NightmAIRway ! - LMA and Bougie FTW !

[RustedFox]

At work now. We NEED to report this'n to the crew.

I just had a nightmAIRway. EMS brings in tongue/throat cancer patient with respiratory arrest. He coded in the field, and they threw in an iGel (worst device, ever), hit 'em with 2x epi and got ROSC.

Now he gets to me. First things first, we need a definitive airway, amirite ?

He's satting 100% on the iGel and BVM. We got all tools to bedside. First look was with oldschool DL. His tongue is giant... GIANT and the larygneal edema from the damn iGel is outstanding. Plus, its a bloody mess. Abandoned DL and went to video laryngoscope. Still... its a bloody red, sticky mess on the screen. Abort/retry/fail? Fine. Bag him up. Guy starts to desat.

LMA in. Boom goes the dynamite. Sats up to 100%.

DChristismi is with me in the room, 'cause we work at the same shop and she's cool like that. She says to me: "Stick the bougie down the LMA?" Sho'nuff. Bougie down LMA, ETT over bougie. Guy didn't drop his sats, placement confirmed via CXR.

This was mentioned once on here before. Hell, it may have been me that posted the idea; but I ... at that hot minute.... did not think of it.

It works, boys and girls. It works.

---

Members don't see this ad.

 

[dchristismi]

Sho' nuff.
Dude, I'm just glad we didn't have to cric him.
I mean, YOU didn't have to cric him.

igels suck. LMAs rock. Bougie through the LMA? Priceless.

 

[Groove]

Rockin. Way to go you two.

 

[Birdstrike]

Good job.


Full code, though?

 

[RustedFox]

Full code.

 

[Zebra Hunter]

nvm

 

[southerndoc]

Why do I-Gels suck? The person had a 100% sat. For a BLS crew, it's a great device and less error prone than a Combitube.

You could've also done a retrograde intubation.

 

[RustedFox]

I-Gels suck because I've never removed an I-Gel and not had a giant, bloody, inflamed, edematous mess of an airway to work with.
Combitubes similarly suck. Its a weekly occurrence in my world where I look at either of those two devices and go "Awww, maaaan!"

Just take a look at the I-Gel body. Its like saying "Here; let me try and fit this TV remote into your airway. Lolz."

Instead; have EMS blindly place the LMA and avoid all the trauma. Its the same as an I-Suck, without the big stupid body and unnecessary plastic. I-Gel has no role in any airway, IMO. LMA >>> I-Gel.

Look at the picture below. I-Gel is on the left, LMA on the right.
Find the one that doesn't suck.
Done? Good.
Now, find the one that looks the LEAST like a big blue plastic dick.
Same one ? Good. Use THAT one.

You Win !

(southerndoc; you know I love you. Its late, I had a loooong, HARD shaft... er, SHIFT, and I'm two glasses of Merlot deep.)

EDIT: This was post #1984 for me. 1984! Big Brother is Watching! Guaranteed this gets deleted.

 

[RustedFox]

Now, in all seriousness, here's what I'm going to do with my next ten "easy" airways:

1. Open airway, place oldschool laryngoscope.
2. Place LMA.
3. Remove laryngoscope. Bag 'em up.
4. Once SaO2 = 100%, then grab bronchoscope (new toy!) and thread it down LMA.
5. Take a good look.
6. Intubate airway with bronchoscope.
7. Pass ETT over bronchoscope. Picture below is worth a thousand words, just replace the iDICK with an LMA.

http://ekja.org/ArticleImage/0011KJAE/kjae-65-61-g002-l.jpg

Or... SNAP ! - I'll thread the bronchoscope down the iDICK (when the next AirwayMess comes in) and see if that works, too.

Goodnight. Lolz.

 

[BAM!]

Now, in all seriousness, here's what I'm going to do with my next ten "easy" airways:

1. Open airway, place oldschool laryngoscope.
2. Place LMA.
3. Remove laryngoscope. Bag 'em up.
4. Once SaO2 = 100%, then grab bronchoscope (new toy!) and thread it down LMA.
5. Take a good look.
6. Intubate airway with bronchoscope.
7. Pass ETT over bronchoscope. Picture below is worth a thousand words, just replace the iDICK with an LMA.

http://ekja.org/ArticleImage/0011KJAE/kjae-65-61-g002-l.jpg

Or... SNAP ! - I'll thread the bronchoscope down the iDICK (when the next AirwayMess comes in) and see if that works, too.

