Adult/adolescent device with strict exclusions

PR-135 applies to adult/adolescent patients weighing at least 50 kg; it is not a pediatric SGA procedure.
Do not place through an intact gag reflex or when upper-airway obstruction, caustic ingestion, oral trauma, distorted anatomy, esophageal disease, or a laryngectomy stoma makes placement unsafe or ineffective.
If vomiting or forceful gagging occurs, turn the patient to the side, remove the device, suction thoroughly, and support ventilation with BVM.
Waveform capnography and continued clinical reassessment are required to detect displacement or inadequate ventilation.

Confirm the indication

An Orange County accredited paramedic may use an SGA to secure the airway of an unconscious adult/adolescent without a gag reflex who needs airway protection and ventilation.
PR-135 supports an SGA as the primary advanced airway when rapid control is needed and intubation is expected to be difficult, during adult cardiac arrest when intubation would likely interrupt compressions, or after unsuccessful intubation.
Use only when the patient weighs at least 50 kg and adequate ventilation and oxygenation cannot be maintained with a less invasive method.

Do not place an SGA with an intact gag reflex, known caustic ingestion, unresolved upper-airway obstruction, significant oral trauma or unstable jaw fracture, anatomy that prevents placement, known esophageal disease, or a laryngectomy stoma.
If trismus prevents opening the mouth after midazolam 5 mg IV/IO/IM, do not force insertion.
Prepare PPE, the correct-size device, BVM, suction, stethoscope, water-based lubricant, a securing method, waveform ETCO2, pulse oximetry, cardiac monitoring, and optional gastric tube. Clear the airway, pre-ventilate with BVM and 100% oxygen, and select the device size.

For an inflatable device, test the cuff for leaks and deflate it. Prepare and lubricate the SGA according to the manufacturer.
Use a sniffing position, or neutral alignment for suspected cervical-spine injury. Open the mouth with chin lift or jaw thrust as appropriate.
Direct the soft tip toward the hard palate, then glide it downward and backward with a continuous gentle push until resistance is felt and the bite-block region rests at the incisors.
If the design uses an inflatable cuff, inflate gently only enough to seal the upper airway for assisted ventilation. Secure the device.

Confirm position with breath sounds, chest rise, and a waveform capnography tracing. Continuously monitor capnography, pulse oximetry, and cardiac rhythm through transfer of care.
For the devices listed in PR-135, size 4 is used at 50-90 kg and size 5 above 90 kg. An optional gastric tube is 12F for size 4 and 14F for size 5.
Document device size, number of attempts and success, pulse oximetry, and ETCO2 as both a numerical value and the airway-confirmation method.

Once placed, the SGA should ideally remain. Removal may be necessary for inadequate ventilation, return of a gag reflex, vomiting, or forceful gagging.
For removal, position the patient on the side while maintaining spinal precautions as needed, have suction immediately ready, remove the device, and reassess airway and breathing for further assisted ventilation.