County of Kern Emergency Medical Services King Airway Policy June 1, 2010 Ross Elliott Robert Barnes, M.D. Director Medical Director SUPRALARYNGEAL AIRWAY- KING AIRWAY I. GENERAL PROVISIONS A. Supralaryngeal airways are approved for use by all paramedics accredited in Kern County. EMT-I’s who have met the training and certification requirement for the skill and who are employed by EMT-I Advanced Airway Providers are authorized to use this airway device. B. Supralaryngeal airway procedures in the pre-hospital setting shall only be preformed using devices approved by the Kern County EMS Department. C. Supralaryngeal airway devices approved for use are the CombiTube and the King Airway. Refer to the CombiTube Procedures for additional information on the use of the CombiTube. D. The CombiTube Policies and Procedures shall no longer be used after December 1, 2010. E. Supralaryngeal airway training conducted after January 1, 2010 shall be only for the King Airway. The intent is to phase out the use of the CombiTube. F. This program is implemented and maintained under the authority of the Kern County EMS Department in accordance with California Code of Regulations Title 22 Chapters 2 and 4. II. OVERVIEW The supralaryngeal airway is a single-use device intended for airway management. It may be used as a rescue airway device when other airway management techniques have failed, or as a primary device when advanced airway management is required in order to provide adequate ventilation. The supralaryngeal airway does not require direct visualization of the airway or significant manipulation of the neck. The main use for the supralaryngeal airway is in cardiac arrest situations. A supralaryngeal airway may be considered preferable for initial use in patients who are obese or who have short necks, patients with limited neck mobility, or when visualization of the airway is difficult due to blood or emesis in the airway. A paramedic is not required to attempt endotracheal intubation before opting to use of a supralaryngeal airway. Supralaryngeal airways are not well tolerated in patients with intact gag reflexes and should not be used in patients with perfusing pulses unless all other methods of ventilation have failed. 1 Placement of a supralaryngeal may be attempted three times. Ventilations should be interrupted for no more than thirty seconds per attempt. Patients should be ventilated with 100% oxygen for one minute via bag-valve-mask device between attempts. If attempts at placement of an advance airway are unsuccessful after three attempts, BLS airway measures shall be resumed. The King Airway is approved for use in three sizes and cuff inflation varies by size: Size 3 – Patients between 4 and 5 fee tall (55 mL air) Size 4 – Patients between 5 and 6 feet tall (70 mL air) Size 5 – Patients over 6 feet tall (80 mL air) III. INDICATIONS • Cardiac arrest of any cause • Inability to ventilate non-arrest patient with other BLS maneuvers in a setting in which endotracheal intubation is unsuccessful or unable to be done IV. CONTRAINDICATIONS • Presence of a gag reflex • Caustic ingestion • Known esophageal disease (e.g. cancer, varices, stricture) • Laryngectomy with stoma • Height less than 4 feet Note: Airway deformity due to prior surgery or trauma may limit the ability to adequately ventilate with a supralaryngeal airway due to the potential for poor seal of the pharyngeal cuff. V. REQUIRED EQUIPMENT • Suction • King Airway Kit (size 3, 4, or 5) • Bag-valve-mask • Stethoscope VI. PROCEDURE FOR USE 1. Assure adequate BLS airway (if possible) 2. Ventilate with 100% oxygen while selecting appropriate size King Airway 3. Test cuff of device by injecting the recommended amount of air into the cuffs. Fully deflate prior to insertion. 4. Apply water-based lubricant to distal tip and posterior aspect of tube. Avoid application of lubricant into ventilatory openings. 2 5. Position head into the “sniffing position”. Neutral position may be used for suspected cervical spine injury. 6. Hold mouth open and apply chin lift (jaw-thrust for suspected c-spine injury). 7. Insert tube rotated laterally at 45-90 degrees with blue orientation stripe touching corner of mouth. Advance behind base of tongue. Do not force. 8. Once tube has passed under tongue, rotate tube back to midline with the blue orientation stripe midline and up towards chin. 9. Advance tube until base connector aligns with teeth or gums. 10. Inflate cuff of tube to required volume, 11. Attach bag-valve-mask and ventilate patient, confirm placement by rise and fall of the chest and lung sounds. 12. Secure tube and note depth marking of tube. 13. Continue monitoring placement of tube throughout pre-hospital treatment and transport. 