Emergency Airway Placement by EMS Providers: Comparison between

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Emergency Airway Placement by EMS Providers: Comparison between pdf




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Emergency Airway Placement by EMS Providers: Comparison between  - page 1
BRIEF REPORT Emergency Airway Placement by EMS Providers: Comparison between the King LT Supralaryngeal Airway and Endotracheal Intubation J. Bracken Burns Jr., DO; 1 Richard Branson, MS, RRT; 2 Stephen L. Barnes, MD; 3 Betty J. Tsuei, MD 2 1. University of Florida College of Medicine-Jacksonville, Department of Surgery, Jacksonville, Florida USA 2. University of Cincinnati College of Medicine, Department of Surgery, Cincinnati, Ohio USA 3. University of Missouri School of Surgery, Columbia, Missouri USA Correspondence: J. Bracken Burns Jr., DO Division of Acute Care Surgery Department of Surgery University of Florida-Jacksonville 655 West Eighth Street Jacksonville, Florida 32209 USA E-mail: bracken.burns@jax.ufl.edu This study was supported by a grant provided by the Ohio Department of Public Safety, Emergency Medical Services Division. Keywords: airway; emergency medical services (EMS); endotracheal intubation; King LT Supralaryngeal Airway Abbreviations: EMS = emergency medical services LMA = laryngeal mask airway METI = Medical Education Technologies, Inc. PPE = personal protective equipment Received: 13 October 2008 Accepted: 10 November 2008 Revised: 15 June 2009 Web publication: 23 February 2010 Abstract Introduction: The ever-present risk of mass casualties and disaster situations may result in airway management situations that overwhelm local emergency medical services (EMS) resources. Endotracheal intubation requires signifi- cant user education/training and carries the risk of malposition. Furthermore, personal protective equipment (PPE) required in hazardous environments may decrease dexterity and hinder timely airway placement. Alternative air- way devices may be beneficial in these situations. Objective: The objective of this study was to evaluate the time needed to place the King LT Supralaryngeal Airway compared to endotracheal intubation when performed by community EMS personnel with and without PPE. Methods: Following training, 47 EMS personnel were timed placing both endotracheal tubes and the King LT supralaryngeal airway in a simulator mannikin. The study participants then repeated this exercise wearing PPE. Results: The EMS personnel wearing PPE took significantly longer to place an endotracheal tube than they did without protective equipment (53.4 sec- onds and 39.5 seconds, p <0.002). The time to place the King LT was signifi- cantly faster than the placement of the endotracheal tube without protective equipment (18.4 seconds and 39.5 seconds, respectively, p <0.00003). There also were statistically significant differences between the time required to place the King LT and endotracheal tube in EMS personnel wearing protective equip- ment (19.7 seconds and 53.4 seconds, p <0.000007). Conclusions: The King LT Supralaryngeal Airway device may be advanta- geous in prehospital airway management situations involving multiple patients or hazardous environments. In this study, its insertion was faster than endotracheal intubation when performed by community EMS providers. Burns JB, Branson R, Barnes SL, Tsuei BJ: Emergency airway placement by EMS providers: Comparison between the King LT Supralaryngeal Airway and endotracheal intubation. Prehosp Disaster Med 2010;25(1):92–95. Introduction The recent increase in terrorist events has heightened the medical communi- ty’s awareness of the need for mass-casualty and disaster planning. Maintaining the knowledge and skills necessary to manage such large-scale incidents is a growing concern. In the prehospital setting, airway management is an essential first step in treating injured patients, and the ability to establish an airway in a timely fashion may be limited by the experience of the personnel available and the type of airway utilized. If multiple patients require airway management, the timing and ease of airway placement may affect personnel management and triage strategies. Furthermore, potential exposure risks may require emergency medical services (EMS) personnel to perform initial medical management in less than optimal environments. Under hostile conditions, which may be encountered in toxic or terrorist events, the use of personal protective equipment (PPE) may be necessary, and this equipment can interfere with airway placement. As such, routine techniques used for airway management, such as endotracheal intubation, Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol. 25, No. 1
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Emergency Airway Placement by EMS Providers: Comparison between  - page 2
