1 Minute Intubation

[HellsBells]

Fair enough. Sounds like a bit of a cluster, I agree with you that it is kind of unreasonable for dispatch to call an off duty medic, just because he lives close to the call. However, in the case of persistant V-Fib, I don't think its totally unreasonable to transport to the hospital, as occured in this case.

As far as the issue of Amiodarone, obviously it is indicated in this situation, but its doubtful it would have made any difference for this pt. Of course your main question was about the intubation time, and I think that its a very valid point. On rereading the 2005 ACLS guidelines the other night, there is certainly a great deal of emphasis put on maintaining CPR and deferring intubation. Which really has me thinking about how we run codes in the city I work in.

Typically, in our system, one engine and an ambulance are called to all code or potential code situations. I find that most paramedics will have the firefighters begin compressions and provide ventilations while we busy ourselves with the monitor, IV, medications, etc. Meanwhile, were not paying as much attention to the quality of of CPR as we should be. Some of the Firefighters are good providers of CPR, but the training in our city's dept. is kind of inconsistant, to say the least. It is interesting that many people in our service, including myself on a few occasions, are leaving what may be the most important aspect of the code in the hands of the least expierenced people on scene. But, I digress.

[Arizonaffcep]

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?

As I was reading the posts for this, I don't remember seeing anyone say the science behind the "new" ACLS changes (they are also coming out with new guidelines this year as well folks), for the AHA. It was the largest study done, certainly by the AHA (possibly ever) and encompassed medicine from literally all over the world. What was discovered was that because the coronary arteries are "filled" on the "back pressure" from the aorta, it does take a significant amount of time and energy (in this case energy=compressions) to bring the perfusion of the myocardium to a state where the muscle is more "accepting" of an electrical charge. Another reason that they are saying "don't stop compressions for LONGER than 10 SECONDS" is because they found that the cardiac output during compressions is at BEST 1/3 of a normal contraction, and the assumption was that it was higher than that prior to the release of the studies. That being said, there really is no reason that you should stop compressions for longer than 10 seconds, especially with the availability of alternative airways. I would prefer the combi-tube or something similar instead of an LMA, but the reality is either will work.

As an addendum to the AHA studies, they found that for every 10 second stop (2 minutes or 5 cycles of 30 compressions and 1 breath-BVM, non-secured airway) it takes about 15-20 compressions to bring that perfusion level in the myocardium back up to the point where it was before the 10 second stop. So, in essence, even with only a 10 second stop, at least 1/2 of the compressions of the next "round" are just used to bring the perfusion back up and not a maintenance.

Edited January 28, 2010 by Arizonaffcep

[Lone Star]

Granted, I'm only a former EMT-B and impending EMT-I, but I've got a few questions here.

In my time in EMS, I've seen LALS and ALS providers remove the OPA/NPA on a patient with a 'secured airway' to drop an ETT for what appears nothing more than for the 'cool factor points'.

Granted, the ETT secures the trachea, and prevents aspiration from abdominal distention; but when working a cardiac arrest, doesn't it make more sense in concentrating on managing the cardiac issues as opposed to remove the device that's secured a patent airway, only to 'resecure it'?

During EMT-I class, we were told that just because we COULD drop an ETT, doesn't mean that we HAVE to do it on every patient.

Second, if attempting to ventilate during compressions, doesn't that effectively diminish the tidal volume being introduced via BVM?

Inspiration is caused by the movement of the diaphragm, creating a low pressure area within the lungs. As fast as compressions are done (when properly performing CPR), each compression would be generating a 'high pressure area' in the lungs, thereby pushing the volume of air you just introduced back out. Is this condusive for adequate gas exchange, and ultimately oxygenation of the patients blood and peripheral perfusion?

