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• PALM consensus statement: estimation of population incidence using an island model.
  Richard J Price
  Published on: 13 January 2014
• PALM: A fringe benefit for a wider group of patients
  Andrew M Mason
  Published on: 25 November 2013

• Published on: 13 January 2014

  PALM consensus statement: estimation of population incidence using an island model.

  • Richard J Price, Consultant
  • Other Contributors:
    • Jeffrey Proctor, Andrew Inglis

  We read with interest the PALM consensus statement (1). This is an airway rescue technique for comatose hypoxaemic patients in the pre- hospital environment. The PALM procedure could also apply to the general practitioner (GP) run community hospital environment since the facilities of a metropolitan hospital, specifically rapid sequence induction of anaesthesia (RSI), are not available.

  The islands of the west c...

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  We read with interest the PALM consensus statement (1). This is an airway rescue technique for comatose hypoxaemic patients in the pre- hospital environment. The PALM procedure could also apply to the general practitioner (GP) run community hospital environment since the facilities of a metropolitan hospital, specifically rapid sequence induction of anaesthesia (RSI), are not available.

  The islands of the west coast of Scotland are served by such hospitals. The catchment population of these hospitals is clearly defined and almost all patients will present to, or be initially transported to, these hospitals. Since these hospitals do not have facilities for ongoing management of intubated patients, critically ill or injured patients are retrieved for ongoing care in metropolitan hospitals. These three circumstances provides for a unique opportunity to estimate the RSI incidence per head of population. It should then be possible to examine these cases to assess if a PALM procedure by the island GP would have been indicated as an initial procedure.

  We examined our service database from 1st Jun 2008-1st December 2013 inclusively for ventilated patients retrieved from the islands of Arran, Barra, Benbecula (and the Uists), Bute, Cumbrae, Coll, Colonsay, Islay, Jura, Mull and Tiree. These islands are served by a GP hospital or surgery. We could not assess deaths under medical care in the pre-hospital setting thus there may be a survivor bias but we suspect this is small. The total population of these islands is 25 204. Over a 4.5 year period, 68 ventilated patients were retrieved. Therefore we estimate that the "all cause" RSI rate is 0.60 per 1000 of population per year.

  We examined our service patient report forms for these 68 patients. 41 were comatose (an initial GCS of <9 either at referral to us or at our initial assessment) and 17 were hypoxaemic (an initial SpO2 <90%). 13 patients were both comatose and hypoxaemic. Of these 13 patients, 4 had airway management without drugs. Of the remaining 9 patients (a potential PALM rate of 0.08 per 1000 per year), 5 had a primary neurological diagnosis and 4 a primary respiratory diagnosis. Of the 13 patients there was mention of an airway problem in 1.

  We agree that PALM is likely to be a rare procedure. Our results, within the clear limitations of our approach, may help inform that opinion. We agree that the faculty should develop a robust registry to inform discussion about this interesting development. We question if the likely frequency of PALM for any one doctor is sufficient to maintain currency unless very clear mechanisms are mandated.

  References: Moss R, Porter K, Greaves I. Pharmacologically assisted laryngeal mask insertion: a consensus statement. Emerg Med J 2013; 30: 1073-1075.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 25 November 2013

  PALM: A fringe benefit for a wider group of patients

  • Andrew M Mason, Immediate Care physician

  It is a pity that the Royal College of Anaesthetists felt unable to support the recent Faculty of Prehospital Care consensus statement on pharmacologically-assisted laryngeal mask insertion (PALM) [1]. PALM was only ever intended to be used as an emergency rescue technique in patients with a lowered level of consciousness (GCS <8-9 or AVPU P or U) AND an SpO2 reading of 92%-or-less. This despite best efforts to reverse...

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  It is a pity that the Royal College of Anaesthetists felt unable to support the recent Faculty of Prehospital Care consensus statement on pharmacologically-assisted laryngeal mask insertion (PALM) [1]. PALM was only ever intended to be used as an emergency rescue technique in patients with a lowered level of consciousness (GCS <8-9 or AVPU P or U) AND an SpO2 reading of 92%-or-less. This despite best efforts to reverse hypoxaemia using basic airway techniques (opening the airway, suctioning, insertion on an OPA/NPAs/both, application of hi-flow O2 therapy using a NRBM or BVM, decompression of a tension pneumothorax, etc.) [2].

  When basic methods intended to improve oxygenation fail and the patient will not tolerate insertion of a supraglottic airway device (SAD), the only two choices open to practitioners below Level 3 status is to undertake an emergency cricothyrotomy, or to wait until the patient becomes so obtunded by virtue of increasing hypoxaemia and hypercarbia that they ultimately submit to SAD insertion. The former is not an option for most UK paramedics who are not adequately trained or equipped to perform a surgical cricothyrotomy (many are not even issued with scalpels), and I maintain that the latter is not in the patient's best interest.

  It is suggested in the consensus statement that PALM will only rarely be necessary in the prehospital environment. While this may be so, insertion of a SAD is a standard strategy on the airway ladder for failed RSIs within UK hospitals. Under these circumstances, anaesthetists are effectively undertaking a PALM procedure to rescue the airway. No anaesthetist working in the hospital environment would perform a surgical cricothyrotomy for a 'cannot-intubate/cannot-ventilate' (CICV) situation before first considering a SAD insertion, so it is difficult to understand why they are unable to support PALM in the prehospital environment too.

  It has been suggested that there should be an official register to record all PALM cases undertaken in prehospital care. I would like to suggest that all failed intubations within UK hospitals where a SAD has been used to rescue the airway are also shown in a linked parallel register. Only then will we know how frequently a PALM-type technique is used in this country to rescue a critical airway situation, and what are the outcomes in such cases. It would be interesting to know if the Royal College of Anaesthetists would be prepared to cooperate on this matter.

  [1] Moss R, Porter K, Greaves I (on behalf of the consensus group, Faculty of Pre-Hospital Care). Pharmacologically assisted laryngeal mask insertion: a consensus statement. Emerg Med J 2013;30:1073-1075 doi:10.1136/emermed-2013-203215

  [2] Mason AM. Prehospital use of the intubating laryngeal mask airway in patients with severe polytrauma: a case series. Case Reports in Medicine 2009; doi:10.1155/2009/938531

  Conflict of Interest:

  Since 1999, AMM has helped to develop and refine the PALM technique and also delivered the keynote presentation at the PALM Consensus Meeting held at BHI (Bromsgrove) on 13/04/12.

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  Conflict of Interest:
  None declared.

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