Pre-Hospital Laryngeal Mask
Airway Insertion
Program
Overview
Program Title
“Pre-Hospital
Laryngeal Mask Airway Insertion”
Student Eligibility
·
Emergency
Medical Technicians certified as Intermediates or Paramedics to perform
endotracheal intubation in the
Course
Format
·
Although
this material may be presented in a number of formats, a lecture / discussion
model with practical scenario is given here. This program may be combined with other
standing programs such as ACLS, PALS, or the Commonwealth’s ALS Interfacility
Transfer Training Program.
Objectives
Upon
completion of the training program, the provider will be able
to:
·
Discuss
the Massachusetts Pre-Hospital Treatment Protocol concerning Laryngeal
Mask Airway (LMA) tube insertion
·
State
the indications and contraindications of placing a LMA.
·
Describe
the procedure of placing a LMA.
·
Demonstrate
the placement of a LMA tube in an intubation manikin in a classroom
setting.
·
Successfully
place the LMA device in a mannequin under the direct supervision
of a licensed practitioner authorized to use the
device.
·
AND/OR
Successfully place the LMA device in an operating room setting
under the direct supervision of a qualified MD, CRNA or other licensed
practitioner authorized to use the device.
Outline
·
See
the attached Program Outline
Teaching Methods
·
Lecture
/ Discussion
·
Video
Tape Presentation
·
Practical
Skill Sessions / Stations
·
Open
Question and Answer Periods
·
Clinical
Application in a Mannequin (Required)
·
Clinical
Application in Operating Room (Optional)
Faculty
·
Any
Pre-Hospital Laryngeal Mask
Airway Insertion
References
Texts:
·
Brady
Basic Trauma Life Support, Fourth Edition,
Campbell, John E., Prentice-Hall, Inc., 2000, pages 58-59,
292-294
·
Brady
Paramedic Care: Principles & Practice, Volume 1:
Introduction,
Bledsoe, Bryan E., Porter, Robert S., Cherry, Richard A., Prentice-Hall, Inc.,
2000, pages 573-574.
·
Emergency
Medicine: Concepts and Clinical Practice, Fourth Edition,
Rosen, Peter, Editor-in-Chief, 1998, pages 14-15.
·
Guidelines
2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, An
International Consensus on Science, International
Liaison Committee on Resuscitation, Supplement to Circulation, Volume 102,
Number 8, August 22, 2000, pages I-98-99.
·
LMA
Classic and LMA Flexible Instruction Manual, Rev. B,
Brain A., Denman W., Goudsouzian N., LMA North America, Inc., Part Number
3000192, March 2000.
·
LMA
Fastrach Instruction Manual, Rev. A,
Brain A., Verghese C., LMA North America, Inc., Part Number 3000158, August
1998.
·
Paramedic
Textbook, Second Edition,
Sanders, Mick J., Mosby, Inc., 2000, pages 412.
·
PHTLS
Basic and Advanced Prehospital Trauma Life Support, Forth
Edition,
Prehospital Trauma Life Support Committee of the National Association of
Emergency Medical Technicians in cooperation with the Committee on Trauma of the
·
Textbook
of Advanced Cardiac Life Support, Cummins,
Richard O., Editor, America Heart Association, 1997, page
2-11.
Journal
Articles:
·
“A comparison of two airway aids for
emergency use by unskilled personnel, the Combitube and laryngeal mask,” Yardy
N, Hancox D, Strang T, Anaesthesia, 1999 Feb; 54(2):
181-3.
·
“The
PTL, Combitube, laryngeal mask, and oral airway: a randomized prehospital
comparative study of ventilatory device effectiveness and cost-effectiveness in
470 cases of cardiorespiratory arrest,” Rumball CJ, MacDonald D, Prehospital
Emergency Care, 1997 Jan-Mar; 1(1) 1-10.
·
“Airway
management during cardiopulmonary resuscitation – a comparative study of
bag-valve-mask, laryngeal mask airway, and combitube in a bench model,” Doerges
V, Sauer C, Ocker H, Wenzel V, Schmucker P, Resuscitation, 1999 Jun;
41(1): 63-9.
·
“Use
of Intubating Laryngeal Mask Airway by Medical and Non-medical Personnel,”
Levitan R, Ochroch E, Stuart S, Hollander J, American Journal of Emergency
Medicine, 2000 Jan; 18(1): 12-16.
Video:
·
“LMA
Insertion Video, Rev. A,” LMA North America, Inc., Part Number
3000200.
·
“LMA-Fastrach
Instructional Video, Rev. A,” LMA North America, Inc., Part Number
3000175.
