Sierra – Sacramento Valley EMS Agency EMT King LT-D Airway Device Optional Skill (Updated 06/2017)

In order for EMT personnel to utilize a King LT-D airway device, they must: Be part of the organized EMS system, functioning under the oversight of an S-SV EMS approved BLS optional skills provider Be authorized by the approved BLS optional skills provider to utilize the King LT-D airway device Have received adequate training on the utilization of the King LT-D airway device

Education/Training Purpose and Objectives To enable authorized EMT personnel to utilize the King LT-D airway device in the prehospital setting Objectives – describe/demonstrate Advantages and disadvantages of utilizing the King LT-D Indications and contraindications for utilizing the King LT-D Components and sizing of the King LT-D Placement and confirmation procedures for the King LT-D Tips, troubleshooting and removal steps for the King LT-D

King LT-D Advantages Disadvantages Indications Contraindications Design/Components Sizing Information

King LT-D Overview King LT-D Advantages Smaller than other devices (e.g., Combitube) More cost-effective than other options Easier/quicker to place (single port, single tube) Does not require interruption of CPR during placement Little or no spinal movement during placement Provides a means for positive pressure ventilation Minimizes gastric insufflation Available in multiple sizes based on patient size

King LT-D Overview King LT-D Disadvantages Patient must be unresponsive with no gag reflex Still a risk of aspiration May decrease cerebral blood flow

King LT-D Overview King LT-D Indications Cardiac arrest Respiratory arrest or severe compromise and unable to adequately ventilate with BVM King LT-D Relative Indications Sustained altered mental status with a GCS ≤ 8 Impending airway edema in the setting of respiratory tract burns or anaphylaxis

King LT-D Overview King LT-D Contraindications Patients under 4 feet tall Responsive patient with intact gag reflex Patients with known esophageal disease (esophageal varices, etc.) Patients who have ingested a caustic substance

King LT-D design/components King LT-D Overview King LT-D design/components

King LT-D Overview King LT-D design/ components Plastic wrapped package includes: King LT-D airway 60 mL syringe Water soluble lubricating jelly

King LT-D Overview King LT-D design/components Imprinted on the side of the airway you will find: Airway size Depth markings in cm How many mls of air required to properly inflate cuffs

King LT-D Overview King LT-D design/ components The primary ventilation opening is located just below the proximal cuff Additional ventilation holes are located on each side of the primary ventilation opening

King LT-D Overview King LT-D sizing

King LT-D Insertion Procedure Confirmation Procedure Tips Troubleshooting Removal Additional Requirements

King LT-D Insertion Procedure Ensure adequate BLS airway Choose correct size King LT-D airway Pre-oxygenate patient Provide BVM ventilation with 100% O2 May also apply/utilize a nasal cannula with high flow O2 for the duration of the procedure if an additional O2 source is available

King LT-D Insertion Procedure Test cuffs for air leak Draw correct amount of air into packaged 60 mL syringe Attach syringe to the cuff port valve and fully inflate Detach syringe and check cuff for leaks Deflate cuffs

King LT-D Insertion Procedure Position the head “Sniffing position” is ideal A neutral position can also be used if trauma is suspected Perform a chin lift Use caution on patients requiring c- spine precautions

King LT-D Insertion Procedure Lubricate distal end of airway with water soluble jelly Avoid introduction of lubricant in or near the ventilatory openings

King LT-D Insertion Procedure Apply the airway Introduce tip into mouth Advance tip behind base of the tongue while rotating tube back into midline Blue orientation line imprinted on tube should face the patient’s chin

King LT-D Insertion Procedure Apply the airway (cont.) Without exerting excess force, advance tube until base of connector is aligned with teeth or gums

King LT-D Insertion Procedure Apply the airway (cont.) Inflate cuff with initial amount of air Size 3 = 50 ml Size 4 = 70 ml Size 5 = 80 ml Important – Remove syringe from inflation port immediately after inflation

King LT-D Insertion Procedure Apply the airway (cont.) Attach BVM and ventilate Slowly withdraw the device until ventilation is easy and free flowing Minimal retraction is usually needed to achieve the best air flow – if significant resistance to flow is met after retraction, it is likely that the device is not in the correct position and should be removed

King LT-D Insertion Procedure Apply the airway (cont.) Correct airway placement must be confirmed utilizing all of the following: Chest rise and fall Presence of lung sounds Absence of epigastric sounds ETCO2 detector color change

King LT-D Insertion Procedure Secure/maintain device Consider securing with tape or commercial ET tube holder Securing with tape or ET tube holder not required, but recommended With cuffs inflated device tends to fit snugly and securely

King LT-D Insertion Procedure King LT-D proper placement

King LT-D Insertion Tips Tips for successful insertion Utilize midline approach: Perform a chin lift and slide the distal tip along the palate and into position in the hypopharynx If tip is placed laterally, it may enter the piriform fossa and the tube will bounce back upon full insertion and release Keeping the tip at the midline assures that the distal tip is properly placed in the hypopharynx/upper esophagus Ensure proper insertion depth: Ventilatory openings of the King LT-D must align with the laryngeal inlet for adequate oxygenation/ventilation

King LT-D Insertion Tips Tips for successful insertion (cont.) Ensure cuffs are properly inflated: Be prepared to re-inflate cuffs with another 10 mL of air in the event of air leakage Do not over inflate cuffs – use the minimum volume of air necessary to seal the airway Avoid damage to the King LT-D: Use caution - cuffs can be damaged by broken teeth/dentures Remove dentures prior to placing device if applicable

King LT-D Insertion Tips Tips for successful insertion (cont.) Avoid airway trauma: Do not force device while inserting as airway damage may occur Reassess/adjust as needed: During spontaneous breathing, the epiglottis or other tissue can be drawn into the ventilatory openings, resulting in obstruction – advancing the device 1 – 2 cm normally eliminate this obstruction

King LT-D Troubleshooting Utilize proper placement procedures To avoid tracheal placement, maintain head in a neutral position Ventilation will not occur if placed in the trachea Most unsuccessful placements result from failure to keep tube in midline during placement If unable to ventilate – remove device and replace If unsuccessful on second attempt, BLS airway management should be resumed

King LT-D Removal Removal steps Once in place, the King LT-D should only be removed in the prehospital setting if absolutely necessary (patient regains consciousness, unable to ventilate, etc.) Suction above cuff in the oral cavity if needed Fully deflate cuffs Remove the device Reassess the patient and continue to appropriately manage the airway

King LT-D Utilization Additional Requirements Other responsibilities Inform other appropriate EMS providers and/or the receiving hospital of any pertinent details related to the utilization of the King LT-D Adequately document the utilization of the King LT-D for reporting and QI review requirements