Check out this video to see a King LT inserted.
After we adopted the King tube a new protocol was written. This was to be used as a primary airway device in the cardiac arrest setting. The idea is that you can obtain an airway during much-needed chest compressions. This, in conjunction with our new ResQPods, should improve our save rates for sure!
Now down here, our system runs EMS transport only. We are not a fire service, but respond in conjunction with the many local fire departments. These fire departments consist of some ALS and some BLS providers. I am fortunate enough to work in a sector with ALS fire departments. They respond to every call, which is kinda overkill, but we become teammates.
We are also stationed together, and as you can imagine, share many a conversation. Recently, the topic of the King tube has been quite a big one. This particular FD does not share our medical director. This particular FD also happens to have a training officer, ex-EMSer, that loves to bash EMS. So me and a couple of firefighter-paramedics engaged in a discussion on this topic.
These two firefighters are both young as well, one only being a medic for a year. There have been a couple times where they have decided to question my treatments, which I have no problem with, an argument has never ensued. The problem I had with the discussion was that, every time I would site factual research to dispute their anecdotal evidence, they would get heated. Instead of listening to the facts, they just wanted to argue their opinion. I understand where they are coming from. Sometimes you see something happen with your own eyes, so who needs the science to back up your opinion. Well we practice evidence-based medicine, so we do need the science.
Their argument became one against EMS. "Just because you guys can't intubate, it doesn't mean we can't". "The combi-tube is way better". "Maybe we should be handling transport". They then made a statement, "if you look up our missed intubation averages compared to EMS,
"I guarantee EMS has way more missed intubations". This had nothing to do with my argument. I don't care how great you are at endotracheal intubation, I will still get that King tube in them faster, and during chest compressions.
I am not against ET intubation, but in the setting of cardiac arrest, the King tube is a better choice.
I decided to present the research to them, so they could see I wasn't talking out of my ass.
The use of the laryngeal tube disposable (LT-D) by paramedics during out-of-hospital resuscitation-an observational study concerning ERC guidelines 2005.
SUMMARY: In the current guidelines of the European Resuscitation Council (ERC), tracheal intubation, as an instrument for securing the airway during resuscitation, has become less important for persons not trained in this method. For those persons, different supraglottic airway devices are recommended by the ERC. The present investigation deals with the application of the laryngeal tube disposable (LT-D) during pre-hospital resuscitation by paramedics. [...] CONCLUSION: As an alternative airway device recommended by the ERC in 2005, the LT-D may enable airway control rapidly and effectively. Additionally, by using the LT-D, a reduced "no-flow-time" and a better outcome may be possible.
Using a laryngeal tube during cardiac arrest reduces "no flow time" in a manikin study: a comparison between laryngeal tube and endotracheal tube.
In 2005 the European Resuscitation Council published new guidelines for advanced life support. One of the issues was to reduce the "no flow time", which is defined as the time without chest compression in the first period of cardiac arrest. In a manikin study, we evaluated whether using the laryngeal tube instead of endotracheal intubation for airway management during cardiac arrest could reduce the "no flow time". [...] CONCLUSION: With regard to the guidelines of the European Resuscitation Council, we are convinced that during cardiac arrest supraglottic airway devices should be used by emergency personnel unfamiliar with endotracheal intubation.
They didn't want to listen to the facts, and one of them stated that these studies are biased. Maybe they are, but you cannot dispute the fact that applying an airway device during chest compressions is far superior to having to stop compressions for intubation.
DeDoncker "Cardiologist supports continuous chest compressions", October 2008
“When you stop for four seconds, the blood pressure drops. If you stop for eight seconds, it drops more,” Harner said. “And, when you stop for 12 or 16 seconds, there is no profusion and when there is no profusion it takes almost 15 compressions to build back up so why stop when you can keep going.”It just bothers me when someone's personal opinions like, "I am better than you" and "they are just trying to take intubation away from us", cloud their ability to be a true advocate. I am pretty sure that these individuals don't do any research outside of work and probably very little when they are at work. They want all the responsibility of providing ALS care but they refuse to educate themselves. I try not to get into arguments at work and I attempt to engage in an educated discussion, but this was futile.
