I was fortunate last night to be able to catch up with Tim Leeuwenberg of ruraldoctors.net when he flew in to Melbourne for the ETMCourse. Along with a very convivial dinner at Bistro Vue on Little Collins street, we managed to bash out a quick podcast as well. We discussed a little of life as a paramedic, treatment of Acute Pulmonary Oedema by MICA Paramedics, and of course the obligatory bit on airway management.
The podcast can be found here at ruraldoctors.net. As always feedback is welcomed.
One thing we did discuss was the recent guidelines from the Royal College of Surgeons Faculty of Prehospital Care on the use of Pharmacologically Assisted Laryngeal Mask insertion (PALM). This has been discussed by Cliff Reid and others over at resus.me.
As I mention in Tim’s podcast, this procedure makes me more than a little uneasy. Obviously there are many ways to go about managing an airway and I am generally hesitant to opine that there is a right way or a wrong way. This best way is that which achieves good outcomes for the patient. Nevertheless I do have misgivings about PALM. I have to admit that I have a reasonably black and white world view about prehospital drug assisted airway management. I believe that it is something that needs to be done properly or not at all. It seems to me that PALM is sort of a half-baked measure where RSI would be the more appropriate intervention. As Minh Le Cong mentions over at resus.me, LMAs are not the most secure of airways. They may reduce aspiration and they may make it easier to oxygenate and ventilate, but they do neither as well as a cuffed tube in the trachea. When we start adding sedation to the mix, it would seem that we are going to make things even more hairy. If a cuffed tube is needed in the trachea I believe that this should be delivered, if not through RSI, then through cricothyrotomy.
There may of course be situations where it is appropriate to try this approach in some patients being managed by some practitioners who are RSI positive. However I think that instituting it as alternative to definitive airway management would be a mistake.
Of course supraglottic airways are, in many places, replacing intubation as the airway of choice in the out of hospital cardiac arrest (OOHCA) patient. This is due to the unacceptable interruptions that have often come with attempts at intubation. As I have mentioned in previous podcasts I don’t believe that there is any need to interrupt CPR to intubate. I also think it is important to make the distinction between the patient with intact airway reflexes and/or trismus and the newly (hopefully temporarily) dead. The OOHCA patient is, by definition, as far down the curve as it is possible to be. The worst that can happen, has happened already, which may not be the case for other patients. Furthermore, the benefit from having no delay or interruptions to CPR and defib is likely to outweigh any potential harm from having less than a gold standard airway in place. The same may not be able to said for the living patient.
Anyway, head over to ruraldoctors.net and have a listen to me pontificate on this and many other issues, and let me know what you think.