Burns, Branson, Barnes, et al 93 may not be as effective under these conditions, and alternative airway devices, such as supraglottic tubes, may be beneficial. The King LT Supralaryngeal Airway (King Systems, Nobelsville, IN) features a single inflation site that inflates two cuffs; one in the hypopharynx and the other in the upper esophagus. It can be inserted blindly and has a high rate of successful placement, even when utilized by person- nel with minimal training. 1–3 This study utilized the METI (Medical Education Technologies, Inc., Sarasota, Florida) simulator to compare the time required for airway management by EMS personnel using the King LT Supralaryngeal Airway or standard endotracheal intubation techniques. Furthermore, this study sought to determine if the utilization of PPE adversely affects the time required for airway management. Methods Study Protocol Emergency medical services providers from three commu- nity fire departments in the greater Cincinnati area partic- ipated in this study during a total of five sessions. The Institutional Review Board of University Hospital, University of Cincinnati College of Medicine, approved the study protocol prior to commencing this study. To ensure anonymity, each participant was assigned a study number. Participants signed informed consent and completed both pre-study and post-study surveys. The pre-study sur- vey was used to assess demographic data and the partici- pants’ level of confidence for performing emergency airway procedures, both with and without wearing PPE. An instructional lecture, which reviewed airway anatomy, endotracheal intubation, and the technique for placement of the King LT supralaryngeal airway, was provided. All participants were provided an opportunity to perform endotracheal intubation and King LT supralaryngeal air- way placement on the METI simulator in order to become familiar with the airway devices and simulator system. Subsequently, the participants were subsequently timed in both the placement of the King LT and endotracheal intubation with and without PPE. Each participant served as his/her own control. Timing started when the study par- ticipant touched the equipment and terminated when suc- cessful ventilation was achieved. Successful ventilation was defined as symmetrical chest rise with manual ventilation. Participants then donned whatever PPE would be available for their department in a mass-casualty or disaster manage- ment situation. Participants were required to have some form of visual and manual impairment during the PPE portion of the study. The PPE utilized were a minimum of protective fire gloves and fire helmet with the shield down. Several participants utilized HazMat suits. Then, the par- ticipants were then timed completing the same two airway management skills. Data Processing Demographic data (age, sex, years of experience, and self- reported frequency of emergency airway placement) were collected. Times to successful airway placement (endotra- cheal intubation and King LT Supralaryngeal Airway) with and without protective equipment were compared, with each participant serving as his/her own control. Subjective level of comfort with emergency airway techniques with and without protective equipment was evaluated by com- paring pre-study and post-study survey results. Data are presented as mean ±standard deviation (SD); t-tests and paired t-tests were used for comparison with significance taken at p <0.05 [SPSS Version 15.0.1, SPSS Inc., Chicago, IL]. To evaluate if use of the simulator affected the level of comfort of practitioners to perform airway management while utilizing PPE, pre-study and post-study surveys were analyzed. Participant self-assessment of their level of confi- dence with performing emergency airway management using bag-valve-masks mechanical ventilation (BVM), placing oral-pharyngeal/nasal-pharyngeal airways, laryn- geal mask airways (LMA), the King LT Supralaryngeal Airway, endotracheal intubation, and performing cricothy- rotomy while wearing personnel protective equipment was rated using a scale ranging from 1 (not confident) to 5 (extremely confident). Results A total of 47 EMS personnel completed the study protocol. The mean age of the participants was 31.8 ±8.6 years (range = 20–52 years) Forty-two of the 47 participants were male (89.4%). The experience of the participants ranged from 1 to >20 years of EMS experience. Eighteen of the participants (38.3%) had ≤5 years of experience. Thirteen participants (27.7%) had 6–10 years of experience; eight participants (17%) had 11–15 years of experience; three participants (6.4%) had 16–20 years of experience; and five participants (10.6%) had >20 years of experience. Participants were surveyed as to their experience with the placement of laryngeal mask airways (LMA) (LMA North America, Inc., San Diego, CA), the King LT Supralaryngeal Airway, and endotracheal intubation. With regards to LMA placement, no participants reported daily usage of this device, one participant (2.1%) reported weekly usage, five partici- pants (10.6%) reported monthly usage, 19 participants (40.4%) reported yearly usage, and 22 participants (46.8%) reported never using a LMA. None of the participants report- ed daily or weekly usage of the King LT Supralaryngeal Airway, four participants (8.5%) reported monthly usage, six participants (12.8%) reported yearly usage, and 37 participants (78.9%) reported having never used this device. No partici- pants reported daily endotracheal intubation, two participants (4.3%) reported weekly intubation, 15 participants (31.9%) reported monthly intubation, 18 participants (38.3%) report- ed yearly intubation, and 12 participants (25.5%) reported never having performed endotracheal intubation. Time used to place the King LT Supralaryngeal Airway was shorter than endotracheal intubation in all scenarios. In the control scenario (no PPE), the time consumed for suc- cessful endotracheal tube placement was 39.5 ±31.5 sec- onds. The time required for King LT placement was 18.4 ±8.1 seconds. There was a statistically significant difference between these times (p <0.00005). The use of personal protective equipment significantly increased the time needed for successful endotracheal intu- January – February 2010 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine
