1 Minute Intubation

[melclin]

Posting from work so I must be brief. More info on request.

To what extent do you feel that taking a little over a minute to intubate a cardiac arrest pt (refractory VF scenario), whilst compressions have been ceased, is acceptable/unacceptable.

This example is from a job I went to recently where the attending medic instructed me to cease compressions for probably around 40 seconds, failed, I did perhaps another 15-20 compressions, while he prepared again. When I ceased, it took another 30-40 seconds to get the tube.

I didn't feel this was acceptable, but given my inexperience, I was wondering what you all thought about the matter. I believe I've heard of some of you yanks tubing with compressions in progress. Did I misunderstand? Whats the go with this issue?

[NRPinNEPA]

Per the National Standard Curriculum, an intubation attempt should take no more than 30 seconds. That is from when ventilation ceases to when ventilation begins again. Anything more is, by the book, unacceptable.

[Kiwiology]

I don't believe this is acceptable at all given the long delays where no compressions are taking place. Drop an LMA if need be rather than peeing around trying to intubate if its that difficult.

[ccmedoc]

Posting from work so I must be brief. More info on request.

To what extent do you feel that taking a little over a minute to intubate a cardiac arrest pt (refractory VF scenario), whilst compressions have been ceased, is acceptable/unacceptable.

This example is from a job I went to recently where the attending medic instructed me to cease compressions for probably around 40 seconds, failed, I did perhaps another 15-20 compressions, while he prepared again. When I ceased, it took another 30-40 seconds to get the tube.

I didn't feel this was acceptable, but given my inexperience, I was wondering what you all thought about the matter. I believe I've heard of some of you yanks tubing with compressions in progress. Did I misunderstand? Whats the go with this issue?

National curriculum or not, this is unacceptable. 30 Seconds is a long time, and I think that the medic should know in a few seconds if the airway will be difficult or not. A rudimentary assessment could possibly clue him in to that before he even gets into the hypopharynx, and maybe allow him into being a bit more prepared.

I would also say that maybe just an OPA and bagging could benefit this patient more, in refractory VF as you state, as well as potentially allowing a more beneficial treatment..ETT is certainly in the plan, but if the airway is open and patent with a more basic airway, then other interventions take priority; i.e. compressions, defib, and meds...

I stand by my assertion that a cursory assessment could predict the airway troubles and dictate perhaps different prep, more assistance, or postponing the ETT for a bit....Simply some armchair quarterback, but this is how I try to approach a situation such as this..

I think that a longer period of compression/oxygenation should be allowed before a second attempt..Was any monitoring of the SaO2 possible while doing this?? Just curious and I am still not sure how accurate this would be...

[FF_EMT7]

Wow.. That is a little bit longer than it should take to intubate a patient from my experience. If the medic didn't feel comfortable he should have just dropped a combi or king. Just my own opinion of course.

[melclin]

National curriculum or not, this is unacceptable. 30 Seconds is a long time, and I think that the medic should know in a few seconds if the airway will be difficult or not. A rudimentary assessment could possibly clue him in to that before he even gets into the hypopharynx, and maybe allow him into being a bit more prepared.

See now that's what I thought. We have a failed intubation drill that involves the use of an LMA which can be inserted in a matter of seconds with little cessation of compressions. I don't like to criticize the workings of the MICA mind but I feel this would have been a much more prudent option once it became apparent after a few seconds that it was difficult going.

I would also say that maybe just an OPA and bagging could benefit this patient more, in refractory VF as you state, as well as potentially allowing a more beneficial treatment..ETT is certainly in the plan, but if the airway is open and patent with a more basic airway, then other interventions take priority; i.e. compressions, defib, and meds...

There was good compliance and air entry, skinny bloke, no obvious abdo distension after 5 or so minutes of resus by paramedics and ~7 mins of bystander CPR (except after one very obvious whoopsie on the part of the same medic, when he gave a mighty ventilation in the middle of my compressions with no warning, and the pts stomach blew up like a balloon), continuing with an opa seemed fine to me.

I stand by my assertion that a cursory assessment could predict the airway troubles and dictate perhaps different prep, more assistance, or postponing the ETT for a bit....Simply some armchair quarterback, but this is how I try to approach a situation such as this..

I think that a longer period of compression/oxygenation should be allowed before a second attempt..Was any monitoring of the SaO2 possible while doing this?? Just curious and I am still not sure how accurate this would be...

Not that I'm aware. It was a crowed (6 or so medics/students), small and messy room, and I had other things to concentrate on, like staying out of more important people's way , so I can't be sure. But I think its a pretty good guess to say no. I wasn't aware it have thought it would be worth having on a patient in full arrest - poor circulation and so on.

All in all I thought it was a poor effort, the first attempt seemed doomed from the beginning because of the patients position precluding the medic from visualizing the airway properly. But thats something that should have been remedied before hand. We get crucified for not moving the pt to a more suitable position for airway management and CPR at uni during pracs, so its certainly not beyond a MICA paramedic.

The pt didn't receive any amiodarone, because it seems, the medic simply forgot. To make matters worse (IMHO) after about 15 mins they (not my crew) transported to hospital, CPR in progress, and we all know how good for the pt/safe that is. I can see no proper clinical reason why that would be and I was quite surprised to hear everyone on scene agree with it when someone suggested it, maybe I missed something. The hospital did nothing we could not do except call TOD (pt have to be in asystole for us to call it), and I suspect that may have been the reason.

Anyway, whats the go with tubing with compressions in progress? (Ben, do you blokes pause for LMA?) It seems to make good sense to me, or at least to do as much as possible and just cease for a few seconds to do the difficult bits, what ever that may be. I've never tubed a real person, so I wouldn't know if this is rubbish or not, but I've heard of it being done.

[Kiwiology]

We do not pause, one does compressions and somebody else puts the LMA

[ccmedoc]

I see no need to pause for intubation, at least not for very long. If you are placing an alternative blind airway, you wouldn't need to stop either. If the medic is prepared, the laryngoscope can be placed and visualization can be done with little cessation of compressions..I guess this is where preparation and a little foresight come in..

Poorly run arrest. You would think that an arrest is the least stressful part of being a paramedic. It should be down cold, with little apprehension.

[DwayneEMTP]

I have little issue with him taking a minute to intubate, but I have serious issues with interrupting compressions so often and for so long.

I'm not a big fan of using an OPA/Bag in place of an ETT for any extended period. It seems that he science is pretty convincing that compressions are the ticket to saving the tiny percentage of these folks that we're actually going to save. OPA/bag means interrupted compressions every 30 seconds (or as close as many come to that) and that is just unacceptable I think, 'specially when it seems that that only gives you 10-20 seconds of actual halfassed blood flow/minute. Once you get the blood flowing, don't screw with your interthoracic pressures if you can help it. Of course electricity is one of the obvious exceptions to this rule.

Do an external exam to estimate your chances of success, prepare your pts placement and your equipment for best chances of success, visualize as much as possible with compressions continuing and shoot your tube.

Of course it's not always so easy, but compressions are king in CPR. Allow the minimum interruption possible.

Dwayne

[Kiwiology]

How come you say you'd have to interupt compressions to use a bag mask? I could see if you were on your own then perhaps maybe but with two or more ambo's at minimum it should be ok; heck it should be dandy right coz of the good ole ambo trick of "more is better" and by the time you get on the stickies, confirm VF and start pounding away, two cops, eight firefighters and the medical director have shown up!