Anaesthesia, 1992, Volume 47, pages 688-689 CASE R E P O R T
The laryngeal mask airway Two cases of prehospital trauma care M. K . GREENE, R. RODEN
AND
G. HINCHLEY
Summary Two cases of emergency prehospital airway control using the laryngeal mask are described. The patients were trapped following road trafic accidents and limited access prevented tracheal intubation. The laryngeal mask airway may be a useful alternative to tracheal intubation in some cases of prehospital trauma care.
Key words Equipment; laryngeal mask.
The laryngeal mask was introduced by Brain in 1983 as a new item of equipment for the maintenance of the airway [I]. It can be inserted blind and may be used in spontaneously breathing patients o r to permit intermittent positive pressure ventilation (IPPV). Although it is primarily used in routine anaesthesia [2] there have been reports of its use in emergency situations [3-51. We believe that these are the first case reports of the use of the laryngeal mask in prehospital trauma care.
Case histories
Case I
A 21-year-old man was the front seat passenger in a car which suffered extensive front impact damage in a head-on collision. The driver was killed instantly. The patient was trapped in an upright position by his legs, pelvis and abdomen. He had a respiratory rate of less than 10 breath.min-’, a weak pulse of 110 beat.min-I, and a Glasgow Coma Score of three. It was not possible to gain access to the patient in order to pass a tracheal tube. A laryngeal mask was passed from in front of the casualty, while his neck was supported in a cervical collar and assisted ventilation was successfully achieved using a bag attached to an oxygen reservoir. Following release of the patient, orotracheal intubation was attempted at the roadside but the vocal cords could not be visualised and there was considerable haemorrhage in the region of the posterior nasopharynx. A cricothyroidotomy was performed and the airway thereby secured and protected for transfer to hospital. This
patient subsequently died from his thoracic and cerebral injuries. Patient 2
A 32-year-old man was trapped by his lower limbs in a car. On examination, his airway was compromised by bleeding from severe facial fractures. His respiratory rate was 6 breath.min-I, his chest expansion was equal, he was pale and had a pulse rate of 120 beat.min-l. He was unresponsive to painful stimuli. Access to the casualty was limited by vehicle damage and attempts to control the airway and assist ventilation through an oropharyngeal airway using bag and mask technique were unsuccessful. A size 3 laryngeal mask was passed and artifical ventilation was successfully achieved. Intravenous fluids were administered and IPPV was continued during extrication of the patient, which took 30 min. Following release the patient’s trachea was intubated at the roadside and he was transferred to hospital with controlled ventilation and a protected airway. After arrival in hospital he underwent emergency laparotomy and was found to have a severely lacerated liver. He died from overwhelming intra-abdominal haemorrhage which could not be controlled during surgery.
Discussion The main objection to the use of the laryngeal mask in the emergency situation is that it does not protect the airway from aspiration of stomach contents or from haemorrhage from above. However, a recent paper has demonstrated that the mask does have a limited ability to protect the
M.K. Greene, MB, BS, FRCS, Senior Registrar, R. Roden, BA, FRCS (A&E), G. Hinchley, MB, BS, FRCS, Registrars, Accident and Emergency Department, Derbyshire Royal Infirmary, London Road, Derby D E l 2QY. Accepted 28 January 1992. 0003-2409/92/080688
+02 %03.00/0
@ 1992 The Association of Anaesthetists of G t Britain and Ireland
688
The laryngeal mask airway airway from blood which collects in the pharynx [6]. In prehospital care there are occasions when access to the patient is so limited that it is impossible to pass a tracheal tube. The alternative technique of respiratory control, using an oral airway, bag and mask, is also difficult to perform when access is limited and to maintain during the period of extrication. The laryngeal mask has the advantage that it may be passed from in front of the patient, and in these two cases the neck was maintained in a neutral position in a cervical collar. This is important in trauma resuscitation when there is a possibility of cervical spine injury and secondary damage to the spinal cord must be prevented. Although both of the patients described subsequently died from their injuries, in each case it was possible to maintain the airway until a more definitive method of control and protection was achieved to permit safe transfer to hospital. We suggest that all those involved in prehospita1 care should be aware of the technique of laryngeal mask insertion, which we have found to be a useful adjunct
689
in the management of some patients who are trapped following their accidents.
References [I]BRAINAIJ. The Laryngeal Mask-a new concept in airway management. British Journal of Anaesthesia 1983;55: 801-5. [2] BRAINAIJ, MCGHEETD, MCATEEREJ, THOMAS A, ABU-SAAD MAW, BUSHMAN JA. The laryngeal mask airway. Development and preliminary trials of a new type of airway. Anaesthesia: 1985;40: 356-61. [3]BRAINAIJ. Three cases of difficult intubation overcome by the laryngeal mask airway. Anaesthesia 1985;40: 353-5. [4]CALDERI, ORDMAN AJ, JACKOWSKI A, CROCKARD HA. The Brain laryngeal mask airway. An alternative to emergency tracheql intubation. Anaesthesia 1990;45: 137-9. [5]BRAINAIJ. The laryngeal mask airway-a possible new solution to airway problems in the emergency situation. Archives of Emergency Medicine 1984; 1: 229-32. [6]JOHN RE, HILL S, HUGHES TJ. Airway protection by the laryngeal mask. A barrier to dye placed in the pharynx. Anaesthesia 1991;46: 366-7.