Emergency Airway Placement by EMS Providers: Comparison between  - page 3
94 Emergency Airway Placement Burns © 2010 Prehospital and Disaster Medicine Burns © 2010 Prehospital and Disaster Medicine Figure 1—Comparison of mean time needed to place endotracheal tube and King LT supralaryngeal airway with and without protective equipment. Time for placement of LT was significantly shorter than ETT without PPE (p <0.00005) and with PPE (p <0.00005; ETT = endotracheal tube; LT = King LT; PPE = personel protective equipment) bation compared to no use of PPE (53.4 ±46.4 seconds vs. 39.5 ±31.5 seconds, p = 0.002). In contrast, the use of PPE did not affect the time required for successful King LT placement (19.7 ±8.8 seconds vs. 18.4 ±8.1 seconds, respec- tively, p = 0.19). There was also a statistically significant dif- ference in the time needed to place an endotracheal tube (53.4 ±46.4 seconds) compared to the placement of the King LT (19.7 ±8.8 seconds) when the participants were in PPE (p <0.00001; Figure 1). There were no significant differences in the level of con- fidence of the participants with regard to performing BVM (4.3 ±0.91 post-study vs. 4.2 ±1.0 pre-study, p = 0.22), or placing oral-pharyngeal/nasal-pharyngeal airways (3.9 ±0.92 post-study vs. 3.8 ±1.2 pre-study, p = 0.21). Post-study par- ticipant level of confidence was increased for the placement of LMA (3.4 ±1.2 post-study vs. 2.8 ±1.2 pre-study, p <0.001), the King LT (3.6 ±1.4 post-study vs. 2.0 ±1.0 pre-study, p <0.00001), and endotracheal intubation (3.2 ±1.5 post- study vs. 2.6 ±1.3 pre-study, p <0.01). The only skill that the participants felt less confident with after the study was cricothyrotomy (1.5 ±1.0 post-study vs. 1.7 ±1.1 pre-study, p <0.05; Figure 2). Discussion The first step in the management of injured patients is ensuring an adequate and secure airway. Endotracheal intu- bation still is the gold standard method of establishing a definitive airway in the prehospital setting. Unfortunately, this skill requires extensive training and experience for suc- cessful outcomes. The situation in which airway management must be undertaken can be affected if there are multiple patients or a hazardous environment. The use of PPE required in hazardous environments also may decrease dex- terity and hinder timely airway placement. This study eval- uated community EMS providers to determine if alternative airway devices, such as the King LT Supralaryngeal Airway, could be placed more rapidly and with a greater degree of Prehospital and Disaster Medicine Figure 2—Comparison of pre-study and post-study level of confidence in performing airway management skills with and without protective equipment (BVM = bag-valve-mask; Cric = cricothyrotomy; LMA = laryngeal mask airway; LT = King LT; ET = endotracheal intubation) confidence than endotracheal intubation, particularly when PPE are utilized. The use of personal protective equipment increases time to successful endotracheal intubation. The King LT Supralaryngeal Airway not only was more rapidly inserted than an endotracheal tube, but the time needed for placement was not affected by the use of PPE. This suggests that the King LT may be a more appropriate method of airway man- agement in situations where PPE is needed. These results support findings that physicians wearing anti-chemical warfare gear were able to complete LMA placement more rapidly than endotracheal intubation. 4 In this same study, a successful placement rate of 100% was noted for the laryngeal mask airway despite the use of PPE. The current study suggests that the King LT Supralaryngeal Airway might be useful as an alternative in certain disaster or mass-casualty circumstances. The major advantage of the King LT over endotracheal intubation appears to be the ability to place the King LT blindly and with minimal training. Other studies indicate that the time required to insert the King LT is similar to that required for placement of the LMA 2 and, in some hands, shorter than the time needed for Combitube (Tyco-Kendall, Mansfield, MA) insertion. 5 The King LT also has proven to be useful as a rescue airway in the event of unsuccessful LMA place- ment. 6 The King LT also has demonstrated other advan- tages over the use of conventional supraglottic airway devices in previous studies. It can be placed successfully when a mouth opening as small as 23 mm is present. 7 Asai et al found the King LT had leak pressures that were greater than those measured for the laryngeal mask airway (LMA). In the same study, they noted no appreciable gastric infla- tion associated with the use of the King LT device. 8 Ochs et al demonstrated the ability to train emergency medical technicians-defibrillation (EMT-Ds) how to place the Combitube supraglottic airway device with minimal training (an eight hour didactic and skills session). They found this supraglottic airway device to be an effective alternative for emergency medical personnel that are not Vol. 25, No. 1 http://pdm.medicine.wisc.edu
Emergency Airway Placement by EMS Providers: Comparison between  - page 4