·
“Taking
Care of Reusable LMA Airways, Rev. A,” LMA North America, Inc., Part Number
9000005.
Pre-Hospital Laryngeal Mask
Airway Insertion
Program
Outline
1.
Program
Overview (5 to 15 minutes)
1.1.
Student
Registration and Administrative Concerns
1.2.
Introduction
of Faculty
1.3.
Program
Objectives
1.4.
Program
Outline
1.5.
Program
Duration
2.
Review
of
2.1.
Statewide
Treatment Protocols
2.2.
Indications
2.2.1.
Airway
control in the absence of other effective methods.
2.3.
Contraindications
2.3.1.
The
manufacturer of the LMA lists the following
contraindications:
2.3.1.1.
The
LMA does not protect the airway from the effects of regurgitation and
aspiration.
2.3.1.2.
Patients
who have not fasted or whose fasting cannot be confirmed.
2.3.1.3.
Patients
with hiatal hernia unless effective measures have been taken to empty their
stomach contents beforehand.
2.3.1.4.
Patients
with fixed pulmonary compliance, such as patients with pulmonary
fibrosis.
2.3.1.5.
Adult
patients who are unable to understand instructions or cannot adequately answer
questions regarding their medical history, since such patients may be
contraindicated for LMA use.
2.3.1.6.
NOTE:
When used in the profoundly unresponsive patient in need of resuscitation or in
a difficult airway patient on an emergency pathway (i.e. “cannot intubate,
cannot ventilate”), the risk of regurgitation and aspiration must be weighed
against the potential benefit of establishing an airway. The LMA should not be used in the
resuscitation or emergency situation in patients who are not profoundly
unconscious and who may resist LMA insertion. In patients with severe oropharyngeal
trauma, the risk of exacerbating the condition must be weighed against the
potential benefit of establishing an airway.
2.3.2.
Warnings,
Cautions, and Adverse Effects
3.
Review
of local policies, including documentation (5 to 15
minutes)
3.1.
Local
Policies inserted here.
3.2.
Local
documentation policies inserted here.
3.2.1.
Documentation
may include:
3.2.1.1.
Time
procedure was performed
3.2.1.2.
LMA
type and size utilized
3.2.1.3.
Tube
placement check, and by what manner
3.2.1.4.
Degree
of difficulty encountered
3.2.1.5.
Complications
encountered
3.2.1.6.
Name
of provider performing procedure
4.
Review
of pertinent anatomy and physiology (15 minutes)
4.1.
Upper
airway structures
4.2.
Upper
gastrointestinal tract
4.3.
Airway
grading
5.
LMA
manufacturer’s video instruction (15 to 45 minutes)
5.1.
Video(s)
appropriate to the device(s) to be utilized.
6.
Equipment
introduction and Procedure demonstration (15 to 45
minutes)
6.1.
Equipment
6.1.1.
Personal
protective equipment
6.1.2.
Laryngeal
Mask Airways of appropriate sizes
6.1.3.
Syringe
of appropriate volume for selected device
6.1.4.
10
or 12 Fr suction catheter
6.1.5.
Water-soluble
lubricant
6.1.6.
Adhesive
tape
6.1.7.
Bag
Valve Mask resuscitator
6.1.8.
Oxygen
source
6.1.9.
Suction
device
6.2.
Standard
Procedure (sharply abbreviated here – see manufacturer’s directions for
use.)
6.2.1.
Ventilate
the patient
6.2.2.
Select
the correct size tube
6.2.3.
Prepare
the LMA for use
6.2.3.1.
Perform
LMA performance tests as specified by manufacturer
6.2.3.2.
Tight
deflation of the LMA cuff without distal wrinkles
6.2.3.3.
Spare
LMA prepared and ready for use
6.2.4.
Lubricate
tube with water soluble lubricant
6.2.5.
Position
the patient’s head
6.2.6.
Properly
orient and grasp the tube
6.2.7.
Insert
LMA upward against the hard palate, and push the device inwards and backward
with the index finger. Advance
until definite resistance is felt.
Do not use force.
6.2.8.
Use
the other hand to press down on the LMA tube before removing index
finger.
6.2.9.
Ensure
that the black line on the airway tube is oriented anteriorly toward the upper
lip.
6.2.10.
Inflate
the cuff with just enough air to obtain a seal. Varies with cuff size and patient
anatomy. Do not hold the tube
during cuff inflation.
6.2.11.
Ventilate
the patient
6.2.12.
Auscultate
breath sounds and confirm placement
6.2.13.
Insert
a bite block and secure the tube.
6.2.14.
Monitor
end-tidal carbon dioxide level.
6.2.15.
Document
the procedure.
