Monday, June 1, 2015

Guest Post: Supraglottic Airway Devices Should Be Your First Line

This is a guest post written by Jeff Poland, NRP, FAWMc, FACPMc, for the Great EMS What-If-We’re-Wrong-A-Thon. I have a lot of experience in prehospital and perioperative airway management, and on every other day of the year am a stark proponent of the use of supraglottic airway devices only as a rescue airway in emergency situations – almost (around 99.9999999999999% of the time) never as a first line. But, below outlines the best reasoning I can come up with for why:


Supraglottic Airway Devices Should Be Your First Line

While endotracheal intubation has long been touted as the gold standard for airway securement, increasingly we are seeing more and more services and geographic areas move away from endotracheal intubation (ETI) in favour of first line placement of a supraglottic airway (SGA), with the option of ETI if the SGA fails. This is a prudent and much-needed step in the right direction for the following reasons:

Several studies [1,2] have indicated that prehospital intubation has a very low success rate. Intubation is a skill which requires a great deal of practice, and has no correlation with the experience that a paramedic has [3]. In other words, if you don’t do the skill a lot, you aren’t very good at it, and I think that is something that we all can agree on. With most of fire-based EMS, and a lot of third service EMS, focusing on a 5:1 paramedic:patient ratio [4], and the already low frequency of patients requiring this delicate procedure, which, if it fails, is catastrophic for the patient, most paramedics, especially in those systems, simply do not get the required amount of practice to remain proficient.

One of the main concerns regarding airway management is that the airway needs to work. SGAs are dislodged only minimally, and rarely are placed wrong [5]. When your patient needs an airway now, you should just put in a SGA and not have to worry about it any more. An old co-worker of mine once told me “why would I use an ET tube when this (the King Airway) is easier, quicker, and I absolutely know it’s in?” High-stress situations such as cardiac arrest and unconscious/unresponsive patients often have providers anxiety levels up, and an unrecognized oesophageal intubation is almost universally lethal. On the other hand, I have had one endotracheal intubation using a King Airway, and that required 45 minutes, a low profile MAC 3, an airway manikin, and a set of long Magill forceps. (Beth Lattone, of the Community College of Aurora’s Paramedic Program, if you’re reading this, this definitely was not on one of your airway heads, so I don’t even know why I brought it up.)

Supraglottic airways have also been shown to provide some measure of protection against vomiting [6]. This has been shown to be similar to that provided by cricoid pressure, a recognized mainstay in every emergency and failed airway algorithm, although it is much easier to use an SGA than it is to use cricoid pressure. Given that they can protect the airway up to 120cmH2O of pressure, tell me again how ETI is the gold standard?

Furthermore, the King LT has been shown to be equal to ETI in cardiac arrest, and the authors also claim that because of the more rapid airway control, it could be considered superior [7]. Instead of mucking around with trying to get a good laryngoscopic view during cardiac arrest, why not just pop in the SGA and not have to worry about it later on?

ETI is an old skill. Technology is increasing, and making things both better and easier for the provider. Why are some people so focused on keeping the old technology and refusing to adapt to the changing world? So many physicians have gone on record saying that they don’t support paramedics intubating, we continue to have abysmally high failure (and worse, unrecognized oesophageal intubation) rates, and those are time and cost consuming to fix. More and more paramedic programs are getting away with 5 simulated intubations, period, in order to pass, and it sounds like we are rapidly recognizing that ETI in the prehospital setting needs to go the way of the dodo. Even anaesthesiologists are using more and more SGAs for more and more cases. Isn’t it about time we get on board with these changes, and leave ETI for the docs who want to stay outdated?

While those are some compelling arguments against endotracheal intubation, I still firmly maintain my view that SGAs are a second-line intervention when ETI fails. Want to find out why? Join myself and my esteemed colleague Benjamin Dowdy on 21 June 2015 while we debate this issue live. For any further questions or comments, I can be contacted at jeff.poland@gmail.com.

