Using the King Tube in Trauma

[jaksasquatch]

Hello guys,
Just entering my second semester of paramedic school. Trying to fine tune by thought process on the use of the King Tube. In my protocols I'm required to limit intubation to 2 attempts. My question is can the King Tube be used in Trauma? I'm not asking if it is contraindicated but is it effective for the short term management of an airway that may have some secretions, blood? Completely get the fact that it doesn't secure an airway but is it effective for management? I understand that if one couldn't ventilate AND couldn't intubate a trauma pt the next step is a cricothyrotomy. Keep in mind that the county I work in has an average transport time of 35 minutes to a receiving facility and 60-80 minutes to a Level I or II trauma center.

 

[NomadicMedic]

Sure, why not? When things are going sideways, any airway is good. In a trauma arrest, a king is a perfect airway for a code that probably won't have a positive outcome.

If the patient is viable, and you have RSI, and you NEED to secure an airway, an ET probably a better choice.

As a new medic, don't fall into the "I gotta get an ET" mentality. BLS airways and SGAs are tools in your airway tool box and there's no shame in using them.

 

[jaksasquatch]

Sure, why not? When things are going sideways, any airway is good. In a trauma arrest, a king is a perfect airway for a code that probably won't have a positive outcome.

If the patient is viable, and you have RSI, and you NEED to secure an airway, an ET probably a better choice.

As a new medic, don't fall into the "I gotta get an ET" mentality. BLS airways and SGAs are tools in your airway tool box and there's no shame in using them.

Only thing I keep thinking is if there are a lot of secretions and the king isn't giving me good ventilation/perfusion should I switch to something more drastic like a surgical cric (considering two ET attempts? More in a viable pt then a trauma arrest obviously.

 

[NomadicMedic]

Don't overthink it. Two failed ETT attempts is either an SGA or a surgical airway.

 

[COmedic17]

ET is the preferred method, but an airway is an airway. If an ET just isn't feasible/obtainable, there's nothing wrong with a BLS airway or supraglottic.


I, however, would not jump from 2 ET attempts to performing a surgical cric. You said you are concerned with "secretions" with the king- but if you have ever preformed a surgical cric- there's blood. Lots of it. It's messy. Your going to have far more secretions/blood in the airway after a cric then if you were to use a king tube. A cric is a last ditch effort.


If you are getting good compliance/ventilaton/lung sounds with an OPA, NPA, or a supraglottic ( when ET is unobtainable) then there's no reason to Cric.


BTW- if there's secretion in the king, you can suction with a French tip as you would an ET.

 

[Carlos Danger]

A properly placed SGA provides more airway security than we are taught. Not as much as an ETT, but ETT's are not infallible either. Its not as if ETT placement always works flawlessly and SGA's always fail. I think the real-world difference between the two in most prehospital airway management is probably fairly narrow.

I actually think the King should be the first-line advanced airway for most EMS systems.

 

[jaksasquatch]

ET is the preferred method, but an airway is an airway. If an ET just isn't feasible/obtainable, there's nothing wrong with a BLS airway or supraglottic.


I, however, would not jump from 2 ET attempts to performing a surgical cric. You said you are concerned with "secretions" with the king- but if you have ever preformed a surgical cric- there's blood. Lots of it. It's messy. Your going to have far more secretions/blood in the airway after a cric then if you were to use a king tube. A cric is a last ditch effort.


If you are getting good compliance/ventilaton/lung sounds with an OPA, NPA, or a supraglottic ( when ET is unobtainable) then there's no reason to Cric.


BTW- if there's secretion in the king, you can suction with a French tip as you would an ET.

Got it. It's more of a logical progression than I thought. Thanks guys.

 

[Ewok Jerky]

And that's why they make algorithms.

 

[systemet]

My question is can the King Tube be used in Trauma? I'm not asking if it is contraindicated but is it effective for the short term management of an airway that may have some secretions, blood?

Yes, you can do that. It will probably work in most situations, but you have to be aware that there are some fundamental limitations. If you need PEEP or high airway pressures to effectively oxygenate the patient, the King may not be the best device, because at a certain airway pressure you're going to bypass the cuff, and end up introducing air into the stomach.

The King is also not going to protect you from progressive airway edema. So, those hangings, caustic ingestions, and tracheal injuries can still progress to obstruction. That being said, I've seen a patient who ingested a large quantity of bleach who had a King LT placed (likely a genuinely difficult airway in an obese gentleman who would have been a difficult cricothyrotomy), for whom the King was lifesaving.

As you allude to, another risky scenario is when the patient is at risk of aspiration, but hasn't aspirated yet. One of our medical directors is fond of pointing out that most of the patients we see who have aspirated, aspirate prior to our arrival.

If you're doing RSI, then using the King tube should only be happening very rarely. I can't imagine a scenario where I'd take a King tube that's allowing me to oxygenate the patient well and go to a surgical airway. I think there's definitely a dangerous area where the patient could be satting in the mid-to-high 80's, where you have to decide whether to cut. A cricothyrotomy is far from a risk-free procedure, and you need to be confident that it's necessary.