I got to insert an LMA the other day. I had previously done one when I was in the Dominican as part of a surgical medical mission team. The anaesthesiologist let me put one in on a patient who was having a hernia repaired. I slipped it in, and then that was that. I went back to my post in the post-op area.

Here’s how my first field LMA went.

Fifty-year-old obese lady. Witnessed arrest by onlookers, but no shock advised when the first responders got there. Asystole for us. The first time I went in for the tube, I couldn’t see anything. The lady had a significant overbit and I had trouble getting the mouth open wide enough. There wasn’t any emesis in the airway. I was just looking at tongue and throat. No chords, no epiglottis. After bagging some, I put a pillow under her head, and also got out the bougie. The problem with the bougie was to store in our house bag, it gets rolled up, so it was sort of hard to manipulate. I didn’t see anything, but gave it a try passing it. It just kept going down so I knew I wasn’t in.

A couple of years ago, we changed our protocols so that medics were limited to two intubation attempts defined as inserting the blade into the mouth, not attempts to pass the tube. So far I have gotten all my tubes within the two-attempt limit. I wondered what I would do when forced for the first time to not go in a third time. Technically we can go in a third time, but we have to have a pretty good reason for it. I suppose I might have if I had seen the chords and was sure I could get it, but I was lost on this airway, so I put in the LMA.

I had been thinking about doing an LMA on a code — we can use it as an alternative instead of a backup airway, but the truth is I like intubating and never wanted to give up a tube. I was talking with a medic about LMAs the other day, and while I didn’t say it, my reaction was, I’d put one in, but I always get the tube.

It has in fact been quite a number of years since I haven’t gotten the tube — and I have had some tough tubes, including a five hundred pounder — but maybe he was just an easy tube despite his weight. It has certainly made me a bit cocky. Again, every time someone tells me about a hard tube and how they had to go to a backup airway, I think, I probably would have gotten the tube.

When I was in paramedic school, I zipped in my first 9 tubes in the ER, thinking man this is easy. Then I missed my next three (possibly my next four) and was quite shaken by it. I had some trouble intubating early on in my career, but I had thought now that I was skilled enough that I could intubate anyone, Mallanpotti be damned. And maybe I would have gotten the tube in this lady. Of course it might have taken me a couple more attempts, which wouldn’t have been good for her at all to try so many times.

The LMA went in quick and easy, and held in place through a difficult extrication. We maintained excellent capnography throughout so she was getting well ventilated. I did detect a bit of abdominal distension so the seal mustn’t have pristine. Still overall I was very impressed. I can tube pretty quickly but the LMA was in in less time than it takes me to open up the ET roll, take out a a sterile tube, stylet and attach a syringe. It was open up the package, attach the syringe, check the inflation, deflate, open the mouth and slide it in. Good to go. Very quick.

But I am finding myself still thinking about not getting the tube. It’s like a puzzle I got two attempts to solve, but they won’t let me play again. I try to figure out how I could have approached it differently, and wonder where the key to it lay. I guess I’ll never know. And I hope my cockiness is not dooming me to a string of difficult airways ahead(maybe all these tubes I have been zipping in have just been a two year strek of easy or lucky tubes). But if a bad streak does come, and it might well, I’ve got the LMA now watching my back.

I’ll keep you posted.


  • medicblog999 says:

    We in the UK have recently been put in the very strange position of now having to class LMA as our first choice advanced airway and are at risk of losing our tubes altogether. The body that provides all of our guidance, the joint royal colleges ambulance liason committee, has deemed that it is safer to use LMA than ET tube. I have had alot of practice with LMA as we can use them as an advaned technician (EMT-B) and I have had frequent trouble with maintaining a good seal and displacement of the device but, hey go, we just do as we are told. I am like you, I haven’t had much problem with tubing patients and it really feels like they are taking one of my fundemental skills off me. I am just about to trial the iGel LMA for my service, so hopefully this will be better, also beause they are telling us not to use ET tubes wherever possible, they are giving us IO guns, so that we always have a secondary drug route. I guess we just have to work on “best evidence based practice” and not let our personal comfort blankets get in the way (I will miss my tubes!!)

  • Anonymous says:

    The problem with JRCALC is that they probably have not had to maintain an airway in the prehospital environment. It is all very well saying that the evidence does not support the use of ETI in the field, but it is still the gold standard of airway management and the only way to truly protect an airway in an emergency. Admittedly, most of the people we intubate in the UK are in cardiac arrest, but I have had the odd obtunded head injury who I have been able to intubate. I would like to see contemporary UK evidence used to make this decision, rather than relying on the current evidence base, a lot of which can not be directly assimilated to the current situation.

