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Sun, 17 Mar 2002 19:04:03 +1100

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I hate that phrase "gold standard". Mainly because there is little to
justify it in the majority of situations where it is used. This particular
issue is an area crying out fro some decent studies, certainlt what is
available at the moment would not support the use of tracheal intubation in
the majority of EMS. For an up to date, objective review of this subject:

Jerry Nolan from the UK has written an excellent  recent review on this
subject. Nolan JD. Prehospital and resuscitative airway care: should the
gold standard be reassessed?. [Review] [90 refs] Current Opinion in Critical
Care. 7(6):413-21, 2001 Dec.  Abstract: In the context of prehospital care
and resuscitation, tracheal intubation has been regarded as the standard in
airway treatment. The evidence for this status is rather weak. It does not
take into account the level of training and experience of the personnel
attempting intubation, and whether they use neuromuscular blockers. In
unskilled hands, attempted tracheal intubation is harmful; unrecognized
esophageal intubation is disastrous. When healthcare providers lack adequate
skills in tracheal intubation, alternative airway devices, such as the
laryngeal mask airway or the Combitube, may be better options than a simple
facemask. Healthcare personnel using any of these devices should be
adequately trained and maintain frequent practice. [References: 90] 

Mike

-----Original Message-----
From: MARK FORREST [mailto:atacc.doc@virgin.net]
Sent: Sunday, March 17, 2002 11:21 AM
To: trauma-list@trauma.org
Subject: Re: Combitube/LMA-overstated risk!?

I couldn't agree more Ian!
I also agree with Pete Barrett about Rowley's comments....how can LMA be
acceptable in the unfasted arrest patient, but not a trauma victim....curry
and beer is curry and beer!!??
On question that interests me is what kind of tubes are the early 'surgical
airway' supporters using. The Cook ones mentioned, although great to use,
are uncuffed and do not remove aspiration risk (although avoiding gastric
inflation).

Some paramedical groups in the UK use size 6.0, cuffed tracheostomy tubes
for surgical airways, with great apparent success and low aspiration risk.

Finally, I would say that we all agree that ETT is gold standard, and if you
are trained and familiar with Combitube then use it, alternatively use the
LMA, simple and safe, which as Peter B says, provides an excellent conduit
for subsequent fibre-optic of Aintree catheter intubation.

Incidentally, more and more of my anaesthetic colleagues are using LMA,
spontaneous breathing + Aintree catheter +scope for difficult intubations
and doing fewer awake intubations, unless essential
Regards
Mark F
----- Original Message -----
From: "Ian Seppelt" <SeppelI@wahs.nsw.gov.au>
To: <Matthew.Wilson@cshs.org>; <trauma-list@trauma.org>
Sent: Friday, March 15, 2002 3:54 AM
Subject: RE: Combitube

I think my first post was misinterpreted a bit.
Agree totally with everyone who says ETT is gold standard. However given
choice of no airway and hypoxic patient (eg after failed intubation or not
trained to intubate, and not trained to do cric) I would choose LMA over a
combitube everytime. Based on other responses on this list, I gather most
people except American paramedics feels similarly. NB: in the NSW Ambulance
paramedics intubate but are not trained to do a surgical airway, so given
the choice of 'can't intubate and 20 minutes of hypoxia in the ambulance'
and 'can't intubate so put in a laryngeal mask' there is no question. There
very little technical skill required to get a good airway with an LMA. The
risk of airway soiling is overstated. Even in patients intubated prehospital
it is common to get some airway soiling and it is usually benign - lots of
ICU patients aspirated at some point but very very few die of it.

Cheers,
Ian Seppelt
Nepean Hospital, Sydney.

>>> Matthew.Wilson@cshs.org 03/15/02 04:29am >>>
Use whatver you are best trained to use.  The question is if given an
option, what then is best?  ETT is the gold standard.  All the rest have
some degree of difficulty associated with them.

