i-gels in drowning i-gel® Supraglottic airway use in drowning: a case series

Objectives & Background

The UK maintains a 24-hour search and rescue (SAR) helicopter service covering the entire country and surrounding maritime regions.

Currently (mid-2015) there are 12 SAR helicopter bases, both military & civilian, and medical provision for those rescued is provided by both HCPC-registered paramedics and technician-level crew.

For the drowning casualty, early positive pressure ventilation, preferably with oxygen, is vital. Tracheal intubation is considered the gold standard for airway management/ventilation in drowning casualties, but alternative methods are required when intubation is unsuccessful/impractical or the winchman is not a paramedic.

Current options include BVM ventilation with adjuncts or the i-gel (Intersurgical Ltd, Wokingham, UK) supraglottic airway device (SAD).

There is growing interest in the use of SADs, but opponents claim that they are not fit for purpose in drowned patients as the pressure required to overcome the decreased compliance of “drowned” lungs exceeds the devices’ seal pressure.

We present a case series of drowning casualties where i-gels were used, in order to establish the efficacy of the i-gel device in this scenario. Methods

The crews of all UK SAR helicopters were contacted by email in early 2015 and asked to report cases where an i-gel had been used during the resuscitation of a drowned casualty.

Specifically, we asked: • Was ventilation achieved? • Did the i-gel “float” out (a

problem with 1st generation SADs) • How well did the device seem to

work in achieving ventilation?

Results

We received 11 replies (two duplicates). The indications for i-gel insertion were: • First choice device (n=5) • Unable to ventilate with BVM (n=2) • Failed intubation attempts (n=2)

Ventilation via the i-gel was achieved in 100% (n=9) of cases. Chest rise was described as “good” in four cases, “OK” in one, “small” in two & was not commented upon in the remainder.

Problems with the i-gel were reported in three cases (33%): • Dislodged with CPR (n=1) • Excessive suction required due to water-logged airway (n=2)

Whilst outcome data was not requested, crews volunteered that one casualty survived to discharge & one died, but the outcome of the other six were unknown.

Conclusion

• This case series confirms that i-gels can achieve ventilation in casualties in cardiac arrest secondary to drowning.

• Water in the oropharynx is common during these events, which may allow a SAD to "float" out, but probably with a lower incidence with the i-gel compared to first generation devices.

• We also realised the i-gel gastric port was rarely used for suction/drainage of gastric/oropharyngeal water, and recommend that pre-hospital users are taught (and reminded) to use this feature of the device.

Linda Dykes, Consultant in EM Ysbyty Gwynedd, Bangor Paddy Morgan, Consultant Anaesthetist North Bristol NHS Trust & Dept of Sports & Exercise Science, University of Portsmouth

AcknowledgementsWe would like to thank the crews of RAF, RN,

Bristow & CHC SAR helicopters for their assistance, Alan Murray for the background photo and

Dr Jason Walker for photo manipulation