6.3.
Thumb
Insertion Procedure.
6.4.
Review
of potential problems with LMA insertion.
6.5.
Review
of manufacturer’s cautions and warnings.
6.6.
Special
patient populations
6.6.1.
Pediatric
patients
6.6.2.
Difficult
airway
6.6.3.
LMA
and failed intubation
6.6.4.
LMA
use and gastric drainage
6.7.
LMA
Flexible
6.8.
LMA
Fast-Trach
7.
Student
practical skill sessions/stations (20 to 60 minutes)
7.1.
Recommended
one instructor per six to eight students and one training manikin capable of
accepting a LMA.
7.2.
Skill
sessions should be scenario-based (see attached sample
cases.)
7.3.
Larger
groups may benefit from station rotation in timed
intervals.
8.
Written
and/or Practical Examination (30 minutes)
9.
Review,
Questions and Answers (15 minutes)
10.
Optional
Clinical Experience (8 hours)
10.1.
The
participant will complete eight hours of clinical observation time in an
operating room setting approved by the Ambulance Service Medical
Director
10.2.
The
participant will successfully place the LMA device in three patients in an
operating room setting under the direct supervision of a qualified MD, CRNA or
other licensed practitioner authorized to use the device.
10.3.
The
participant will document this clinical experience.
Total
Program Time
Lecture / Didiactic:
130 to 270 minutes
Optional:
Clinical:
8 hours
Pre-Hospital Laryngeal Mask
Airway Insertion
Sample
Cases
Case
One
A
37-year-old female patient collapsed in her living room. She is in cardiac arrest and routine
ACLS care is in progress. You have
been unable to intubate the patient’s tracheal after multiple attempts, and your
attempts at bag-valve-mask ventilation are inadequate. Using the manikin and materials
provided, describe and perform all airway maintenance procedures indicated by
Massachusetts Protocols.
Case
Two
A
15-year-old female pedestrian was struck by a motor vehicle at a moderate
speed. She unconscious to deep
painful stimuli and is suffering from severe facial trauma. Your efforts at maintaining the
patient’s airway with BLS techniques and generous suctioning are inadequate. The
patient is approximately
Case
Three
You
are called to the local recreational center where the lifeguards have removed a
ten-year-old male patient from the pool.
You find him deeply unconscious, without a gag reflex. His respirations number 4 per minutes
and he has a blood pressure of 150/100 mmHg. He has been c-spine immobilized prior to
your arrival. The patient is over
four feet tall. As you prepare to
intubate the patient, you find your laryngoscope is not operational. Using the
manikin and materials provided, describe and perform all airway maintenance
procedures indicated by Massachusetts Protocols.
Case
Four
You
have been unable to intubate a 55 year-old male patient unconscious after
receiving a gunshot wound to the thorax.
You are having difficulty maintaining the patient’s airway using BLS
methods. Using the manikin and
materials provided, describe and perform all airway maintenance procedures
indicated by Massachusetts Protocols.
Case
Five
A
31-year-old male patient was involved in a motorcycle accident. He does not respond verbally, is
bleeding from facial injuries, and is combative while lying supine on the
roadside. His vital signs are BP
88/P, P134, and R44. Using the
manikin and materials provided, describe and perform all airway maintenance
procedures indicated by Massachusetts Protocols.
Pre-Hospital Laryngeal Mask
Airway Insertion
Performance
Checklist
Provider’s
Name________________________________________
Date______________________
Mass.
EMT Number #__________________ Level
(circle)
EMT
EMT-I
EMT-P
Service
___________________________________________________________________
When
demonstrating the insertion of a Laryngeal Mask Airway the provider
should:
Pass
Fail
Verbalizes
the indications for the Airway
Verbalizes
the contraindications for the Airway
Proper
use of PPE
Assembles
all necessary equipment
Selects
appropriate LMA size
Ventilates
patient prior to insertion
Properly
prepares LMA for use, including proper cuff deflation
Lubricates
tube on posterior surface only
Opens
and clears airway and positions head properly
Inserts
device properly into oropharynx and advances correctly
Inflates
cuff / pilot balloon to achieve proper seal
Ventilates
effectively and auscultates breath sounds
Verbalizes
appropriate breath sounds for correct placement
Properly
utilizes bite block device
Properly
secures device in place
Utilizes
end-tidal carbon dioxide detection device
Verbalizes
proper suctioning method
Final Performance PASS FAIL
Comments_____________________________________________________________________________________________________________________________________________________________________________________________________________________
Instructor
/ Examiner Print Name_________________________
_________________
Credentials
Instructor
/ Examiner Signature__________________________
_________________
Date