[treaux]

An OPA/NPA is not a secured airway. Placing an ETT tube is what secures the airway. I've seen codes run without any type of advanced airway placed, and they usually go the same way: Pt gets bagged with a BVM/OPA throughout the code and their abdomen becomes distended and eventually induces vomiting, which gets immediately aspirated due to the ventilation through an unsecured airway. This is in adults of course as the subject of intubating pediatrics has shown it not to be beneficial unless they have a difficult airway or inadequate ventilation.

The matter at hand is keeping the focus of a cardiac arrest on the compressions. They are the key to reviving someone and every action taken during the code should be done with consideration of good compressions. According to AHA, you stop your CPR every two minutes to re-check pulses and change the person giving compressions. During one of these breaks you should be all set up and ready to intubate. As soon as the tube is in (we're talking 10-20 seconds depending on the airway) you should immediately resume compressions while securing the tube. If this isn't happening, then you need to get with your employer or school or someone and practice intubations. There's nothing wrong or demeaning about that. In fact, it makes you a good medic for keeping up on what can be infrequent skills for many.

So yeah, over a minute is grossly unacceptable and it sounds like that call could use some review to prevent it from happening again.

[DwayneEMTP]

Granted, I'm only a former EMT-B and impending EMT-I, but I've got a few questions here.

In my time in EMS, I've seen LALS and ALS providers remove the OPA/NPA on a patient with a 'secured airway' to drop an ETT for what appears nothing more than for the 'cool factor points'.

By no definition is a pt with an OPA/NPA to be considered to have a 'secured' airway. Temporarily patent perhaps, but in no way secured. Every time that I've removed one of these devices and placed an ETT instead I've heard rumblings that I 'was just trying to be cool.' In my mind, dropping a tube is the least cool thing that I do. It exposes me to the teeth, saliva and all of the nasty shit that comes out of the lungs upon successful placement, not to mention it's not exactly rocket science. I can tell you that 100% of my ETTs were placed in the hope of increasing the odds of a positive medical outcome and that, to the best of my goofy knowledge, my ego was not consulted before hand.

Granted, the ETT secures the trachea, and prevents aspiration from abdominal distention; but when working a cardiac arrest, doesn't it make more sense in concentrating on managing the cardiac issues as opposed to remove the device that's secured a patent airway, only to 'resecure it'?

Sure, if managing this one tiny moment in time is my only responsibility. But abd distention has side effects, as does aspiration. And again, in this scenario it was never secured to begin with. I like to intubate early in many cases simply because I no longer have to effect compressions for ventilation, which is my main goal. It has the added benefit that I also stop all of the shit that tends to be running out of the esophagus because of a full belly/over aggressive bagging prior to my arrival. Our job isn't to look good, but to do good. Intubation is a great tool, and I think that you'll begin to see the difference in application as you continue your education.

During EMT-I class, we were told that just because we COULD drop an ETT, doesn't mean that we HAVE to do it on every patient.

And I think that you'll come to appreciate (hopefully this is true) that many of the tubes you witnessed came because of a perceived medical need following assessment as opposed to a medic attempting to prove to the world that he has a penis.

Second, if attempting to ventilate during compressions, doesn't that effectively diminish the tidal volume being introduced via BVM?

Great question. But I think that as you look into this further, as I'm certainly not the best choice to attempt to explain it, that you'll find that it has more to do with inter-thoracic pressure than with tidal volume. A dead person needs very little ventilation.

Inspiration is caused by the movement of the diaphragm, creating a low pressure area within the lungs. As fast as compressions are done (when properly performing CPR), each compression would be generating a 'high pressure area' in the lungs, thereby pushing the volume of air you just introduced back out. Is this conducive for adequate gas exchange, and ultimately oxygenation of the patients blood and peripheral perfusion?

I can't provide a sources for this, but I believe that there is argument in the CPR community over whether or not it is. Some say that more than enough air is being moved to provide ventilation, others that you are moving only dead space air for the most part. I tend to believe, based on ETCO2 during arrests, that the PPV that we deliver has limited value in the short term, but I'm still waiting for the smart folks to figure it out and tell me what to do.

Fair questions LS.

Dwayne