FIELD REFERENCE
Full criteria & treatment guidance
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.
Screen contraindications & prepare
- 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.
Insert the device
- Identify the device before preparation. i-gel has a non-inflatable cuff: do not attempt cuff inflation or deflation. LMA Supreme has an inflatable cuff; perform its leak check and preparation according to the current manufacturer instructions. Lubricate the selected device as directed.
- 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.
- For LMA Supreme, inflate the cuff only as directed by its current instructions, observing the manufacturer pressure limit. i-gel requires no cuff inflation. Secure the selected device and confirm effective ventilation.
Confirm, monitor & document
- Confirm position with breath sounds, chest rise, and a waveform capnography tracing. Continuously monitor capnography, pulse oximetry, and cardiac rhythm through transfer of care.
- The linked PR-135 names i-gel and LMA Supreme and lists size 4 at 50-90 kg and size 5 above 90 kg, with an optional 12F gastric tube for size 4 and 14F for size 5. These are the county source's stated specifications, not a universal sizing rule for all SGAs. Check the exact device's current instructions and agency authorization; resolve any difference with medical direction rather than combining device-specific instructions.
- Document device size, number of attempts and success, pulse oximetry, and ETCO2 as both a numerical value and the airway-confirmation method.
Remove only when necessary
- 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.
VISUAL FIELD REFERENCE
SGA: eligibility, confirmation, and removal triggers
Adult & adolescent · ALS
Check all contraindications and use the manufacturer-specific preparation and placement instructions.
- At least 50 kg
Check patient and scope
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.
Use only when the patient weighs at least 50 kg and adequate ventilation and oxygenation cannot be maintained with a less invasive method.
Confirm and monitor continuously
Confirm position with breath sounds, chest rise, and a waveform capnography tracing. Continuously monitor capnography, pulse oximetry, and cardiac rhythm through transfer of care.
Vomiting or forceful gagging
If vomiting or forceful gagging occurs, turn the patient to the side, remove the device, suction thoroughly, and support ventilation with BVM.
- 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.
Selected checkpoints; read the complete guide for criteria, exclusions, doses, and ongoing care. PR-135
UNDERSTAND THE CARE
Why airway confirmation continues through handoff
The SGA is a means of supporting ventilation, not an endpoint in itself. Patient eligibility, an appropriate device and preparation for suction and BVM support are required before placement. The local procedure’s weight and population limits must remain visible; this is not a pediatric SGA pathway.
Applying the guidance
After insertion, join chest rise and breath sounds to waveform capnography and monitor continuously through transfer. Movement can change device position, so reassessment continues during packaging and handoff. A returning gag reflex, vomiting or inadequate ventilation changes the plan and requires the source’s removal and support instructions.
Repeat airway confirmation
Putting it together
Teaching example: ventilation was adequate before moving the patient, but the waveform and chest rise change afterward. Reassess the patient, device and ventilation rather than assuming the original placement is still effective.
Diagram text & teaching checkpoints
- Eligibility
- Population, weight, gag reflex and exclusions.
- Preparation
- Device, suction, BVM and monitoring.
- Confirmation
- Chest rise, sounds and sustained waveform.
- Continuity
- Recheck during movement and transfer.
Sources for this explanation
Original OCMedic teaching synthesis of the references below. Educational expansion updated ; this is not a new independent clinical-review date. Source-specific dates and limitations remain in the full guidance.
Match the device instructions to the device in hand
The local procedure defines eligibility and exclusions, while the manufacturer instructions define preparation for the particular SGA. Identify the model and size before using the insertion sequence. A step referring to an inflatable cuff applies to a device that has that feature; it should not be converted into a universal instruction for every supraglottic airway.
Prepare the backup ventilation and suction plan before insertion. This matters because the clinical task is to maintain oxygenation and ventilation, and an attempt may fail or an initially effective device may later become unsuitable. The page’s weight and gag-reflex restrictions remain part of patient selection throughout preparation.
At handoff, name the device and size, number of attempts, confirmation findings and any change during movement. Include the current waveform and clinical ventilation findings rather than only the successful insertion time. If gagging, vomiting or inadequate ventilation led to removal, report the reason and the support that followed. The existing removal instructions and complete PR-135 remain the authority for those actions.
Sources: PR-135