Removing an LMA and performing intubation

[Nova1300]

Agreed. An RSI certainly would have been the right thing in this case, but as I mentioned, no RSI or any pharmaceutical assistance, no VL and no help if things went pear shaped. In this case, a King was the right choice.

Caught. I didn't read that far down.

 

[Tigger]

But why? What's the deal with paramedics not providing advanced airways to our patients just because a BLS airway is "working" The ED is going to place a ET tube the moment you get in there so why not just do it right the first time. "There's only 2 ways to do things, the right way, or again"

I'm not sure why working is quotes. Are you able to ventilate the patient effectively? Isn't that what matters above all? And doesn't a King occlude the esophagus?

 

[VentMonkey]

Perhaps the op was a tad in over his head when he began this thread, nonetheless, it sure did spark some insightful dialogue

 

[SpecialK]

If the LMA was working well and hospital was close (i.e. five to fifteen minutes away) I would leave the LMA in place.

What will make the difference is whether the patient can be oxygenated, not how they are oxygenated.

 

[Harleyjon]

I am very new to all of this medical stuff, I have only been a paramedic for a year. I also only had a little more than a year as an EMT. I spent 30+ years as a mechanic (cars, trucks, motorcycles). In my years as a mechanic I found that that there is a WHOLE LOT OF TRUTH to the saying "If it works, don't fix it". I have also learned that God gave each of us a brain and it is the responsibility of each of us to use it. I have learned that you are left handed and I am right handed and the way you hold something I would have a very hard time doing, and vice versa. I understand that the job we all have is the same but the method of implementation each of us use is most likely somewhat different.
I remember a self inflicted GSW to the head. The man had a pulse (78bpm) and was breathing, albeit very shallow and maybe 4-5bpm. The mans jaw was clenched very hard and it was all we could do to use a bite block to open it enough to insert an OPA and start bagging the guy. I honestly don't remember the room air O2 but bagging him we achieved 98-99% with oxygen. Our protocols do not allow RSI but they do allow Med assisted intubation (Of which I have very limited knowledge and no experience). We had a 20-25 min T/P. After all other interventions were taken care of (IVs, fluids, monitor). I rechecked his jaw and he was clenching hard. He still had 98-99% O2 and NC ETCO2 showed 40+ we decided to run him in as is. Was I right or wrong, I do not know. The only thing I know for sure was that when we arrived at the hospital he still had a pulse, His color told me that he was still perfusing decently for his situation. Capnography was still showing 40ish.
I am certain that someone else would have run that call differently. The man did not make it in the end. Should I have halted T/P to "get a better airway"? Somebody correct me if I am wrong but with the SPO2 and ETCO2 that I had I felt that his best chance came when I got him to a higher level of care. I am constantly studying and learning new stuff and today I might handle a similar situation differently.

Jon

 

[Akulahawk]

I am very new to all of this medical stuff, I have only been a paramedic for a year. I also only had a little more than a year as an EMT. I spent 30+ years as a mechanic (cars, trucks, motorcycles). In my years as a mechanic I found that that there is a WHOLE LOT OF TRUTH to the saying "If it works, don't fix it". I have also learned that God gave each of us a brain and it is the responsibility of each of us to use it. I have learned that you are left handed and I am right handed and the way you hold something I would have a very hard time doing, and vice versa. I understand that the job we all have is the same but the method of implementation each of us use is most likely somewhat different.
I remember a self inflicted GSW to the head. The man had a pulse (78bpm) and was breathing, albeit very shallow and maybe 4-5bpm. The mans jaw was clenched very hard and it was all we could do to use a bite block to open it enough to insert an OPA and start bagging the guy. I honestly don't remember the room air O2 but bagging him we achieved 98-99% with oxygen. Our protocols do not allow RSI but they do allow Med assisted intubation (Of which I have very limited knowledge and no experience). We had a 20-25 min T/P. After all other interventions were taken care of (IVs, fluids, monitor). I rechecked his jaw and he was clenching hard. He still had 98-99% O2 and NC ETCO2 showed 40+ we decided to run him in as is. Was I right or wrong, I do not know. The only thing I know for sure was that when we arrived at the hospital he still had a pulse, His color told me that he was still perfusing decently for his situation. Capnography was still showing 40ish.
I am certain that someone else would have run that call differently. The man did not make it in the end. Should I have halted T/P to "get a better airway"? Somebody correct me if I am wrong but with the SPO2 and ETCO2 that I had I felt that his best chance came when I got him to a higher level of care. I am constantly studying and learning new stuff and today I might handle a similar situation differently.

Jon

Good numbers, good color. Patient still has a pulse and (I'm sure) the ED probably knew this well before your arrival... Yes, they probably RSI'd him nearly immediately on arrival. Doesn't mean you didn't do right by the patient. Incidentally, if you're in this situation, best to call the ED early so they can get RT, a vent, a room, and the like all ready ahead of time so they can do their assessment and airway management easily and early.

On the whole, not bad. Perhaps if you were more familiar with a med assisted intubation or if this patient qualified for NTI (if allowed in your system) or a ton of other options... you might run this call differently in the future but at least you had a good effective airway in place, even if it wasn't exactly "secure". My only concern is the possibility of gastric insufflation with BVM ventilation, but it sounds like you probably avoided most of that problem.

