Backup airways: which to keep in the ALS bag?

[chbare]

I think we have gone a little off topic; however, I enjoy the discussion.

With all of this arguing, I think we must accept a few facts:

Many physicians and groups are advocating the use of "alternative airways" in place of traditional tracheal intubation. Even the AHA states in their published provider manual that "it is acceptable to use the ETC as an alternative to an ET tube for airway management in cardiac arrest." AHA also states, "This device (ETC) provides adequate ventilation comparable to an ET tube." The AHA also has similar statements regarding the LMA.

Regardless of your agreement to the AHA, many people tend to follow and advocate AHA recommendations. I am not saying that the trend is a good one; however, this is the way things are moving. Heck, in my state, first responders are allowed to place LMA's and ETC's. In spite of our personal views, many people who have the power to institute policy seem to advocate this approach to airway management. In addition, there is allot of data that supports the use of "alternative airways." I attended an airway conference in the last year and a well known flight company medical director drafted and put into place an RSA (Rapid Sequence Airway) protocol that has been used. In essence, you administer the same meds as an RSI, but opt to place an "alternative airway" in place of traditional tracheal intubation.

So, in a sense AZCEP is correct with his points. This is a hot topic and I think it will only intensify.

Take care,

chbare.

[VentMedic]

Endotrachel Intubation with an ETT is still the optimal way to establish an airway at least after ROSC. However, it is now shown that skills are not maintained to be proficient at establishing this airway in the prehospital setting.

The guidelines set by the AHA concern CPR. In the hospital, the BVM and/or LMA might be used for a short period of time only during CPR. If ROSC is restored, the ETT goes in. There are many other instances where the LMA or Combitube will not be appropriate as in anyone who may still have a gag reflex. The CHF and COPD patients near failure may fall into that category. For those patients, the BVM may be your only choice until someone who is skilled (or more skilled with more tools and protocols) in ETI is available. Inside the hospital we do have more ways of facilitating ETI because Combitubes, Kings, LMAs or whatever "rescue" device can not go on a ventilator. Our skills have to be maintained. Period.

http://circ.ahajournals.org/cgi/content/fu.../24_suppl/IV-51

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Part 7.1: Adjuncts for Airway Control and Ventilation

[Scaramedic]

If a patient is tolerating an OPA, they need a definitive airway such as an ETT. An OPA is not to be left in the patient for any length of time due to aspiration risks. It is used primarily when using the BVM until ETI is performed. It is also not to be left in after ETI unless absolutely necessary or you have no other tube guard to protect against clenching teeth.

Let me give you one quick scenario of the situations I am talking about in this post. A heroin OD who is apneic or damn near apneic. Rather than intubate and then extubate after a bolus of Narcan I prefer to drop an OPA. The patient can be bagged effectively and the OPA can be pulled easily after their LOC increases.

Peace,

Marty

[chbare]

Correct, the current AHA modalities only apply to the arrest situation. However, people seem to be pushing this into more aspects of airway management. I do not disagree that ETI will produce a more secure airway when properly performed; however, the trend appears to be moving away from ETI as a means of managing the airway in several areas. As more people utilize these "alternative airways" we will see more data on their use. I am curious to see how patient outcomes will change.

I do not see people receiving proper airway education however. I see less OR time and less "real" intubations related to many anesthesia providers having concerns with liability and crowding of the OR's. (students) In addition, many cases are performed with the use of a supraglottic airway device. So, where does this put us as pre-hospital airway providers?

I am curious to see where this will all end up.

Take care,

chbare.

[tniuqs]

Let me give you one quick scenario of the situations I am talking about in this post. A heroin OD who is apneic or damn near apneic. Rather than intubate and then extubate after a bolus of Narcan I prefer to drop an OPA. The patient can be bagged effectively and the OPA can be pulled easily after their LOC increases.

Peace,

Marty

Marty: One can find a scenario for everything and we should be looking at the BIG picture thing is about your scenario is your assuming it is a heroin OD, what if it is a mixed OD...and you just complicated an Airway capture opportunity?

The real question in my mind is do we use alternatives in airway protection, when the real question is do we generally allow other groups to dictate and test their theories... a TECHNICIANS approach. OR do we assure a HIGH LEVEL of skill/ competency as a Paramedic Practioner, there is a huge difference here.

As for basic levels having the ability and latitude to provide improved airway protection...hey I am ALL for that, because why you may ask....in most cases these are cadavers that they are practicing on....and a coarse as that may sound it will advance the more basic levels to promote better care in their communities.

cheers

[Scaramedic]

Good points Tniuqs though I should of added part of the reason I choose that approach is high probability that we are not going to transport after reviving an OD. More and more I am finding hospitals (who are increasingly overloaded and understaffed) are not appreciating the old approach of bringing the patient back to A to V and then letting them sleep it off in the ER. So more and more I am bringing them back to A&O and letting them decide transport, most are refusing and PD doesn't really give a damn anymore to arrest.

If the Narcan doesn't work then I can upgrade the airway to ETI. I would also like to see some new airways to give us more of a choice. I do not like the new alternatives though, maybe I am to old school.

LMA- Trained in these by an Anesthesiologist who absolutely loved them. Then again he (by his own admission)rarely deals with trauma. I haven't used it yet but I am still a little iffy on it.

King LT - Not in our system yet.

Combitube - My favorite backup, only used it a couple of times though.

PTL - Never used it, not in my system.

Personally I would like to see a combo BVM/Combitube type pharyngeal device, no not an EOA, but something quick and easy to use. Something minimally invasive that can secure the trachea quickly and be used by any level of EMT.

I agree it shoudld not be a protocol issue but a provider using his education and experience to decide the airway. Unfortunately lots of people do not like to use their noodle.

Peace,

Marty

[tniuqs]

The Bougie is MY favourite aid, and its cheap like cabbage like 10 bucks?

cheers

[1EMT-P]

I have been using the Combitube since 1994 and I have not had any problems with it. I think it is a good alternative airway device. The LMA is a good device if your patient has been NPO, but lets face it most of our patients have not been NPO and are at high risk for vomiting.

If I had to rate the alternative airways I would say: 1. King, 2. Combitube, 3. LMA & 4. PTL.

[Paradude]

Try to intubate... try hard. Get your partner to try. If unsuccessful, then consider a surgical cric. We're talking about airway aren't we? Shouldn't we stop &^%*ing around and get it done?

-Paradude-

[chbare]

Well, I guess you could go that route. However, if you had a highly effective rescue option that did not involve cutting, would you not consider utilizing that option?

Take care,

chbare.