ER Basics for Rookies

For every emergency physician, airway management begins with bag-mask ventilation and often progresses to endotracheal intubation. But there’s an essential “middle ground” tool that rookies sometimes overlook: supraglottic airway devices (SGAs).

SGAs save lives when intubation fails, BVM is inadequate, or you need rapid airway control without advanced equipment. They are critical for Plan B in the airway algorithm and should always be part of your setup.

What Are Supraglottic Airway Devices?

• Airway devices placed above the vocal cords.
• Sit in the pharynx, providing a channel for ventilation.
• Examples: Laryngeal Mask Airway (LMA), i-gel, Combitube, King LT.

Why they matter in the ED:

• Quick to insert (seconds, not minutes).
• Don’t require visualization of the cords.
• Provide hands-free ventilation once secured.

When to Use an SGA

1. As a Rescue Airway (Failed Intubation)

• When multiple intubation attempts fail and oxygen saturation is dropping, SGAs are the fastest way to restore oxygenation.
• They buy you time while preparing for a surgical airway.

2. When BVM Ventilation Is Inadequate

• Difficult mask seal (beard, trauma, obesity).
• High airway pressures needed.
• Fatigue during prolonged BVM.

3. In Cardiac Arrest

• During CPR, SGAs provide a quick, effective way to oxygenate without interrupting compressions.
• Many guidelines allow SGAs as acceptable airway management in resuscitation, especially for providers not expert at intubation.

4. As a Bridge to Intubation

• For unstable patients where intubation must be delayed (e.g., difficult airway anticipated, need to resuscitate first).
• Secure oxygenation and ventilation while preparing for definitive tube.

5. As a Definitive Airway (select cases)

• In prehospital or resource-limited settings, some patients can be managed with SGAs alone if intubation isn’t possible or safe.
• Certain LMAs allow passage of an ETT through them for conversion.

Types of SGAs Common in the ED

1. Classic LMA

• Inflatable cuff, sits over glottis.
• Requires cuff inflation.
• Good for rescue, but less effective with high airway pressures.

2. i-gel

• Non-inflatable, gel cuff that molds to anatomy.
• Easier and faster to insert.
• More stable seal, can tolerate higher pressures.
• Widely favored in ED/prehospital use.

3. King LT (laryngeal tube)

• Dual cuff design (oropharynx + esophagus).
• Provides good seal, especially for EMS use.
• Less commonly used in hospital EDs compared to i-gel/LMA.

4. Combitube

• Older dual-lumen device.
• Inserted blindly; one lumen ventilates trachea if lucky, the other ventilates via esophagus.
• Mostly replaced by i-gel and King LT.

How to Insert an SGA (General Steps)

1. Choose correct size (based on weight or height).
2. Lubricate posterior surface.
3. Open mouth with scissor technique.
4. Insert device along hard palate until resistance felt.
5. Inflate cuff (if needed) or confirm placement (i-gel).
6. Attach bag/ventilator.
7. Confirm ventilation with waveform capnography (not just chest rise).

Common Pitfalls

• Wrong size → poor seal, ineffective ventilation.
• Forgetting to confirm with EtCO₂ → risk of misplaced device.
• Assuming it’s definitive → remember SGAs don’t protect from aspiration like ETTs do.
• Not securing device → accidental dislodgment during resuscitation.

Rookie Pearls

• Always have an SGA on your airway tray—Plan B should be visible, not theoretical.
• Practice inserting i-gel or LMA during simulation; the skill is simple but must be second nature under stress.
• Don’t be afraid to switch to SGA after a failed intubation attempt—oxygenation is more important than pride.
• Some SGAs (i-gel, certain LMAs) allow intubation through them using a bougie or fiberoptic scope—learn which your department stocks.

Take-Home Message

For rookies, supraglottic airways are not a sign of failure—they are a lifesaving bridge. They keep patients oxygenated when intubation fails, when bag-mask ventilation is inadequate, or when you simply need time to resuscitate before definitive tube placement.

Every airway plan in the ED should include:

• Plan A: Intubation (VL/DL).
• Plan B: Supraglottic airway.
• Plan C: Surgical airway.

Preparedness means your SGA is ready, sized, and within arm’s reach before you ever push RSI drugs.