Goodnight. Lolz.

Does yours have a video hookup? looking down the end of the handle is a pain.

 

[Doctor Bob]

I use the iGel in our interventional pulmonary suite. It works pretty well but you don't get the same hard resistance point as you do with an LMA. If you're seeing a lot of raw edematous airways after removal, then they're probably cramming the thing in too hard and too deep (... ...); a common problem with EMS airways. It's probably less of a device issue and more of an operator issue.

 

[RustedFox]

Does yours have a video hookup? looking down the end of the handle is a pain.

Don't know about video hookups, as I also didn't know that we had this toy until DChristismi said so yesterday. Now, I want to play with it. I know that we also have one at my OtherJob, but no video hookup. I'll have to look down the handle.

 

[Janders]

(1) Solid work
(2) Bougie through LMA is a good trick. Bronch through LMA is a good fancy trick. If I could figure a way to shove my glidescope into the LMA, I'd retire having won the game.
(3) One of my partners LOVES LMAs. More specifically, he loves intubating LMAs. Get some for your shop. They are great for "pre" oxygenating (LMA with a BVM and a PEEP valve will get you excellent sats) the truly ill; they are great for codes / floor crashes (issue in PACU? throw in the LMA! Issue on the floor? throw in the LMA! issue in the back of the bus? throw in the LMA!). One you bag them up via the LMA (or get ROSC... whatever the issue), everyone can take a deep breath and calmly use the special flexible tube and intubate through them. We have LMA Fast Track brand ones...

Being a small place where during the middle of the night often the only "airway" person is the ED doc, we've been encouraging the rest of the hospital to get comfortable throwing LMAs in... easy and buy time for ED / Anesthesia to get there and help.

 

[RustedFox]

Someone please explain to me what makes an "intubating LMA" an "intubating LMA", please.
Seems like a regular old LMA did the trick.

 

[Arcan57]

Someone please explain to me what makes an "intubating LMA" an "intubating LMA", please.
Seems like a regular old LMA did the trick.

It's got the flap that directs the tube anteriorly. Bougie probably works through a similar mechanism. i-LMAs tend to work ok but there's a moment where you're extracting the LMA off the tube that it seems should result in the tube being pulled cephalad out of the trachea. It doesn't, but it creates a pretty tight sphincter tone. Have you had any experience with King tubes via EMS? These seem to result in less blatant f'-ups than Combitubes and I haven't seen the significant airway edema you describe with the i-Gel.

 

[Hoya11]

Now, in all seriousness, here's what I'm going to do with my next ten "easy" airways:

1. Open airway, place oldschool laryngoscope.
2. Place LMA.
3. Remove laryngoscope. Bag 'em up.
4. Once SaO2 = 100%, then grab bronchoscope (new toy!) and thread it down LMA.
5. Take a good look.
6. Intubate airway with bronchoscope.
7. Pass ETT over bronchoscope. Picture below is worth a thousand words, just replace the iDICK with an LMA.

http://ekja.org/ArticleImage/0011KJAE/kjae-65-61-g002-l.jpg

Or... SNAP ! - I'll thread the bronchoscope down the iDICK (when the next AirwayMess comes in) and see if that works, too.

Goodnight. Lolz.

Why do you need a laryngoscope to place an LMA?

An "intubating" LMA, if you look closely at it vs a regular LMA, is shorter overall. This means you can more easily remove it over an ETT that has been placed through it, you can also put the tube deeper down the trachea, because sometimes when you intubate through a regular LMA, you can only just barely get the cuff through the cords if at all, before you run out of tube inside the LMA.

Also, i consider the igel to be a type of LMA, not sure what the difference is, its like an LMA supreme (OG tube included) from what I can tell.

Also, you can intubate through a regular LMA with a FO scope , bougie, or just even use a tube. Using a bougie im not sure how that helps, just put the tube through it, blow up the cuff, and see if your in. If you understnad what an LMA does, you should understand that a bougie would not help, the LMA finds the tracheal opening and anything you put through it should end up finding its way into the airway.

To get an LMA OUT once the tube has been passed through it you need to use a tube extender (or macgyver some smaller tube inside of the other tube) so have a plan for that.

 

[RustedFox]

You don't need a laryngoscope to place the LMA. I just like "taking a look", cause you never know what you'll find. I've found undigested pills, foreign bodies etc. just by "looking".