Burns, Branson, Barnes, et al 95 trained in endotracheal intubation. 9 In a study of Army medic students, McManus et al found that the King LT could be successfully placed faster than the Combitube. Participants in that study preferred the King LT tube as they felt it was more easily placed. 5 The participants in this study felt no significant change in their level of confidence in basic airway management skills, including bag-valve-mask mechanical ventilation and the placement of oral-pharyngeal or nasal-pharyngeal air- ways in situations that would require protective equipment. The EMS providers did feel more confident about more definitive airway techniques including the placement of LMA devices, the King LT, and endotracheal intubation. This occurred despite a significant time increase required to place endotracheal tubes while wearing protective gear. Overall, the level of confidence survey showed that simula- tor based practice increased level of confidence in those procedures that are considered more invasive, such as LMA and endotracheal tube insertion. The only skill that the EMS providers felt less confident about was cricothyroto- my. This may be due to the infrequent use of this technique and the perception that this would be even more difficult with the interference of PPE. Although not a part of the current study, simulator practice and assessment of this uncommonly utilized skill may improve confidence levels in a similar manner. The current study did have some limitations. One limi- tation was the variability of the PPE utilized by the partic- ipants. The participants were asked to utilize what PPE would be available to them in a disaster management situ- ation. Most providers did not have what would be recog- nized as standard HazMat PPE. In an effort to simulate the visual and manual difficulties of such equipment, par- ticipants were required to wear at least fire gloves and hel- met with visor. An additional limitation was recognized after the com- pletion of the study. The study surveys did not ask for the highest level of training of the participants. Unfortunately, these data could not be compiled after the study was com- pleted. This limitation was somewhat overcome by the sur- vey information available on how frequently the participants utilized the different airway skills. It is difficult to ascertain if simulator training in the air- way management techniques translates to improved ability to perform these skills in real clinical situations. A larger study with post-training follow-up might prove valuable, but would be a difficult undertaking. However, the ability to practice airway skills that are not commonly utilized is of particular value to community EMS departments that may not have the resources to undertake such education and training. While this study focused on airway management skills, it is quite reasonable to propose a more complex sim- ulation exercise that would incorporate multiple patient care skills. The development of regional simulator sites, which often have been used to educate hospital personnel, may have expanded benefits in educating prehospital personnel. Conclusions This study indicates that the King LT supralaryngeal air- way device has a significantly shorter time to successful placement by prehospital personnel when compared to endotracheal intubation. While the use of PPE increased the time required for successful endotracheal intubation, there was little effect on the time for LT placement. As such, the use of the King LT may be advantageous in pre- hospital airway management situations involving multiple patients, where timely intervention is necessary, or hazardous environments that require the use of additional protective gear. Furthermore, the use of a simulator for education and practice increased provider confidence levels for invasive airway management techniques and may be of benefit for other aspects of prehospital personnel education. 5. McManus J, Parsons D, Proulx C, Cain J, Hill G. Combat trauma airway management : Combitube versus the King laryngeal tracheal device by Army combat medic students. Acad Emerg Med 2005;12; Suppl 1:162. 6. Asai T, Matsumoto S, Shingu K, Noguchi T, Koga K: Use of the laryngeal tube after failed insertion of a laryngeal mask airway. Anesthesia 2005;60(8):825–826. 7. Gaitini L, Vaida S, Somri M: An evaluation of the laryngeal tube during gener- al anesthesia using mechanical ventilation. Anesth Analg 2003;96(6):1750–1755. 8. Asai T, Kawashima A, Hidaka I, Kawachi S: The laryngeal tube compared with the laryngeal mask: insertion, gas leak pressure and gastric insufflation. Br J Anaesth 2002;89(5):729–732. 9. Ochs M, Vilke G, Chan T, Moats T, Buchanan J: Successful prehospital air- way management by EMT-Ds using the Combitube. Prehosp Emerg Care 2000;4(4):333–337. References 1. Asai T, Murao K, Shingu K: Efficacy of the laryngeal tube during intermit- tent positive-pressure ventilation. Anaesthesia 2000;55(11):1099–1102. 2. Doerges V, Ocker H, Wenzel V, Schmucker P: The laryngeal tube: A new simple airway device. Anesth Anal 2000;90(5):1220–1022. 3. Hagberg C, Bogomolny Y, Gilmore C, Gibson V, Kaitner M, Khurana S: An evaluation of the insertion and function of a mew supraglottic airway device, the King LT, during spontaneous ventilation. Anesth Analg 2006;102(2):621–625. 4. Goldik Z, Bornstein J, Eden A, Ben-Abraham R: Airway management by physi- cians wearing anti-chemical warfare gear: Comparison between laryngeal mask airway and endotracheal intubation. Eur J Anaesthesiol 2002;19(3):166–169. January – February 2010 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine
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