14. Document placement of tube using the Department approved form. VII. AIRWAY REMOVAL Once a supralaryngeal airway is placed, ideally it should not be removed. Circumstances that necessitate removal of the device may include presence of a gag reflex or inadequate ventilation with the device. Removal of the device may cause vomiting and the following steps should be followed: A. Position patient on side, maintain spinal precautions as needed. B. Have suction available. C. Deflate cuff/cuffs completely and remove smoothly and quickly. D. Reassess airway and breathing to evaluate the need for other adjuncts. VIII. PATIENT HAND-OFF/TRANSPORT PROCEDURES A. Patients with supralyryngeal airways that have been placed by EMT First Responders may be released to a paramedic or to an EMT-I with equal training for transport to the hospital. B. In cases where an EMT-I ambulance is the transporting unit and the staff is not trained in the use of the device, the first responder must accompany the patient and maintain care responsibility of the airway device until release of the patient at the emergency department. EMT-I transport personnel will maintain responsibility for all other patient treatment and decisions during the transport to the emergency department. C. If the King Airway is inserted prior to arrival of ALS, the King Airway is to be left in place if the device is adequately ventilating and protecting the airway. 3 Reasons for any case of supralaryngeal airway removal must be documented in the patient care record. IX. DOCUMENTATION REQUIREMENTS A. For each case of supralaryngeal airway insertion, or attempted insertion by advanced scope EMT-I providers an “EMT-I Advanced Airway Report Form” shall be submitted to the Kern County EMS Department within forty-eight hours of use. Form is attached. B. Paramedics or ambulance EMT-Is using supralaryngeal airways shall document insertion on the patient care record for submission in accordance with the E-PCR Policies and Procedures. 4 EMT-I ADVANCED AIRWAY REPORT FORM Date:__________________ Agency:_________________________________ Unit ID:________________ Call Location____________________________________________________________________________ Call Type_______________________________________________________________________________ TIMES Call Time_______________On Scene ______________________ Patient Contact_____________________ Ambulance On Scene ________________ Transport__________________Completed__________________ PATIENT INFORMATION Name (Last, First)_______________________________________________________________________ Address_______________________________________________________________________________ City/State/Zip___________________________________________________________________________ Age__________ DOB______________ Sex___________ Wt.____________(lbs/kg) Ht.____________ Past Medical History_____________________________________________________________________ Medications_____________________________________________________________________________ VITAL SIGNS NARRATIVE Time B/P Pulse Resp. _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ INDICATION FOR USE Unresponsive/No gag reflex______ Respiratory or Cardiac Arrest________ Other (please indicate)_______ Number of Attempts______ By____________________________ Size _________ Time_______________ Outcome_______________________________________________________________________________ Transport Ambulance and Unit ID___________________________ Hospital Destination_______________ COMPLETED BY ___________________________________________ __________________________________________ Print Name Signature 5 Appendix A 6 EMT-I TRAINING AND ACCREDITATION-KING AIRWAY I. TRAINING A. King Airway training shall be provided in accordance with manufacturer guidelines and Department policy and procedures by a person certified in the skill and recommended by their employer. B. Initial King Airway training shall be a minimum of four hours and shall cover the King Airway Procedure and the manufacturer training curriculum (Appendix A). C. Each student must pass a twenty question written exam approved by the Department with a minimum score of eighty percent and successfully demonstrate the skill using the King Airway Skill Sheet with a minimum of seventeen points (Appendix B). D. Upon successful completion of King Airway training the student shall be issued a course completion document that includes the following information: 1. Student name 2. Date(s) and hours of training 3. Instructor name and signature E. Employers conducting King Airway training shall maintain course rosters, written and skill exams for a period of four years. F.