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Prehospital Airway Management Using the Laryngeal Tube an Emergency Department Point of View

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Prehospital Airway Management Using the Laryngeal Tube an Emergency Department Point of View Notfallmedizin Anaesthesist 2014 · 63:589–596 M. Bernhard1 · W. Beres2 · A. Timmermann3 · R. Stepan4 · C.-A. Greim5 · U.X. Kaisers6 · DOI 10.1007/s00101-014-2348-1 A. Gries1 Published online: 2. Juli 2014 1 Emergency Department, University Hospital of Leipzig, Leipzig © Springer-Verlag Berlin Heidelberg 2014 2 Department of Anaesthesiology and Intensive Care Medicine, Main Klinik Ochsenfurt, Ochsenfurt 3 Department of Anaesthesiology, Pain Therapy, Intensive Care Medicine and Emergency Medicine, DRK Kliniken Berlin Westend und Mitte, Berlin Redaktion 4 Department of Public Health, Fulda County, Fulda A. Gries, Leipzig 5 Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Hospital of Fulda, Fulda V. Wenzel, Innsbruck 6 Department of Anesthesiology and Intensive Care Medicine, University Leipzig, Medical Faculty, Leipzig Prehospital airway management using the laryngeal tube An emergency department point of view Securing the airway and maintaining ox- Studies describing the successful use of mittee of the Medical Faculty of Leipzig, ygenation and ventilation represent es- the laryngeal tube in the prehospital setting Germany. Single cases were documented sential life-saving strategies in emergen- sound promising [9, 10, 22]. However, the initially after ED admission. The case se- cy medicine [1, 2, 3, 40]. Depending on results of these studies and of case reports ries was evaluated retrospectively, was not the experience of the person performing were not reported by an independent ob- preregistered, and written informed con- the procedure and on the individual in- server and, therefore, reporting bias could tent could not be obtained. tubation conditions, endotracheal intuba- be possible [11, 22]. Only one prospective, tion (ETI) is still considered to be the gold randomized study has confirmed that the Results standard [4, 5, 40]. LTS-D is comparable to ETI in the prehos- Failed prehospital ETI is a common pital setting [41]. Indeed, the successful use Patient characteristics and the clinical occurrence and associated with increased of the laryngeal tube depends on individu- problems associated with the use of the mortality. Reliable airway devices such as al performance in carrying out the airway LT are described in detail in the follow- supraglottic airways (SGA) are needed for maneuver (e.g., skill, experience, and qual- ing section. rescuers who are less experienced in ETI ification). The following case series pres- [2, 3, 40]. The different types of larynge- ents the problems and complications upon Case report 1 al mask airway (LMA) and the laryngeal arrival in the emergency department de- tube have been reported as acceptable al- scribed by emergency physicians indepen- A 50-year-old patient fell down the stairs. ternative devices [6, 7, 8, 40]. dently of the prehospital emergency per- He was initially in stable cardiopulmo- The laryngeal tube was introduced as sonnel. These observations raise questions nary condition but unconscious according an alternative to the LMA for managing concerning the safety and usefulness of a to the Glasgow Coma Scale (GCS), with difficult airway situations, both in the hos- laryngeal tube in the prehospital setting. a GCS of 3. An EMS physician inserted a pital and in the prehospital setting. The la- LTS II without attempting ETI first. Cap- ryngeal tube then became rapidly estab- Methods nography was not used at the scene or dur- lished in many emergency medical ser- ing transport. Upon arrival in the ED, the vices (EMS) and its use was implemented Clinical observations were made in a non- patient was severely cyanotic. Upon hospi- in international guidelines [2]. The laryn- consecutive series of patients between tal admission, the patient developed asys- geal tube has now been modified so that 2007 and 2012. All patients were admit- tole. Cardiopulmonary resuscitation (CPR) different versions of this device are used ted to the resuscitation rooms of emer- was initiated immediately. End-expiratory in the prehospital setting [laryngeal tube gency departments (ED) at tertiary care carbon dioxide (etCO2) could not be detect- (LT), disposable version (LT-D), larynge- hospitals (University Hospital of Heidel- ed using capnography after handing the pa- al tube suction mark II (LTS II), and dis- berg, Hospital of Fulda, University Hospi- tient over in the ED. Considering misplace- posable version (LTS D), all VBM, Sulz, tal of Leipzig). Reporting data in the pres- ment and expecting an endotracheal posi- Germany]. ent form was approved by the ethics com- tion, the LT was removed immediately, and Der Anaesthesist 7 · 2014 | 589 Notfallmedizin blade. The patient survived without any ry and metabolic acidosis (pH 6.6, paCO2 neurological sequelae. 