First of all, we would like to stop and take a minute and thank Dan and Seth for their help on this episode and their dedication to resuscitation research. Secondly, although we refer to several different commercial devices throughout this episode, we have NO conflict of interest with any of these corporations, and are not being paid to plug any of these products.
Justifying SGA Placement in OHCA
- Does not require chest compressions to stop for placement.
- Depending on available personnel, allows ALS providers to focus on scene oversight; i.e. defibrillation, medications, etc.
- Taking into account that EMS is a revolving door, many providers are not proficient intubators… This is an instance that a patent airway is important regardless of type. Repeated airway attempts have been proven to lower rate of neurologically intact patients post ROSC.
- People are obese! Obese airways can be very difficult… even proficient intubators will admit that they have had to place SGAs during an arrest because of this.
Why SGAs Fail
- There is significant controversy about the impairment of carotid blow flow from SGA placement as opposed to ETI. Depending on what sources you look to, you will find conflicting arguments. Something to consider.
- There are several different types of SGA devices out there; due to unfamiliarity, providers are at risk for over/underinflating them.
- Improper technique (i.e. not controlling the tongue) can lead to occlusion of the ventilation port, rendering the device useless.
Justifying ETI During OHCA
- Experienced providers can often intubate without interrupting chest compressions.
- ETI definitively protects the airway better than an SGA; less reported long term effects from aspiration; i.e. pneumonia.
- Depending on the studies you read, ETI has a markedly improved rate of neurologically intact ROSC patients.
Why ETI is a Dying Skill
- As we mentioned previously, EMS is a revolving door. Academic standards have changed drastically with many programs only requiring two successful intubations during paramedic class.
- A study out of Australia revealed that paramedic students require 25 attempts before reaching a 69% first pass success rate at ETI.
- We are intubating less people thanks to devices like CPAP/BiPAP and the wide distribution of naloxone.
- The anatomy of society is changing. We are getting bigger! Bigger airways are harder airways, and many providers are opting to just place an SGA device.
- Depending on the material you look at, some studies show that ETI can take as long as 90 seconds!
Introducing VL to the Prehospital World
- The British Journal of Anaesthesia found that providers with less experience are reaching higher first pass success rates with VL than with DL.
- VL does not require chest compressions to be interrupted to place an ET during OHCA.
Why VL Fails
- Think about the basics of introducing a camera to a wet environment; whether it is just bloody or full of secretions, cameras can be hindered. If you fail to suction, you are significantly likely to have to multiple attempts even using VL.
- With anything mechanical, there can be malfunctions. Screens crack. Batteries die. If you don’t have a backup readily available, adverse effects can occur. You have to be proficient at your backup plan.
Resuscitation is an art form. There is no one-size fits all approach to resuscitation, and you have to remain adaptable. No two arrests are the same. As an ALS provider, your choice of airway needs to remain based on what you believe will give the patient the best outcome possible. If you have an experienced crew and are working with another ALS provider that can helps with meds and interventions, then why not intubate? If you have a less experienced crew or aren’t as great of an intubator, then why not place an SGA? Resuscitation is situational, but we have to remind ourselves that this debate cannot be about what skills you want to perform, but what is best for your patient. Despite all of the rhetoric and black/white thinking out there, I think the best answer we can offer is… it depends. Early and high quality CPR as well as timely defibrillation are really the heroes of the story, though.
Sources and Extra Reading
- DL Terminated
- Impairment of carotid artery blood flow by supraglottic airway use in a swine model of cardiac arrest
- Out-of-Hospital Cardiac Arrest Surveillance — Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005–December 31, 2010
- Are Extraglottic Airways Harmful in Cardiac Arrest?