 

[Akulahawk]

Something that hasn't been touched on in this thread is the possibility that some SGA's will allow an ETT or a bougie to pass through it into the trachea and then will allow the SGA to be removed. Otherwise I'm pretty much in agreement with the idea of "ain't broke, don't fix it" because if I've got something that is working reasonably well, I'm going to be fairly reluctant to change things up unless I'm reasonably confident that I can improve the situation by switching to a different airway management tool.

 

[SeeNoMore]

I understand the general idea of "not broke don't fix etc". However, if you are not delaying transport and have providers present with experience and the right tools (equipment, meds etc) , I wonder if it is not reasonable to provide a more secure airway. This touches on a broader discussion on how significant the risk of aspiration is in the prehospital population vs the risks of RSI/intubation in the field. Common wisdom of course suggests that leaving a King Airway or other device in is essentially signing a death warrant and placing an ETT is the greatest life saving gift you can ever give. Reality of course does not often correlate with the opinions of Paramedics.

 

[Carlos Danger]

I understand the general idea of "not broke don't fix etc". However, if you are not delaying transport and have providers present with experience and the right tools (equipment, meds etc) , I wonder if it is not reasonable to provide a more secure airway. This touches on a broader discussion on how significant the risk of aspiration is in the prehospital population vs the risks of RSI/intubation in the field. Common wisdom of course suggests that leaving a King Airway or other device in is essentially signing a death warrant and placing an ETT is the greatest life saving gift you can ever give. Reality of course does not often correlate with the opinions of Paramedics.

The two sentences that I highlighted above represent the crux of the whole debate over field intubation. Yes, we've always been taught that aggressive airway management is the most important thing you can do for your patient. We were also taught that spinal immobilization and maintaining a normal BP in your trauma patient with MAST pants and and 2 large-bore IV's was important. I think it is an interesting contrast between how enthusiastic most paramedics are about "the evidence" when it means they can abandon doing things that they don't like doing (KED-ing every patient involved in a parking-lot speed MVC), as compared to what the evidence says about the sexier interventions (RSI-ing everyone who appears to have a head injury).

Here are a few of the things that are in the forefront of my mind whenever I consider these issues:

• Field intubation has never been shown to improve outcomes (in case I've never mentioned that ), despite numerous attempts at demonstrating that it does. I'm pretty confident at this point that if it worked, it would have been demonstrated by now. Does this mean that it is never indicated? No, but it does mean that it should not be routine.

• Following point number 1, systems that do not have RSI do not have worse outcomes than systems that do.

• Also following point number 1, intubation in the field has never been shown superior to SGA placement.

• The risk of aspiration is very much exaggerated, I believe. However, when the risk of aspiration is often brought up as a justification for aggressive airway management, the risks of RSI are virtually never mentioned.

• In my 18 years as a paramedic and over 1000 HEMS transports and several years as an ED nurse in a level I trauma center, I have only seen really difficult to manage emesis a few times. I have seen complications from intubation attempts much more often.

• VL is a game changer, making intubation much easier across the board. I don't think that has much bearing on this debate though, because in most of the literature, success rates are actually high, so the problem isn't that we aren't getting the tubes, it is other things.

• Improved supraglottic devices are also a game changer.....over the next decade or so, I think they will have a bigger impact on field airway management than VL does.

• "They are just going to have _____ done when they get to the ED, so we might as well do it now" is not a reasonable justification for doing anything to a patient. The ambulance is not the same as an ED, and a paramedic / EMT crew is not the same as an entire ED staff led by a board-certified EM physician who has many resources at hand.

 

[StCEMT]

I don't feel like counting, but I have 10+ hospitals within the area I work. It does not take me long to get to a hospital at all, even driving non-emergent. So if I have a relatively short transport time and the patient is adequately oxygenating and perfusing then why do I care what method that is done by? Recently had a person my partner probably would have intubated, but we were about 2 miles away. By the time he would have gotten ready, I was already at the entrance.

 

[VFlutter]

I have only seen an I-Gel a few times but don't they have a channel to pass a gastric tube? If it makes you feel better just drop a OG and decompress the stomach.

To add to what Remi said, I have seen many patients with LMAs (procedural) or bagged for prolonged periods of time and emesis is rarely an issue.

 

[Alan L Serve]

Are you removing an LMA from a live patient? Are they conscious? Did you put in the LMA while they were eating breakfast or lunch?

 

[palmer1121]

Technically the answer is easy. Is the SGA working? And do the benefits of removing it and intubating the patient outweigh the risks/complications?

But making that choice relies on good clinical judgement, without pride and ego. Judgement that takes experience and training that many people in this profession do not get unfortunately.

 

[ERDoc]

Don't do it. The ER doc wants that tube and you are taking it away from him. I think the right answer is that is depends and there can also be more than one right answer. There are so many variables that it is hard to give a set answer. Personally, I would never criticize a crew for doing it one way or another as long as either was done properly.

 

[SeeNoMore]

• "They are just going to have _____ done when they get to the ED, so we might as well do it now" is not a reasonable justification for doing anything to a patient. The ambulance is not the same as an ED, and a paramedic / EMT crew is not the same as an entire ED staff led by a board-certified EM physician who has many resources at hand.