References

  1. http://informahealthcare.com/doi/abs/10.1080/10903120902935280
  2. http://emj.bmj.com/content/22/1/64.full
  3. http://www.rochestergeneral.org/~/media/Images/Imported/gedownload/etisuccessrate.pdf
  4. https://www.auroragov.org/cs/groups/public/documents/document/019791.pdf
  5. http://circ.ahajournals.org/cgi/content/meeting_abstract/122/21_MeetingAbstracts/A52
  6. http://journals.lww.com/anesthesia-analgesia/Abstract/2008/02000/A_Comparison_of_Seal_in_Seven_Supraglottic_Airway.15.aspx
  7. http://www.sciencedirect.com/science/article/pii/S0300957204000103


18 comments:

clar said...

Interesting post
DalagangFilipina.info

Elizabeth Matheus said...

HELLO EVERYONE.. FEW MUNINETS TO REDY THIS INFOR ON HERPES CURE 2018..
2017 MY MOTHER WAS DIAGNOSED OF HERPES/ KNOWN AS GENITAL WARTS ,I SPENT A LOT OF MONEY ON HER MEDICATION TILL A POINT I EVEN LOST HOPE,BECAUSE MY MOTHER WAS GRADUALLY DYING AND LOST HER MEMORY TOO, I WAS SO DESPERATE TO GET MY MOTHER BACK TO NORMAL, ONE DAY MY UNCLE WHO LIVES IN LONDON UNITED KINGDOM TOLD ME ABOUT DR OLIHA ,WHO HELPED HIM GET RID OF HERPES /GENITAL WART WITH HERBAL MEDICINE AND HIS HERBAL SOAP ,I WAS SO SHOCKED WHEN HE TOLD ME ABOUT THIS ,ALTHOUGH I NEVER BELIEVE IN HERB BUT, I KEEP TO BELIEVE BECAUSE MY UNCLE CAN'T TELL ME LIES WHEN IT COMES TO HEALTH CONDITION I CONTACTED DR OLIHA VIA HIS EMAIL; OLIHA.MIRACLEMEDICINE@GMAIL.COM , YOU CAN TALK TO HIM VIA CALL OR WHATSAPP MESSENGER ON +2349038382931 , HE REPLIED AND ASK ME TO SEND MY HOME ADDRESS AND MY MOTHER'S DETAIL AND THEN I PURCHASED THE HERBAL MEDICINE,SENT ME THE HERBAL MEDICINE THROUGH COURIER SERVICE, WHEN I RECEIVED THIS HERBAL MEDICINE USED IT FOR 2 WEEKS, AND 4 DAYS OF USAGE THE WARTS FELL OFF, MY MOTHER I NOW TOTALLY CURED AND MY MOTHER IS LIVING FREE AND HAPPY AGAIN. YOU CAN TALK TO DR VIA HIS MOBILE NUMBER OR WHATS APP HIM ON +2349038382931.ALL THANKS TO DOCTOR DR OLIHA  

buy erection pills said...

Yesterday, while I was at work, my cousin stole my iphone and tested to see if it can survive a forty foot drop, just so she can be a youtube sensation. My apple ipad is now broken and she has 83 views. I know this is entirely off topic but I had to share it with someone!

erectile dysfunction natural remedies said...

First of all I would like to say terrific blog! I had a quick question in which I'd like to ask if you do not mind. I was interested to know how you center yourself and clear your mind before writing. I have had a hard time clearing my thoughts in getting my thoughts out. I truly do enjoy writing but it just seems like the first 10 to 15 minutes are generally lost simply just trying to figure out how to begin. Any ideas or hints? Many thanks!

T Mitchell said...

I’ve been Feeling weak and always feeling sleepy for some time which I went for a test and I was told i am diagnosed with Amyotrophic lateral sclerosis Disease (ALS DISEASE) ever since then I've followed a wide variety of medical treatments, I have even combined with different pills and antibiotics without clear results. My health was deteriorating more and more. But thanks to a Herbal Doctor's herbs method that I found on the internet which has saved so many lives and also helped me to achieve the results i wanted, i knew from the beginning that this could help me after much learning and the cure Dr sent to me and which I began to follow the method from the Herbal Doctor called (Dr Aziba) and the results were wonderful: I recommend you to get in contact with him via Email: priestazibasolutioncenter@gmail.com and on WhatsApp: +2348100368288 for ALS, HPV, HSV, HERPES, Virginal Infection Cure etc.. DR is also available to help!