169 mmHg, paO2 89 mmHg, base excess −22 mmol/l). The patient was transferred Case report 3 to the cardiac catheter laboratory for im- mediate PCI but died of multi-organ fail- A 65-year-old patient (body mass index ure on hospital day 7 on the ICU. 57 kg/m2) suffered from out-of-hospital cardiac arrest. A LTS II was inserted initial- Case report 5 ly by an EMS physician without attempting ETI first. ROSC was achieved in the pre- A 25-year-old patient suffered a high- hospital setting after CPR. However, cap- speed motorcycle accident and was found nography was not used in the prehospital with a GCS 5. After failed ETI within two setting. Upon arrival in the ED, peripheral attempts and aspiration of a considerable oxygen saturation could not be detected al- amount of blood from the oropharynx, a though blood pressure and heart frequency LT was placed by the EMS physician. The were normal. A clearly audible ventilation patient was then handed over to an air res- synchronous leak was perceived alongside cue team. Due to the information reported Fig. 1 8 Swelling of the tongue after brief dura- the inserted LT in the ED. The end-expi- by the first EMS team, the physician of the tion of ventilation after a laryngeal tube was in- ratory minute volume was low (3.5 l/min). air rescue system abstained from switching serted in the prehospital setting After introduction of emergency anesthe- the LT to a tracheal tube. Mechanical venti- endotracheal intubation was performed sia, the LT was removed and laryngosco- lation was assumed to be sufficient for the without any difficulty. Return of spontane- py showed a severely cyanotic and thick- patient and difficult ETI conditions were ous circulation (ROSC) was achieved with- ened tongue; the posterior pharyngeal wall suspected. During air transport, the pa- in the following 3 min of CPR. Immediate- was swollen, and blood had covered the en- tient suffered from cardiac arrest and ar- ly after endotracheal intubation, blood gas tire oropharynx. Conventional laryngos- rived in the ED undergoing CPR with in- analysis showed combined severe respira- copy demonstrated a Cormack–Lehane adequate ventilation. In the ER, ETI was tory and metabolic acidosis (pH 6.7, pa- grade IV. ETI was performed successfully performed immediately and without any CO2 164 mmHg, paO2 62 mmHg, base ex- with a McCoy blade. Thereafter, a CT scan problems. Owing to an instable chest with cess −21 mmol/l). CT scan demonstrated was performed and confirmed a pulmo- several rib fractures, bilateral tension pneu- extensive brain edema, a massively swollen nary embolism. The patient died of right mothorax was clinically suspected and im- stomach, abnormally large amounts of air ventricular failure in the course of the next mediately treated by inserting chest tubes. in the small and large intestines, and mas- few days on the ICU. The CT scan confirmed a thoracic trauma sive aspiration. The only injury found was with pneumothorax and severe aspiration. a fracture of the spinous process of the sev- Case report 4 The patient died of abdominal and thorac- enth cervical vertebra that did not com- ic injuries in the ED. promise the spinal cord. The patient died A 55-year-old patient suffered from out- 6 days after being admitted to the intensive of-hospital cardiac arrest. After CPR was Case report 6 care unit (ICU). initiated by bystanders, a paramedic in- serted a LTS II without attempting ETI A 22-year-old patient was the victim of a Case report 2 first. After 20 min of CPR and after arrival high-speed motor vehicle accident. Ini- of an EMS physician, the patient achieved tial GCS was 5 but his respiration and car- A 55-year-old patient suffered from an ROSC. During the prehospital course, a diopulmonary condition were stable. Still out-of-hospital cardiac arrest and asso- clearly audible ventilation synchronous entrapped in his vehicle, a LTS II was in- ciated fall. A LT was inserted by a para- leak was perceived alongside the inserted serted by an EMS physician through the medic without attempting ETI first. The LT; however, no attempts were made to window on the driver’s side. During ex- arriving EMS physician refrained from manage this problem. After arrival in the trication and 20 min after insertion, the switching over to a tracheal tube in the ED, this sound was remarkable, the abdo- LTS II was subsequently dislocated. It was field. However, as a result of using LT dur- men was obviously swollen, and mechani- not possible to reinsert the LTS II. Laryn- ing the prehospital interval of 45 min, the cal ventilation was inadequate [low etCO2, goscopy demonstrated massive swelling of patient’s tongue had swollen considerably low end-expiratory minute volume (2.4 l/ the throat and vocal cords. The patient’s (. Fig. 1). After ED admission, the LT min)]. The LT was removed immediate- cardiopulmonary condition worsened was removed and subsequent laryngosco- ly, and subsequent ETI proved to be very and he ultimately suffered cardiac arrest. py proved to be very difficult (Cormack– easy (Cormack–Lehane grade I). Due to Cricothyroidotomy was performed, and Lehane grade IV), most probably as a con- hypoventilation during the prehospital the patient arrived in the ED under pro- sequence of the swollen tongue.
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