  • Walt Trachim says:

    New Hampshire protocols allow the LMA, King-LT, and CombiTube to be used as alternate devices when intubation isn’t possible or has failed. Device use is based on the choice of the service. At the two places I work at up here, one carries CombiTubes and the other carries the King-LT. And it’s always good to remember that no matter which alternate is used they all have pros and cons. There are people I know who swear up and down that the King is the best alternate out there, while others like the CombiTube and yet others love the LMA. It is an ongoing debate – not a bad thing, in my opinion.Also, I have to point out that that the AHA would disagree about intubation being the “gold standard” of airway management, as they modified their stance on it in the 2005 ECC guidelines. They say the following:”The endotracheal tube was once considered the optimal method of managing the airway during cardiac arrest. it is now clear, however, that the incidence of complications is unacceptably high when intubation is performed by inexperienced providers or monitoring of tube placement is inadequate. The optimal method of managing the airway during cardiac arrest will vary based on provider experience, emergency medical services (ems) or healthcare system characteristics, and the patient’s condition.”Again, these are not my words and not necessarily my viewpoint. I’m simply pointing out what’s been said about this subject.

  • Gertrude says:

    We have the ILMA in our system and the King. On my last difficult to tube patient I popped in the ILMA and whileI still had difficulty tubing through it I had great bag compliance, chest rise, color change and lung sounds. So I agree the LMA is a great tool to have and works much better (in my mind) than the combi-tube.

  • fiznat says:

    You know whats more frustrating? Knowing that you’re not prepared for your next intubation attempt. I got two tubes last year. T W O. How can I (and people like me) expect to maintain proficiency when thats all the practice we get? Maybe I’d better brush up on my backup airways just in case…

  • Tom B says:

    Wake County EMS has a 37% save rate (49% in the City of Raleigh) and they use the King LT as the primary airway about 80% of the time. It doesn’t interrupt chest compressions, and it’s becoming increasingly clear that uninterrupted chest compressions save people in cardiac arrest. The impedance threshold device (ResQPod) and induced hypothermia also helps.Walt Trachim quoted the evidence based guidelines, and I applaud him for it! It amazes me how we in EMS (on the whole) tend to dismiss evidence based guidelines we don’t like.There are a minority of EMS systems who do a great job with tracheal intubation. But they are the same EMS systems who utilize experienced providers with strict quality controls, a defined number of intubations to maintain competence, and an atmosphere of continuing quality improvement.Even if you have these things in place, it may turn out that cardiac arrest patients do better when compressions are not interrupted for the sake of putting a tube in the right hole. Time will tell. But most EMS systems do not have these things in place, and should take a long, hard look in the mirror.It’s time we start measuring our success.

  • Rogue Medic says:

    Tom B., I agree. We also need to look at the reasons for managing the airway of not-quite-dead-yet patients. In a cardiac arrest, our goal is resuscitation. Yet, when the patient is alive, and maybe awake, the goal is entirely different. We want to keep the patient from dying, but we also want to avoid making the patient worse.Head injured patients were mentioned. These are a bit of a special case. What is the best method to avoid raising the intracranial pressure? We do not know. Too much time attempting an ETT is bad. Stuffing things in the patient’s mouth is bad. Using lidocaine is something that is alleged to prevent increases in ICP, but is it just wishful thinking? Is it a good idea to give people with apparent head injuries a drug that may cause seizures (lidocaine)? Using paralytics makes a lot of people uncomfortable with alternative airways, but is it bad to use a paralytic with the intent of placing an alternative airway?Rapid Sequence Airway (RSA)–a novel approach to prehospital airway management.Prehosp Emerg Care. 2007 Apr-Jun;11(2):250-2.Braude D, Richards M.Department of Emergency Medicine, University of New Mexico, Albuquerque, NM 87131-0001, USA. dbraude@salud.unm.eduThis article presents a case in which an air medical flight crew encountered a potentially difficult airway when a trauma patient deteriorated in-flight. The crew elected to sedate and paralyze the patient and place a laryngeal mask airway without a prior attempt at direct laryngoscopy and endotracheal intubation. The term Rapid Sequence Airway (RSA) is coined for this novel approach. This article describes and supports this concept and provides definitions of alternative and failed airways.PMID: 17454819 [PubMed – indexed for MEDLINE]

  • Anonymous says:

    You can’t possibly remain skilled or proficiant with only two intubations a year. I don’t know what the standard is or if there even is one but two isn’t it. I work in a busy urban based system and have had two intubations this month, with a third missed. In regards to LMA’s in PA the King tube is becomming more popular so I can’t say which I would perfer. But when it comes to ‘missing’ and sticking to the rules neither is easy.

  • Herbie says:

    I can count on one hand how many intubations I’ve missed in the past 7 years. But it does happen.I prefer the Combi-Tube or the King.

  • TOTWTYTR says:

    The “Gold Standard” is not a device, it is a result. What we are looking for is adequate ventilation, by whatever means works the best. This is the time when we should NOT let out paramedic sized egos get in the way of what is best for the patient. I’ve transported many patients, not just cardiac arrest patients, with an OPA and a BVM. Some of them I’ve not even attempted to intubate even though I knew they would be as soon as we got to the ED. The device matters not at all, the result matters above all else. Strong work, Peter. PS. The two attempt rule is a dumb attempt to achieve a good result. I’d guess that the rationale is that some medics would spend too much time trying to get the tube to the detriment of the patient. It says something not reassuring about the regard in which the people who write the rules hold medics in the system. That’s sad.

  • Love in a Firetruck says:

    I’m guessing the LMA is akin to a combi-tube? Where I run a basic is allowed to use a combi-tube per protocols. However, I have yet to do one in the field because the medics usually arrive on scene quite rapidly.

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