I’ve been Feeling weak and always feeling sleepy for some time which I went for a test and I was told i am diagnosed with Amyotrophic lateral sclerosis Disease (ALS DISEASE) ever since then I've followed a wide variety of medical treatments, I have even combined with different pills and antibiotics without clear results. My health was deteriorating more and more. But thanks to a Herbal Doctor's herbs method that I found on the internet which has saved so many lives and also helped me to achieve the results i wanted, i knew from the beginning that this could help me after much learning and the cure Dr sent to me and which I began to follow the method from the Herbal Doctor called (Dr Aziba) and the results were wonderful: I recommend you to get in contact with him via Email: priestazibasolutioncenter@gmail.com and on WhatsApp: +2348100368288 for ALS, HPV, HSV, HERPES, Virginal Infection Cure etc.. DR is also available to help!





I’ve been Feeling weak and always feeling sleepy for some time which I went for a test and I was told i am diagnosed with Amyotrophic lateral sclerosis Disease (ALS DISEASE) ever since then I've followed a wide variety of medical treatments, I have even combined with different pills and antibiotics without clear results. My health was deteriorating more and more. But thanks to a Herbal Doctor's herbs method that I found on the internet which has saved so many lives and also helped me to achieve the results i wanted, i knew from the beginning that this could help me after much learning and the cure Dr sent to me and which I began to follow the method from the Herbal Doctor called (Dr Aziba) and the results were wonderful: I recommend you to get in contact with him via Email: priestazibasolutioncenter@gmail.com and on WhatsApp: +2348100368288 for ALS, HPV, HSV, HERPES, Virginal Infection Cure etc.. DR is also available to help!

Unknown said...

Hello everyone , this is the most wonderful thing i have ever experienced and i need to share this great testimony. I Vanessa Tobby and i just want to say thanks to DR ISIKOLO for taking time to help me cast the spell that brings back my ex lover who suddenly lost interest in me after six month of engagement but today we are married and more happier than never before. I was truly flabbergasted and shocked when he did the work for me and in 48 hours after, Kris returned to my house and started begging for forgiveness and for me to accept him back.. I am really short of words and i don't know how much to convey my appreciation to you DR ISIKOLO you are a God sent to restore broken relationship. He deeply enjoy helping people achieve their desires, find true love, getting their ex lovers back, stop abusive relationships, find success, attract happiness, find soul mates and more. Contact him today, and let him show you the wonders and amazement of his Love Spell System. He deliver results at his best in real spell casting. Send an email: isikolosolutionhome@gmail.com You can also Whatsapp him on: +1(725)240-4536

Paula Mastop Bentes said...


We are a certified private lender and I offer local and international lending services to meet your financial needs such as: B. Home loans, auto loans, mortgage loans, business loans, international loans, personal loans, public refinancing and debt consolidation at an affordable rate. For more information, please contact me by email: (challotloan@gmail.com)
Urgent Loan Offer .

Blogger Santiago said...

He topado con tu blogger de anime y es divertido.

Jose Anthony Jr said...

My father was diagnosed with ALS in the summer of 2013;  His initial symptoms were quite noticeable. He first experienced weakness in his right arm and his speech and swallowing abilities were profoundly affected. We all did our best to seek help for this disease, no medications they prescribed worked ,we were all scared we might lose him due to his condition, as he had been his brother's caregiver a few years earlier for the same disease before he passed. doctor recommend natural treatment from multivitamincare .org for his ALS we have no choice to give a try on natural organic treatment ,this herbal cure has effectively reverse my father condition ,losing his balance which led to stumbling and falling stop  after the completing the herbal supplement which include his weakness in his right arm and his speech, home remedies from multivitamincare .org is the best although their service is a little bit expensive but it worth it, they save lives.

Cormon Toyato said...

Thanks for the great content. It is nice to go through the process at a high level.

IV Therapy Near Me

Yoton Romann said...