The laryngeal mask airway Two cases of prehospital trauma care M. K . GREENE, R. RODEN
AND
G. HINCHLEY
Summary Two cases of emergency prehospital airway control using the laryngeal mask are described. The patients were trapped following road trafic accidents and limited access prevented tracheal intubation. The laryngeal mask airway may be a useful alternative to tracheal intubation in some cases of prehospital trauma care.
Key words Equipment; laryngeal mask.
The laryngeal mask was introduced by Brain in 1983 as a new item of equipment for the maintenance of the airway [I]. It can be inserted blind and may be used in spontaneously breathing patients o r to permit intermittent positive pressure ventilation (IPPV). Although it is primarily used in routine anaesthesia [2] there have been reports of its use in emergency situations [3-51. We believe that these are the first case reports of the use of the laryngeal mask in prehospital trauma care.
Case histories
Case I
A 21-year-old man was the front seat passenger in a car which suffered extensive front impact damage in a head-on collision. The driver was killed instantly. The patient was trapped in an upright position by his legs, pelvis and abdomen. He had a respiratory rate of less than 10 breath.min-’, a weak pulse of 110 beat.min-I, and a Glasgow Coma Score of three. It was not possible to gain access to the patient in order to pass a tracheal tube. A laryngeal mask was passed from in front of the casualty, while his neck was supported in a cervical collar and assisted ventilation was successfully achieved using a bag attached to an oxygen reservoir. Following release of the patient, orotracheal intubation was attempted at the roadside but the vocal cords could not be visualised and there was considerable haemorrhage in the region of the posterior nasopharynx. A cricothyroidotomy was performed and the airway thereby secured and protected for transfer to hospital. This
patient subsequently died from his thoracic and cerebral injuries. Patient 2
A 32-year-old man was trapped by his lower limbs in a car. On examination, his airway was compromised by bleeding from severe facial fractures. His respiratory rate was 6 breath.min-I, his chest expansion was equal, he was pale and had a pulse rate of 120 beat.min-l. He was unresponsive to painful stimuli. Access to the casualty was limited by vehicle damage and attempts to control the airway and assist ventilation through an oropharyngeal airway using bag and mask technique were unsuccessful. A size 3 laryngeal mask was passed and artifical ventilation was successfully achieved. Intravenous fluids were administered and IPPV was continued during extrication of the patient, which took 30 min. Following release the patient’s trachea was intubated at the roadside and he was transferred to hospital with controlled ventilation and a protected airway. After arrival in hospital he underwent emergency laparotomy and was found to have a severely lacerated liver. He died from overwhelming intra-abdominal haemorrhage which could not be controlled during surgery.
Discussion The main objection to the use of the laryngeal mask in the emergency situation is that it does not protect the airway from aspiration of stomach contents or from haemorrhage from above. However, a recent paper has demonstrated that the mask does have a limited ability to protect the
M.K. Greene, MB, BS, FRCS, Senior Registrar, R. Roden, BA, FRCS (A&E), G. Hinchley, MB, BS, FRCS, Registrars, Accident and Emergency Department, Derbyshire Royal Infirmary, London Road, Derby D E l 2QY. Accepted 28 January 1992. 0003-2409/92/080688
+02 %03.00/0
@ 1992 The Association of Anaesthetists of G t Britain and Ireland
688
The laryngeal mask airway airway from blood which collects in the pharynx [6]. In prehospital care there are occasions when access to the patient is so limited that it is impossible to pass a tracheal tube. The alternative technique of respiratory control, using an oral airway, bag and mask, is also difficult to perform when access is limited and to maintain during the period of extrication. The laryngeal mask has the advantage that it may be passed from in front of the patient, and in these two cases the neck was maintained in a neutral position in a cervical collar. This is important in trauma resuscitation when there is a possibility of cervical spine injury and secondary damage to the spinal cord must be prevented. Although both of the patients described subsequently died from their injuries, in each case it was possible to maintain the airway until a more definitive method of control and protection was achieved to permit safe transfer to hospital. We suggest that all those involved in prehospita1 care should be aware of the technique of laryngeal mask insertion, which we have found to be a useful adjunct
689
in the management of some patients who are trapped following their accidents.
References [I]BRAINAIJ. The Laryngeal Mask-a new concept in airway management. British Journal of Anaesthesia 1983;55: 801-5. [2] BRAINAIJ, MCGHEETD, MCATEEREJ, THOMAS A, ABU-SAAD MAW, BUSHMAN JA. The laryngeal mask airway. Development and preliminary trials of a new type of airway. Anaesthesia: 1985;40: 356-61. [3]BRAINAIJ. Three cases of difficult intubation overcome by the laryngeal mask airway. Anaesthesia 1985;40: 353-5. [4]CALDERI, ORDMAN AJ, JACKOWSKI A, CROCKARD HA. The Brain laryngeal mask airway. An alternative to emergency tracheql intubation. Anaesthesia 1990;45: 137-9. [5]BRAINAIJ. The laryngeal mask airway-a possible new solution to airway problems in the emergency situation. Archives of Emergency Medicine 1984; 1: 229-32. [6]JOHN RE, HILL S, HUGHES TJ. Airway protection by the laryngeal mask. A barrier to dye placed in the pharynx. Anaesthesia 1991;46: 366-7.