 

[dchristismi]

I think my experience with the igels reflect Foxy's - it's probably operator error, and IME, they aren't secured well and always seem halfway out. Maybe that's just how they are, and maybe it's the securing device, but I am not a fan. Of course, once someone's been mucking in an airway, it's never as good as the first shot.

I once saw a huge chunk of steak obstructing the entire larynx - intermittently, thankfully for her sake. The family was like "alright, who gave grandma the steak??? Grandma, why didn't you chew it???"
I never really thought about it academically, but I also like to look first with the good old mac. One never knows what one might find.

 

[Janders]

Someone please explain to me what makes an "intubating LMA" an "intubating LMA", please.
Seems like a regular old LMA did the trick.

So as mentioned above, you can totally intubate through a normal old LMA. Especially if you have bronch/FO capabilities.

That said, the intubating LMAs I am familiar with have a couple of features that make it easier to pass an ETT through them, especially blindly:
(1) It is overall shorter, so you can get a tube down it all to way past the cords
(2) It is overall wider, so you can throw a cuffed 8.0 ETT down it.
(3) It has a solid handle on it, easier to hold it securely while you shove things in and out of it
(4) It has a little plastic bar at the aperture, which elevates the epiglottis out of the way when the tube comes down and lifts it!
(5) The disposable ones are clear with length markings on the side, helpful to see how far your tube is in
(6) It comes with a SPECIAL ETT which is extra-flexible to make it easier to push through the LMA
(7) It comes with a SPECIAL obturator / stabalizing rod, which you insert into the end of the ETT after you've intubated, to hold it in place while you remove the LMA.

Just call 1-800-Janders-401k to order now!

 

[BAM!]

One thing to keep in mind is that intubating-LMAs have a large rigid handle on them. It sticks out at an angle from the tube. This can be very cumbersome and awkward. Not to mention the tube portion is very rigid and makes a J-shaped turn. This can be very hard to get into the patient's mouth. MUCH HARDER than a lubed up LMA, or an ET tube. For this reason, many people (myself included) don't like them.

 

[JerseyED]

Sooooo... I don't get why no one has mentioned putting the bougie down the iGel in the first place. (The rep in our shop actually stated that it is an intubating LMA, but I found that way to cumbersome - though definitely feasible.) If you have a moment and a flex scope, put in an iGel in (even in a mannequin) and take a look - nothing but cords.

 

[TooMuchResearch]

Thank you for a thread unlike most other recent threads.

 

[RustedFox]

In response to "Bougie down the i-GEL in the first place":

Yeah, I'm totally doing that, next time. The only reason I have not yet done that is because.... I was trained to intubate via DL, and hate the i-GEL for all the nonsense that it brings me.

Seriously... take a look at those plastic "wings" around the tube. WTF ?!

an I-GEL is just a bulkier LMA. No advantage. Bye-bye, i-GEL... meet your new friends, the walkman and the VCR.

 

[tkim]

LMA looks like vagina-on-a-stick. I know everyone was thinking that, but were too polite to say it.

 

[RustedFox]

Sooooo... I don't get why no one has mentioned putting the bougie down the iGel in the first place. (The rep in our shop actually stated that it is an intubating LMA, but I found that way to cumbersome - though definitely feasible.) If you have a moment and a flex scope, put in an iGel in (even in a mannequin) and take a look - nothing but cords.

UPDATE:

Had a case today with an i-GEL as well; sadly, a 44 year-old female arrest. Unresponsive. Asystole. No idea what could have caused her to arrest. According to husband; they were at a restaurant, enjoying a meal and a few beers when she went up to go use the ladies room and just didn't come back after awhile. EMS found her on the toilet, pulseless. After the fact, dChristismi looks at me and says: "Blew an aneurysm?" Who knows.

I-gel in place. I thread the bougie down the I-gel and remove it, then pass the ETT over bougie. Good color change, condensation in the tube... and a rapidly inflating stomach. Nevermind the SaO2, she was cold long before she got to us. I pulled the BVM off of the ETT and pushed on the abdomen. Big gush of air right back in my face. Thank God for my safety specs. I went ahead and intubated her via DL through the mess that the i-GEL left me.

Reason #3 why LMA >>>> i-GEL.

 

[Birdstrike]

LMA looks like vagina-on-a-stick

No home model available by chance? Just need to know, you know, for a "friend."