Keep sharing such a valuable information. Thanks..
IV Therapy Near Me

Norarho Villomns said...

Thanks for sharing Good Information

liquid iv ingredient

Anonymous said...

Nabízím vám jediný financní pujcku od prímého investora od 50 000 do 60 000 000 Kc. Tato nabídka platí pro celou Ceskou republiku a pro všechny obcany. Splatnost tohoto úveru muže být stanovena na 240 mesícu s možností predcasného splacení za jakoukoli cenu a bez zvýšení. Vezmete úver v plné výši a zaplatíte své prostredky do 24 hodin. Chcete-li pujcit, napište na adresu:ihjan51@gmail.com

Morgan Taylor said...

I GOT $10,000 ON PAYPAL TODAY

CONTACT: (Ethicsrefinance@gmail.com)WEBSITE:(WWW.Ethicsrefinance.com)

I saw a comment about www.ethicsrefinance.com on the web and I decided to give it a trial. Just few minutes ago, they granted my application and added $10,000 to my PayPal. I am super amazed that it works for me

Samantha Avila said...

Sometime early August, I fell for a binary option scam which promised a higher return and I lost close to $95,000. Most of my investment for trading and paying their fees came from loans from and some from family members. I became completely broke and barely manage to survive with very little money. I decided to take a step of talking to my neighbor coz I was really depressed. To my surprise, she too had had a similar situation. She introduced me to Software Specialist who had helped her recover the funds. She gave me his email: softwarespecialist@usa.com and told him what had happened and I needed his help urgently. He truly helped because after 2 days of working, I got an email from him that I should send him my wallet so he can transfer the funds. This was the best news I had heard during that week. Thank God for my neighbor who introduced me to a legit and certified recovery Agent that helped me recover all my lost funds.

Linda Anthony said...

Get $2,000 USD everyday for 2 Yeras. Contact for more info email: ( darkwebonlinehackers@gmail.com ) or WhatsApp number : ( +18033921735 )

Ludvik Rudolf said...

Potřebujete kredit? Dobrý den, paní/pane; Nabízíme půjčky na posílení ekonomické aktivity vaší společnosti a vašich služeb. Poskytujeme půjčky jednotlivcům i firmám. Nabídka se pohybuje od 30 000 Kč do 70 000 000 Kč na dobu 1 až 25 let. Potřebujete půjčku na konsolidaci podnikatelského dluhu? Jaká je vaše profese nebo obor v České republice? Jste důchodce nebo zaměstnanec s pracovní smlouvou? Řekněte nám o svých problémech s žádostí o půjčku a my vám dáme druhou šanci neodmítnout váš soubor? SCHVÁLENÍ PROSTŘEDKŮ PRO 24 HERUIS Přístup k ready pro všechny osoby od 20 let do maximálně 75 let. Než požádáte o půjčku, musíte být zodpovědným člověkem a člověkem, který drží slovo. Aby mohl být váš spis úředně ověřen v registru, potřebujeme podepsané Potvrzení o oddlužení. Pokud Vás nabídka zaujala, zašlete prosím Vaši poptávku z Vašeho pracoviště nebo oddělení na emailovou adresu: rudolfludvik7@gmail.com

David Garcia said...

HOW I QUICKLY RECOVERED BACK MY STOLEN FUNDS - WALLDRIVE CYBER SECURITY SERVICE

Juliet and I want to utilize this platform to warn everyone about cryptocurrency scams. Juliet and I were struggling financially a few months ago before a friend of mine gave me the name of a reputable and trustworthy company where I was assisted in recovering my stolen BTC and USDT. I accidentally transacted with a fake company, which led to my involvement in crypto investment fraud. I attempted to invest in crypto, and I was conned out of $600,000 worth of crypto. All thanks to Walldrive Cyber Security Service, a reliable and secure source to recover your crypto. I’m thankful we were able to get back our money. This whole recovery process took just 72 hours. You can contact Walldrive Cyber Security with the information below.

E-mail: walldriveservice @ techie . Com 

Whats app: +44 7 9 6 1 2 0 2 4 9 3

Goodluck