> ----------
> From: Jeff Brosius[SMTP:medic245@mindspring.com]
> Reply To: trauma-list@trauma.org
> Sent: Thursday, March 14, 2002 3:15 AM
> To: trauma-list@trauma.org
> Subject: Re: Combitube
>
> Reading with interest the commentary on the Combi-Tube.  To quote Spock:
> "Fascinating."
>
> What is the consensus for the management of the airway in the case that
> ETT
> cannot be done for (**insert reason here...unable to visualize, clenched
> teeth w/o RSI, funky anatomy, poor skill of the medic, etc.**)???
>
> Please assume a 20 minute transport, no helicopter available, limited
> resources (call it two people in the back of the ambulance,) and no MD on
> the scene.
>
> Interested to hear what y'all think.  It just might help me treat my
> patients a little better.  For the record, I like the ETT first, and the
> Combi-Tube as my bail-out device.
>
> Best,
>
> Jeff Brosius
> Paramedic, etc.
> Atlanta, GA
> medic245@mindspring.com
> "The fate of the wounded rest
> in the hands of the one that
> applies the first dressing."
> -- Nicholas Senn, 1896
>
>
> ----- Original Message -----
> From: "Holmes John" <Jholmes@mater.org.au>
> To: <trauma-list@trauma.org>
> Cc: "Ian Seppelt" <SeppelI@wahs.nsw.gov.au>
> Sent: Wednesday, March 13, 2002 6:35 PM
> Subject: Re: Combitube
>
>
> > I agree, I think combitubes are inappropriate and dangerous given the
> > infrequency that they would be used.  However, the LMA is not a
> definitive
> > airway either - especially in emergent situations.  Paramedics must
> realise
> > that ETT is always the gold standard -  any other artificial airway
> (other
> > than cuffed crich) is always a compromise and should ONLY be used to
> > retrieve a situation where there is no other way of ventilating.  Bag
> and
> > valve ventilation (spont or controlled) is an OK short term measure in
> most
> > cases - but fundamentally, if an artificial airway and positive pressure
> > ventilation is mandated by the clinical scenario, then a cuffed ETT is
> the
> > only way to go.
> >
> > John L Holmes
> > Director Emergency Medicine
> > Mater Health Services, Brisbane
> >  ----------
> > From: Ian Seppelt
> > To: ncielens@bigpond.com; trauma-list@trauma.org
> > Subject: Re: Combitube
> > Date: Wednesday, 13 March 2002 19:50
> >
> > Simple answer - they are big nasty dangerous things with major
> complications
> > and there is a much better alternative (the laryngeal mask airway).
> > Considered by the NSW Ambulance and rejected as inappropriate and
> dangerous.
> > I wouldn't go near the bloody things if I were you
> >
> > Cheers,
> > Ian Seppelt
> > Staff Specialist in Anaesthesia and Intensive Care
> > Nepean Hospital, Sydney, and
> > Flight Physician, NRMA Careflight.
> >
> > >>> ncielens@bigpond.com 03/06/02 01:42pm >>>
> > Hello all,
> >
> > Late last year there was a thread on pre-hospital airway management by
> > paramedics. I am about to write a paper on the suitablility of the
> Combitube
> > (double-lumen oesophageal tracheal airway) for my ambulance service in
> > Victoria Australia as part of my final year of training. I am after
> > information from other services who use the Combitube. In particular, I
> am
> > after their protocols (guidelines) for its use, including emergency
> > indications, precautions, contra-indications and method of insertion. If
> you
> > also have any stats on its success (or lack of) and other problems (or
> > advantages) encountered from its use, it would be greatly appreciated.
> >
> > As this topic has already been covered before please feel free to email
> > directly to me or the mailing list as you see fit.
> >
> > Thanks in advance.
> >
> > Nanto Cielens
> > Ambulance Paramedic
> > Metropolitan Ambulance Service
> > Victoria, Australia
> >
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Combitube/LMA-overstated risk!?