Guidelines on prehospital drug-assisted LMA insertion

The UK’s Faculty of Prehospital Care has published a number of consensus guidelines in this month’s EMJ
Dr Minh Le Cong‘s PHARM blog has summaries of three of them:

The final one is the most contentious: Pharmacologically assisted laryngeal mask insertion: a consensus statement(1). Here is the summary:

  1. The PALM technique is an acceptable tool for managing the prehospital airway
  2. The PALM technique is indicated in a rare set of circumstances
  3. The PALM procedure is a rescue technique
  4. The PALM procedure should be checklist driven
  5. At least a second generation SAD should be used
  6. End-tidal CO2 monitoring is mandatory
  7. No preference is expressed for any particular drug
  8. No preference is expressed for any particular dosing regime
  9. Flumazenil is highly unlikely to have a role in managing the PALM patient
  10. The PALM procedure should only be carried out by practitioners of level 7 or above competences
  11. The availability of a trained assistant, familiar with the procedure would be advantageous
  12. The training required to achieve competency in performing the PALM procedure must include in-hospital insertion of SADs, simulation training and training in the transfer of critically ill patients
  13. Data should be collected and collated at a national level for all patients who receive the PALM procedure

They qualify the first point with the statement: The consensus group felt that, in the hands of a specific set of practitioners and in certain circumstances, patients would benefit from the technique. It was recognised that pre-hospital airway management can be very challenging, and deeming the technique unacceptable could deprive patients of a potentially life saving intervention. It was felt that having another tool available to clinicians which could potentially improve patient outcome was important. This was despite the lack of a robust evidence base. It was felt that the technique is indicated in, and should be limited to, a very specific set of circumstances as described below
The publication lists some ‘Organisations represented at the consensus meeting’, which include some commercial training and equipment companies.
It also states that ‘The Royal College of Anaesthetists, although represented at the initial meeting, was unable to support the outcomes agreed by the other represented organisations.
This is a very interesting development. I can see the pros and cons of this. Since practitioners are out there doing PALM anyway, it is in the interests of patients to produce a statement that encourages monitoring, checklists, training, and data collection. To meet all the requirements, one must undergo ‘training in the transfer of critically ill patients’, which would normally necessitate more advanced airway and anaesthesia skills anyway.
A tough one – what would you want if there was no RSI capability but you were hypoxic with trismus and basic airway maneouvres were failing? An all out ban on PALM, or PALM provided by someone trained in surgical airway if it fails (as per the consensus recommendations)?
This and some of the other statements can be downloaded in full at the Faculty of Pre-hospital Care site
1. Pharmacologically assisted laryngeal mask insertion: a consensus statement
Emerg Med J. 2013 Dec;30(12):1073-5

6 thoughts on “Guidelines on prehospital drug-assisted LMA insertion”

  1. thanks Cliff
    I find the consensus statement a bit weird.
    there has been some research into this technique, PLMA or rapid sequence airway as per Dr Braude
    note the high rate of vomiting with use of the King LT. its a worry
    the authors note insufficient evidence to replace rSI with RSA/PLMA
    having said that , I note a recent French Samur paper where nurse providers trained in Fastrach ILMA used this successfully for prehospital intubation and ventilation. However most were OHCA not needing drug assisted airway technique.
    I just dont see the point of limiting the provider to LMA in prehospital setting, if you are going to train them to give drugs to assist airway intervention

  2. Prefer an RSI positive practitioner, of whatever ilk (doc, nurse, paramedic, SOT etc)
    …but if push came to shove, then would accept PALM as opposed to catastrophic desat as per your example.
    Chatting with some of the BASICs docs from Scotland last month…some RSI positive, some LMA & drugs only. They all felt need to move to RSI.
    As you say, good to have a guideline around PALM happens, is a valid bail out in specific circs….
    …but we come full circle to fact that those doing should be skilled in crit care, airway management and to me that means RSI-ESA capable.

  3. It’s a good guideline given the current state of play – defining the status and context of a sub-optimal intervention, where the gold standard cannot be applied.
    The fact is, there are a large number of prehospital services with a large number of non-RSI current doctors within them. These practitioners are often valuable, skilled and experienced; but will either never be RSI competent, or remain RSI current.
    PALM is, to my mind, a reasonable compromise to allow these folk an option to manage the (admittedly rare) case of a patient in extremis who has a rapidly failing airway which is both unmanageable by simple means, and too far from an ED to scoop and run to to facilitate timely RSI.
    If the patient will die, and the intervention is felt to be of merit, it would be madness to “Ban” it.
    Of course having your remit of doctors RSI trained and current is the gold standard; but in Third World countries like where I work (Northern Ireland), the sum total financial input into providing a medical prehospital service is = Zero.
    Many services simply can’t provide a rota of total cover, never mind a rota where everyone can RSI. I wish we could, but we can’t.
    Striving for gold standard is something we should all be doing at an organisational level, but when you can’t achieve it; you don’t aim for nothing – you try and maintain a Silver standard!
    PALM is perhaps the Prehosptial thoracotomy of the airway, A time critical, temporising intervention delivered for the purpose of saving life, when the gold standard isn’t available either on scene or by timely transfer.
    Of course, like any intervention; PALM must be delivered for predetermined indications, by SOP, with robust follow-up within a tight governance structure, for it to be used to best effect.

  4. thanks John for your comments but you cannot compare prehospital thoracotomy to PALM!
    PALM is to be used when patient is not dead. prehosp thoractomy in general is done when pt is clinically dead…or for all intents and purposes will be dead very soon!
    dont get me wrong, PALM I have used successfully in prehospital cases and it definitely has a place. but not sure if it is to provide a group of practitioners an alternative to RSI?!
    it makes no sense to allow prehosp provider to do surgical airway , FMV, and PALM and yet not RSI?
    what on earth is the issue?
    lets be frank, the LMA even second generation ones are not the most secure airway in the prehospital setting. I know of several cases where they work and then they dont! especially in the bloody airway!
    and if they need a better airway and are credentialled to do surgical airway, then why not do the surgical airway, rather than giving Midazolam to insert a LMA!
    and what if the prehospital provider has an intubating LMA like the fastrach, are they allowed to intubate via it? if so what on earth is the differenec between that and RSI?!!

  5. I’m slightly torn on the issue of PALM.
    I can see where it may have a role where you have a Pre-Hospital practitioner who doesn’t have RSI skills but is faced with a patient with a seriously compromised airway where basic airway manoeuvres / adjuncts have failed to remedy the situation and where the patient is unable to tolerate a SGA without the assistance of some sleepy medicine.
    The problem though is that this situation is incredibly rare – usually with proper ‘basic’ (I hate that term) airway management and patient positioning the airway can be managed until the patient can reach somewhere where advanced airway management can be carried out.
    My issue with PALM is that I worry it will end up being seen as a valid alternative to RSI in patients that actually could have been managed appropriately simply by performing the basics. I’m also concerned that the basics may be neglected / bypassed and PALM used almost as a first line approach. Once a formalised guideline is introduced there’s a risk people will see it as a technique that can be used routinely (even if that’s not the intention of the guideline).
    There’s a huge potential for causing patient harm – especially as, by definition, the practitioners using it won’t be equipped with the skills to secure the airway if the PALM procedure goes pear-shaped e.g. if the SGA doesn’t fit well, the patient vomits etc..
    So, essentially, I can kind of see that on very rare occasions it may be a reasonable rescue airway technique, but I think it has a greater potential to cause harm than it does to make a positive difference.

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