1. 1 Charlie Alvarenga The LMA Supreme

2. 2 My Presentation Today The Extraglottic device The algorithms (The manual for emergency airway management Ron Walls) The LMA supreme – Anatomy – Preparation – Placement – Placement confirmation – Gastric suctioning Video review Documentation “Quisque volutpat condimentum velit.”

3. 3 My Presentation Extraglottic Airways Can be separated into three classes – This will be based on the placement and seating of the airway out side of the epiglottis and trachea. Supraglottic Airways. Which sits above and surrounds the epiglottis. Retroglottic Airways. Which pass behind and beyond the larynx to enter the upper esophagus. Infraglottic Airways. Which pass behind and beyond the larynx to enter the upper esophagus

4. 4 My Presentation When are they needed? In cases of airway management, and the inability to place an endotracheal tube with the equipment on hand. Source: Manual of Emergency Airway Management (third edition) -Ron M. Walls MD, FRCPC, FACEP, FAAEM 2008

5. 5 My Presentation When are they needed? In cases of airway management, and the inability to place an endotracheal tube with the equipment on hand. Source: Manual of Emergency Airway Management (third edition) -Ron M. Walls MD, FRCPC, FACEP, FAAEM 2008

6. 6 My Presentation When are they needed? In cases of airway management, and the inability to place an endotracheal tube with the equipment on hand. Source: Manual of Emergency Airway Management (third edition) -Ron M. Walls MD, FRCPC, FACEP, FAAEM 2008

7. 7 My Presentation The LMA supreme The new supraglottic airway used as a “second out” incase of failed endotracheal tube placement. The LMA supreme comes in 4 separate pediatric sizes! 1 and 1 ½ 2 and 2 ½ Covering neonates to 30kg Pediatric Sizes The implement of Gastric suctioning through the distal drainage tube, reduces the risk for aspiration as well as stomach decompression prior to emergent flight. Gastric suctioning Unfortunately a common occurrence in the field not only due to inexperience and intubation failure, but patient anatomy malformations. The difficult airway The safety net, the ability to care for each patient, fallowing the AHA, AAP, NRP, and the critical care algorithms for airway control and protection. The gold standard

8. The LMA supreme Integral bite block The unique elliptical airway tube is stable in situ and allows for easy placement and no kinking (found in other LMA models) Fixation tab helps maintain proper cuff depth Larger distal pre-curved cuff for improved fit and effective seal Model fins protect airway from epiglottic obstruction Single pilot balloon Reinforced tip and molded distal cuff resist folding, as well as drainage tube OG drainage port Ventilation Port

9. Example Case upon airway manipulation the epiglottis is unable to be manipulated due to anatomy malformation... All done by an experienced operator. Dispatched to a respiratory distress on a 2 Mo female turned CPR in progress in route. At 0300 Upon arrival the pt was brought to you with CPR currently in progress, by the fire department. Fire states that the pt was found in respiratory arrest by the mother with an unknown down time the mother was in bed with the pt when the respiratory distress was realized CPR continued and Airway manipulation attempted with Miller 1 X 1 Miller 2 X 2 Mac 1 (would not fit in airway)

10. Example Case In route to hospital airway protection consisted of Proper positioning of the patient Three total intubation attempts OPA placement And proper BVM ventilation with 2person mask seal. At the hospital, With video laryngoscopy the pt was DX with a bifid epiglottis and was able to be intubated and ventilated.

11. Sizing for your patients 11 Mask size Patient size Product descriptionMax. cuff inflation volume Largest OG/NG tube size 1Neonates/ infants up to 5 kgLMA supreme size15ml6 French 1 1/2Infants 5-10kgLMA supreme size1 1/28ml6 French 2Infants 10-20kgLMA supreme size 212ml10 French 2 1/2Children 20-30kgLMA supreme size 2 1/220ml10 French 3Children 30-50kgLMA supreme size 330ml14 French 4Adults 50-70kgLMA supreme size 445ml14 French 5Adults 70-100kgLMA supreme size 545ml14 French

12. 12 My Presentation Performance test and Preparation Like all other Extraglottic airways. – Examine for breaks, damage, scratches or kinks – Examine interior for blockages or particles not of the airway – Deflate and then re-inflate for spontaneous inflation.

13. Insertion Preparation Deflation – Firmly connect appropate syringe for size of LMA supreme. – Place your thumb and index finger on distal end of airway and compress while deflating. – Be sure to hold the device so that the distal end is curled slightly anteriorly. Lubrication – Lubricate the posterior surface of the mask and distal portion of the airway tube just prior to insertion. – If applicable lubricate patients lips to prevent tugging during insertion. 13

14. Insertion Preparation Capnography/Capnomatry – This must be used on every airway including extraglottic airways – This will monitor ventilation and as well as Ph of the patient. – This must be used in tandem with Spo2 14

15. Insertion Post lubrication – Stand behind the patient – Place head in neutral (inline OA,PA,LA) or “sniffing” position (unless in spinal precautions) – Hold device with index finger and thumb on fixation tab, with the remaining fingers on the opposite aspect of the tube. – Press the tip against the inner aspect of the upper teeth or gums, and slide along hard and soft palate. – Advance the device into the hypopharaynx until resistance is felt. 15

16. Fixation then Inflation Prior to inflation of pilot ballon – Use a piece of adhesive table 30 -40cm long, holding it horizontally by both ends – Press the adhesive tape transversely across the fixation tab, continuing to press downwards so that the ends of the tape adhere to the patients checks. Post fixation inflate pilot balloon to proper cuff inflation volume slowly Initially ½ max volume then inflate to proper amount to create proper seal. 16

17. Placement confirmation and ventilation Capnography/Capnography Equal and bilateral chest rise Lung sounds equal on both sides Spo2 No gastric sounds or inflation Proper placement should produce a leak free seal against the glottis with the mask tip at the tip of the esophageal sphincter 17

18. Gastric suctioning Confirmation Prior to utilizing gastric suctioning – Place 1-2ml of gel lubrication over the proximal end of the drain tube. Then press on the – Apply gentle pressure on the suprasternal notch you should see an up and down movement of the meniscus in coloration with the pressure applied to the suprasternal notch. – This will indicate that there is a proper seal to over the upper esophageal sphincter Be sure to utilize the proper gastric tube size and not supersede the maximum size. 18

19. Refirm Ventilation/Respiration – Use all tools stated in confirmation, Etco2, Bilateral lung sounds with equal chest rise, Spo2, and suprasternal notch test. – Be sure to check for dislodgment as well as proper tape security on fixation tube. 19 Etco2 waveform Chest rise Spo2

20. Documentation !!!!!!!!!!!! DOCUMENTATION!!!! Is very important as prospective studies can be done on the implement of the new LMA supreme especially the pediatric airway. On scene time: Ventilation with BVM (prior to EMS arrival or upon) Intubation attempts (specify) Use of NPA/OPA Time LMA supreme utilized with ETCO2 confirmation and waveform and all confirmation steps At time of turn over be sure to reassure proper ventilation as you would with any airway including ET tubes. 20 DOCUMENT!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

21. Videos 21 http://www.youtube.com/watch?v=f0xL5Dadw5g http://www.youtube.com/watch?v=W15asfhaTE4 Only 10 more minutes.. No tears.