Cartoon found at www.artstudio7.com
*****Update May 4, 2009*****
Here is another pretty recent study I found on the use of the King LT:
INTRODUCTION: In 2003, the King Laryngeal Tube (LT) received FDA approval for US sales. Prehospital systems in urban setting have begun evaluating and adopting the LT for clinical airway management. However, it is not routinely approved by State EMS Boards for use by all prehospital providers. Given the LT's simple design there may be benefit to using this tool for airway management in all levels of prehospital providers. This pilot study reviews cases where the King LT was used in a rural Iowa county EMS system. METHODS: In 2006, the Iowa Department of Public Health / Bureau of EMS approved a 12 month pilot evaluating the King LT by all levels of EMS providers in a rural county EMS system. Following a didactic and competency training session on using the King LT, the providers were instructed to continue airway management per usual protocol but were allowed to use the King LT as a first line airway tool if they felt indicated. Successful placement of airway devices used were determined by colourimetric end-tidal CO2, chest auscultation and rise as well as vital sign and skin colour improvement. Review of the data was approved by the University of Iowa Institution Review Board (IRB). RESULTS: During the 12-month pilot period, the King LT was used in 13 patients with a mean age of 60.7 years (24-81). All patients had cardiopulmonary or traumatic arrest. The King LT was successfully placed on the first attempt in all but one case. The King LT was placed following endotracheal intubation failure in 6/13 (46.1%) cases and in 3/13 (23.1%) of cases of Combitube attempt / failure. CONCLUSIONS: This small pilot project emphasizes the need for additional rapid airway management tools given the demonstrated ETI failures. The authors believe the King LT has significant potential to impact prehospital airway management as a primary airway device or backup to other failed strategies. Further study is necessary to evaluate the LT's efficacy compared to current strategies.
*****End Update*****
2 comments:
With the availability to utilize so many different airways now I believe we will see the end of intubation in the field very soon...and its death knell has already sounded in many areas. Many will scream to the bottom of the fall about it...but the reality is... the quality of airway maintenance with the King or LMA really precludes the necessity of intubation in the field. I have been "tubin'" for years but there are times, especially now that I have RSI (and in some areas RSA - the "A" being for airway, which ever is used) is becoming so prevalent that unless a medic works in a very busy system where they tube all the time, the skill is easily lost. And we all know how diligent every medic is about keeping up their skills :o
My personal policy in the field (and my company's, as I own a small side EMS company that does Special Event EMS) is if the tube isn't hit first time go to a King or LMA and be done with it. This is especially true in cardiac arrest situations. Here, we have been using CCR for many years, and the most valuable lessons are saving time and concentrating on the basics. Much valuable time is wasted in a code if medics are more concerned about "gettin' the tube" than keeping up good compressions and appropriate electric/drug therapy.
I only use the King LTS-D's as they work very well, they're easy to insert without the necessity of multiple syringes to fill lumens, take up far less space in a tube roll, and they can also be suctioned through. And, if you get the chance, get your medical director to let you do a field study, only if you have capnography, and set it up so that you can evaluate the oxygenation of both airways (King and intubation). Then compare the ABG's when they arrive at the ED. You will be quite surprised at the results and may also make you rethink the "necessity" of keeping intubation in your system. Sometimes we have to evaluate when some of our skills are more ego than practical. I'm sure that that will upset some of my fellow "old timers!" :)
Maybe they are, but you cannot dispute the fact that applying an airway device during chest compressions is far superior to having to stop compressions for intubation.
DeDoncker "Cardiologist supports continuous chest compressions", October 2008
“When you stop for four seconds, the blood pressure drops. If you stop for eight seconds, it drops more,” Harner said. “And, when you stop for 12 or 16 seconds, there is no profusion and when there is no profusion it takes almost 15 compressions to build back up so why stop when you can keep going.”
I believe that your argument is sound, however I would not use this quote from "Harner" to back it up since this individual does not even know the difference between "perfusion" and "profusion".
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