 

[southerndoc]

]I-gel in place. I thread the bougie down the I-gel and remove it, then pass the ETT over bougie. Good color change, condensation in the tube... and a rapidly inflating stomach. Nevermind the SaO2, she was cold long before she got to us. I pulled the BVM off of the ETT and pushed on the abdomen. Big gush of air right back in my face. Thank God for my safety specs. I went ahead and intubated her via DL through the mess that the i-GEL left me.

Reason #3 why LMA >>>> i-GEL.

Why would you do this? The i-Gel is not like an intubating LMA.

Ron Walls supports the i-Gel. 'nuff said for me to support it. He's the EM airway king.

 

[sanityonleave]

UPDATE:

Had a case today with an i-GEL as well; sadly, a 44 year-old female arrest. Unresponsive. Asystole. No idea what could have caused her to arrest. According to husband; they were at a restaurant, enjoying a meal and a few beers when she went up to go use the ladies room and just didn't come back after awhile. EMS found her on the toilet, pulseless. After the fact, dChristismi looks at me and says: "Blew an aneurysm?" Who knows.

I-gel in place. I thread the bougie down the I-gel and remove it, then pass the ETT over bougie. Good color change, condensation in the tube... and a rapidly inflating stomach. Nevermind the SaO2, she was cold long before she got to us. I pulled the BVM off of the ETT and pushed on the abdomen. Big gush of air right back in my face. Thank God for my safety specs. I went ahead and intubated her via DL through the mess that the i-GEL left me.

Reason #3 why LMA >>>> i-GEL.

Heroin? That's always my first assumption when someone ends up pulseless on the john. Maybe I'm just jaded from the amount of heroin addiction we're seeing these days (and so much of it white and suburban, too).

I haven't had experience with the i-GEL, but the bougie-through-the-LMA trick sounds awesome. I'll definitely put that to use.

 

[Old_Mil]

"Stick the bougie down the LMA?" Sho'nuff. Bougie down LMA, ETT over bougie. Guy didn't drop his sats, placement confirmed via CXR.

This was mentioned once on here before. Hell, it may have been me that posted the idea; but I ... at that hot minute.... did not think of it.

It works, boys and girls. It works.

Glad to hear it worked, we had this discussion at the last Ron Walls course that I went to while we were playing around with the equipment and the thought was that it might not work because of the geometry of the LMA.

(issue in PACU? throw in the LMA! Issue on the floor? throw in the LMA! issue in the back of the bus? throw in the LMA!)

Yeah, I am using LMAs a lot more than I ever did in residency. Espeically on codes.

 

[RustedFox]

Why would you do this? The i-Gel is not like an intubating LMA.

Ron Walls supports the i-Gel. 'nuff said for me to support it. He's the EM airway king.

I did this because (read prior posts in thread; someone even said the iSUCK was an intubating LMA).\

Now.... n = 1, but it didn't work.

LMA >>> iGEL.

 

[deleted59964]

hi EM folk

I've used iGels a bit - my opinion is

• they either work or not, since cant play with inflation of cuff.
• sometimes they work better after they warm and soften up.
• have used them only electively (anaesthetics) - no issues from airway trauma or from them sitting halfway out ... this is operator dependant
• the "wings" on the side are a bite block ... when we wake up young patients with them they sometimes bite down, occluding the LMA - and if left occluded can result in negative pressure pulmonary edema.

whether they're any good prehospital - I leave to you guys ... not my field.

 

[deleted59964]

ps the epiglottic elevator bars in intubating LMA's are hinged - to allow easy passage of the ETT

 

[Apollyon]

OK, folks, I write this as both an EM doc, and a paramedic. LMAs are **** in the field. They are NOT secure. Period. Any field medic will tell you that. Hell, the anesthesiologists will tell you the LMA is for the ASA1's and MAYBE 2s, who are the chip shots. Zero aspiration protection (and, of course, I know that the ETT will also allow microaspiration), and great for an immobile patient. However, it's a fool's errand to use one regularly in EMS situations.

As far as the iGel, I've never used it, but I like the King airway. Can't screw it up!

 

[pseudoknot]

The iGel is a type of LMA. I don't have personal experience with it.

Remember there are a bunch of different LMAs and even many "intubating LMAs." I'd had great experiences with the CookGas Air-Q LMAs, through which you can intubate.

Be careful about the bougie through LMA idea. It seems appealing but a cadaver study had a 50% success rate doing this: http://www.ncbi.nlm.nih.gov/pubmed/20411068

Blind intubation through some of these devices may actually have a higher success rate. As noted above, if you have a bronchoscope then it is usually trivial to intubate through them.