Question: I have a quick question on the PCP supraglottic airway medical directive. What is the rationale for the "must be VSA" condition on the directive for PCP, yet ACP's can use it as a back-up device for failed airway management. Would it not make more sense to make the conditions for PCP something like "Patient must have a GCS=3 and other airway management is inadequate or ineffective"?

The issue here could be two-fold. First, if BVM ventilation is ineffective as a PCP, there is nothing you can fall back on, whereas the ACP can use either ETI or a SGA as indicated. If this ineffective BVM situation occurs as a PCP and the patient is GCS=3, why can't we insert a SGA as a rescue device for ineffective BVM ventilation?

Secondly, with some new evidence beginning to show that SGA's may actually not be as great as we thought in VSA patients, is there a risk we could abandon them entirely from the PCP level, in essence "throwing the baby out with the bathwater" and abandoning a valuable device simply because the conditions for its use were restrictive.

Also, do you have any idea when the new revised BLS standards may be coming out from the MOHLTC? I'm hoping there are new evidence based oxygen therapy guidelines. Any thoughts? Thanks.

 Thanks for your excellent questions. As for the rationale for different conditions for PCP and ACP as to the use of supraglottic airways (SGA), it is based upon the ability of ACPs to be able to sedate a patient if required if the patient's level of consciousness improves.

We have had situations where paramedics have attempted to place an SGA for a suspected GCS 3 and found that the level of consciousness was actually higher than originally assessed or improves during transport. In these situations, ACPs may follow the Procedural Sedation Medical Directive whereas PCP's do not have this ability within their current scope of practice.

As for your comments regarding the literature surrounding SGA's in general, you are correct that advanced airways (SGA and ETT both) have been de-emphasized. However, this de-emphasis is more generalized than just VSA patients so at this point, the role of advanced airways in prehospital medicine in general will most likely continue to evolve: it is not limited to PCPs and VSA patients.

Finally, as for the release of the new BLS manual, we completely agree with your desire for better evidence based guidelines for oxygen administration. The Regional Base Hospital Programs have all contributed to numerous edits to the new version of the BLS manual including a rationale for oxygen titration by paramedics. The release of the new BLS manual is up to MOHLTC-EHS and we have no deadline information in this regard.

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