EMS World

JAN 2019

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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EMSWORLD.com | JANUARY 2019 29 A s paramedic We s Ogilv ie re sponded to a "diabetic male" nor th of Houston in 2010, he wasn't too concerned about managing the airway. "I figured the sugar was either too high or too low," the Austin native recalls. That was before Ogilvie and his crew found their obese patient in cardiac arrest. "We weren't sure how long he'd been down," Ogilvie says. "My partner tried to intubate but couldn't see the cords, so I inserted a King." The King Airway is one example of extraglottic or supraglottic air ways (SGAs). They differ from endotracheal tubes (ETTs) mostly because they're inserted blindly and their distal ends sit in the hypopharynx or esophagus, rather than in the trachea. Wes should have been able to ventilate his patient through a properly placed King but couldn't. "When I tried nothing happened," he says. "I couldn't get any air in. Maybe we should have considered a cric, but we were close to the hospital. It was frustrating." Although Ogilvie keeps up with the literature and seeks advice from EMS veterans like Gene Gandy and Dr. Jef- frey Jarvis, he wishes his 2007 airway training had been more comprehensive. "Most of our practice was on manikins," he says. "Our OR time was discontinued midway through the course. I did get two or three tubes, but the only comment I heard from the CNAs (certified nurse anesthetists) who monitored us was something like, 'Yeah, that looks OK.' "Field clinicals were even less help- ful. I rode with a very rural service and didn't have a single chance to intubate. I realized I was just going to have to learn what I could on my own." Gaining endotracheal intubation (ETI) experience became even more of a challenge for most prehospital pro- viders after revised ACLS algorithms rendered cardiac arrests less-likely opportunities for practice. As devices like the King and Combitube became alternatives to ETTs in many systems, Wes wasn't the only paramedic won- dering whether SGAs and changing priorities would one day relegate laryn- goscopes to the same storage locker as MAST pants. Mastering the Tools, Embracing the Research Darren Braude, MD—EMS physician, professor of emergency medicine at the University of New Mexico, and medi- cal director of "Difficult Airway Course: EMS"—became interested in SGAs when he noticed an ends-justify-the- means philosophy about ETI among his residents and flight crews. "They were making too many attempts," he says. "It was a matter of getting the tube in one way or another and not really thinking about the harm we might be causing." Braude, who began as a paramedic in 1991 and still retains that certification, remembers carr ying EOAs (esopha- geal obturator air ways) and Combi- tubes that were rarely used because they were considered inferior to ETTs, particularly as a means of preventing aspiration. Now he feels that concern was overstated. "What we discovered was that many of our patients had already aspirated by the time we got to them," the 49-year- old author and speaker says. "And for those who hadn't, extraglottic airways provided substantially more protection than most providers realized." Braude cites retrospective research comparing prehospital aspiration asso- ciated with SGAs and ETTs. 1 Eight per- cent of SGA patients aspirated, versus 12% of those who'd been intubated. "It's a small study—by no means defini- tive—but I never would have guessed the rates would have been so close, or even better for the extraglottic group," Braude says. "There's lots of evidence that those devices do much of what we want from endotracheal tubes and may be a better option in the field for cardiac arrests. They're certainly used extensively in ORs. It becomes a matter of weighing the security of endotracheal intubation against the difficulty of maintaining that skill." Photo: Pat Songer

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