Hi folks. From March 2013 Air Med Journal again…
I have written about this with Dr Darren Braude before on a podcast
Check out the references in the show notes for that podcast!
Ok , well this new study by a HEMS unit in Minneapolis tried to demonstrate that primary insertion of a King LTS-D with using RSI drugs ( Etomidate and Suxamethonium) was going to be better first pass success rate and time to achieve established airway compared with traditional endotracheal intubation ( they used historical controls).
Mean years of experience of the flight paramedics and nurses in this study was 15.9 +/- 6 years. Thats pretty experienced in my book!
Surprisingly, the results were not really different SGA vs ETI, with similar first pass success rates and time to successful airway.
6 patients in the study had a failed SGA attempt, 4 rescued with ETI, 1 with BVM and the last with surgical cric.
Vomit in the airway was reported as high as 46% , most commonly (29%)before insertion of SGA. This is not unusual in the prehospital setting and literature. At least they used a SGA with a gastric access channel to try to divert vomit away from the airway.
Pre and post SaO2 & EtCo2 values were not significantly different between primary SGA vs ETI techniques.
Cited reasons for failure of SGA placement were mainly facial trauma.
The authors conclude that this study does not support the concept of replacing ETI with SGA as a primary airway for Medication Assisted Airway Management ( MAAM). They suggest that primary SGA placement using drugs may be best selected for certain patient cases like need to protect cervical spine and keep head neutral position, or securing airway with patient in lateral position.
Take home messages:
- In prehospital setting, oral insertion of any airway device will have its limitations and facial trauma deserves particular caution, ETI or SGA!
- In this service’s hands with a paramedic and flight nurse crew, ETI ( historical control) or SGA technique using drugs to assist placement were equivalent in first pass success rate and time to establish airway. SaO2 and ETCO2 measures were equivalent pre and post placement of the ETI or SGA.
- There are several study limitations to note : small sample size, use of historical controls, timing data variability, no outcome measures esp in regard to pulmonary aspiration from vomitus in airway.
- The rapid sequence airway concept is a worthy one to consider adding to your airway skill set. Note how ventilation and oxygenation were equivalent between ETI and SGA in this study ( albeit note the study limitations!). In the patient with poor oxygenation, RSA is a useful bridging technique to improve ventilation and oxygenation prior to proceeding to ETI. Even better is the technique of using the SGA to intubate through, once oxygenation is optimised with the SGA!