to have an article about the King but I haven't seen it as of yet.

I do think if you can place an OP airway you can place a King. A monkey can be taught how to intubate or place a King or OP or combitube. The trick is you have to teach the monkey WHEN to do any of the above. Different story. I have said before that I thought the King could be a BLS skill but I now recognize the limitations of that because of the many comments on this site. You guys are right.

I used a King just the other night. 14 year old was unresponsive and had agonal respirations. I arrived on scene just as one of the medics was intubating. His skills stink and of course he put the tube in the goose. I took over and bagged her until her color improved and her sats came up. Scene time was already about 15 minutes and she wasn't doing well. We were on the second floor in a small bedroom and intubating was going to be difficult because of limited space. I thought about just bagging her while we carried her out in the reeves and then tubing her in the truck. Instead I placed a #3 King and was able to carry my end of the reeves while also bagging her while we went down the steps to the truck. In the truck I thought about changing the King for an ETT but her sats were 100%, ETCO2 was 36, we had good compliance and breath sounds were clear and equal. I figured the only thing I would do by changing the tube was make things worse so I left it alone.

I hate having to change a combitube in the ER and would much rather change a King. Most of our ER docs don't want to deal with it so they call anesthesia to change the things if the patient has survived to the point where they are admitted. If either a King or combitube is in a cardiac arrest patient they leave it alone as long as they are ventilating easily. If there is no ROSC they just call the code and leave whatever airway device is in place.

Live long and prosper.

Spock

Live long and prosper.

Spock

[akroeze]

I'm in the ACP program. The PCP only service in the area I'm doing my hospital clinicals in insert LMAs on arrests. Any arrest I've seen them come in with the physician leaves it up to the RT to decide what to do (they are the experts after all). Every time they keep the LMA in until they have signs that it is no longer effective for one reason or another then they switch it out.

[flyin dutch]

I was wondering, when dustdevil would put in his 4 cents, AGREED !

I agree, too--in a perfect world, everyone WOULD have paramedics and we wouldn't be having this discussion . . . but as we all know, this isn't a perfect world. Many of the places I fly have only a clinic with maybe an MD but most of the time a PA-C or NP is the highest level of provider. And then to expect that same community to be staffed with paramedics? It's not going to happen!

Regards