Engine 201, Rescue 4 and Medic 11 are dispatched to an unconscious person near a bayside hotel. It’s reported that bystanders are attempting to rescue the patient from the water. When you arrive, E201 has just finished extricating the patient from the water, placed him supine on a back board and safely on the dock. First responders advise that citizens attempted to perform CPR.
Several witnesses report they saw the patient fall from a platform that extends off the side of the hotel, approximately 25 feet above the water. One bystander says the victim hit a railing prior to entering the water.
First responders restart CPR and complete C-spine precautions, and begin to make several priority decisions. In just seconds, these EMS providers need to answer a life-or-death question in order to begin resuscitation: Why is he in cardiac arrest?
Is the cause of the arrest medical or trauma? Did he have a myocardial infarction, syncope or seizure before he fell? If so, on-scene ACLS treatment may be his best chance of survival. Conversely, if the cause of his cardiac arrest is the result of blunt or penetrating trauma, then scoop-and-run has to be a priority. Or, it could be a combination of both. The providers need to quickly assess everything at their fingertips and begin their treatment plan.
Discussion
Whether you stay and treat or scoop and run, one of your initial decisions should always be to address airway management. Who will maintain the airway? What adjuncts can be used? And now, more than ever before, you should be asking yourself, “What is the most appropriate airway for this situation?”
For the past few decades, paramedics have reached for an endotracheal tube (ETT) as the first (advanced) airway for an adult in need of ventilation. ETTs are a great treatment option and provide logistical benefits for prehospital crews. They provide positive control of the airway, use less oxygen (decreased bottle changes at scene) and all-but-eliminate vomiting after insertion. Unfortunately, the opportunity for an ETT to be misplaced or displaced is a reality, which occasionally results in an unrecognized esophageal placement. Infection caused by the introduction of a tube that becomes contaminated in the field is increasing as we become more keenly aware of the morbidity and mortality of patients that end up with Ventilator Associated Pneumonia (VAP). And, unless the end tidal CO2 detector is constantly monitored, (not just for initial ETT placement confirmation) this airway option can quickly turn into a lethal complication.
If ETTs were our only option to manage an airway, then the complications might be worth the risks. But when you do a risk-benefit analysis and evaluate other adjunct options, such as the King LT Airway, bag-valve-mask (BVM) or other airway devices, serious thought must be given to not using an ETT.
Clinical data indicate that survival from a cardiac arrest isn’t necessarily improved because of the presence of an ETT. So, if well-documented studies show ETT placement carries the real risk of serious complications, why do we still intubate before considering options?
I believe many paramedics still view the ETT as the “paramedic’s first-line airway” and think using a “back-up airway” in some way implies the medic settled for second best or even failed. However, over the past few years, we’ve successfully moved this advanced airway procedure down in the CPR algorithm, concentrating first on chest compression optimization and drug therapy. This paradigm shift–delaying intubation in favor of good BLS airway management–felt uncomfortable at first but now feels routine.
Why was this advanced airway procedure moved down from the top of the list of initial things to do when beginning to resuscitate a cardiac arrest patient? The answer appears to be threefold:
1. The patient’s blood is often still saturated with oxygen and capable of supporting perfusion efforts with good BVM ventilations and an oral airway;
2. The time to actually intubate the patient and perform the various logistical tasks associated with the procedure takes away from optimizing compressions, which we now know is critical to a successful resuscitation, and;
3. Data doesn’t show any better survival from cardiac arrest with an ETT than with BLS airway management.
Perhaps finding a middle ground, somewhere between an ETT and BLS airway management is the solution. Maybe there’s an appropriate way to protect the airway better than with BLS airway management, not delay or interfere with chest compressions and eliminate the lethal complications associated with an unrecognized esophageal intubation.
I believe we already have the answer at our fingertips—such rescue airways, such as the King LT. We encourage paramedics in our system to use the best overall airway for the patient at that time and fully support them if they choose to use such adjunct airway devices. In fact, we want our paramedics to be experienced in placing these adjunctive airway devices prior to encountering difficult airways that can’t be intubated, such as a complicated massive facial trauma patient.
Conclusion
How would you manage this airway? Consider the three most common choices–ETT, adjunctive airway device or BVM and oral airway? Which tool best fits this scenario?
During the actual resuscitation of this patient, the paramedic chose the King LT. When I spoke to her after the call and asked how she arrived at this decision, she said she assumed the patient might have had a C-spine injury because he was immobilized, so the ETT was moved to the bottom of her list of airway management choices because of the need to limit neck and spine movement.
Because this patient was rescued from the water, protecting the airway from emesis was also a priority. The paramedic had numerous previous experiences inserting King airway devices. She knew it could be done quickly, wouldn’t complicate C-spine immobilization and wouldn’t disrupt or diminish ongoing chest compressions. She also knew she could ventilate her patient well with the King LT, monitor EtCO2 values that assist in guiding the overall resuscitation plan and intubate the patient later if necessary.
This patient survived due to the paramedic’s ability to adapt to the situation, shift from an old airway p aradigm and use acceptable alternatives to manage the patient’s airway. JEMS
This article originally appeared in October 2010 JEMS as “Airway Encounters: Adjunct devices offer providers airway management options.”
Learn more from Criss Brainard at a special panel discussion on endotracheal intubation, “Should We Be Intubating?” at the 2011 EMS Today Conference & Exposition. Visit www.EMStoday.com for more about the 2011 schedule.
