CPR and Intubation

[croaker260]

BIAD during CPR, if an ROSC is achieved I'll pull it an intubate. If I have to tube during the CPR, it's while compressions are ongoing.

Uhmm... While I am very pro-ETT, I have to say that if I place a blind airway, and its working, it is counter productive to replace it with an ETT "Just because" . In my experiance, everytime I or a doc has removed a blind airway to intubate...even when justifed, it has been a difficult tube and usually is a horrible mess.

Moral: once a blind airway is placed, it stays in unless I have a specific reason to remove it.

[Kiwiology]

Intubation is a waste of time, nobody in cardiac arrest ever died from not having an ET shoved down thier gob

Put in an LMA or King-LT and you're set

[Bernhard]

Put in an LMA or King-LT and you're set

I'm totally agreeing with this sentence. Since two years or so we use LT here and despite beeing very sceptic in the beginning I am totally convinced now. It's so easy and quick and secure enough. And you don't have to waste a thought on the "ongoing compression" discussion, simply put it in...

But there remain situations, when a LT simply doesn't work. Last year I had two "can't intubate, can't ventilate" situations (extreme adipose patients), where LT didn't fit, mask was very difficult and questionable, and the whole team (medics and physicians, not to forget the patient) all had a very hard time to insert an e.t. tube in multiple tries. Both times it finally was a death on scene anyway. However, next time in such a situation I want to try inserting the LT with help of an laryngoscope - something we just thought of afterwards.

Plus when using auomatic respirators and/or chest compression systems, a 100% secure airway is required (which can stand the pressure of both compressions and respiration at the same time) - the LT is not sufficient for that, only e.t. tubing is the option here, so we re-intubate then. But this is only for transport under full CPR conditions (relativly rare) and sure after the first "chaotic" minutes in a more controlled setting, already having a sufficient airway access (LT).

With all this said, the LT is a nice but additional tool in our box, adding to our abilities in meeting specific needs on scene. Meanwhile it's my standard tool of choice, mask remains for assisted breathing or backup, e.t. if nothing other works or a 100% pressure secure airway is needed. But I wouldn't let the e.t. totally out of scope as you suggest in your post.

Was recently in your fair State of Bavaria. BEAUTIFUL country.

You're welcome. Drop a line next time and maybe we can arrange something!

Edited June 24, 2011 by Bernhard

[DwayneEMTP]

Uhmm... While I am very pro-ETT, I have to say that if I place a blind airway, and its working, it is counter productive to replace it with an ETT "Just because" . In my experiance, everytime I or a doc has removed a blind airway to intubate...even when justifed, it has been a difficult tube and usually is a horrible mess.

Moral: once a blind airway is placed, it stays in unless I have a specific reason to remove it.

Why was it more difficult and what made it a mess? Sincere questions....

Though I agree that in the vast majority of arrests that just about any airway will do, we don't really do medicine for the majority do we? We plan for worst case scenario. The over bagged 300lb'er that is going to belch his stomach contents all over the place, the ROSC that is going to vomit, etc. The problem I have with your statement is that by the time you realize that it's not 'working' you will have aspiration and you just can't unring that bell.

And I've always wondered, as I've never used the King/LMA, other than inserting a few LMAs in the OR, how well they withstand compression pressure at the seals. Intuitively it doesn't appear that they would do well.

Dwayne

Note: Posting at the same time as Bernhard, similarities are accidental.

Edited June 24, 2011 by DwayneEMTP

[Kiwiology]

But I wouldn't let the e.t. totally out of scope as you suggest in your post.

In the setting of cardiac arrest I don't see the point in intubating the patient really, some still do here but thats more old dog syndrome.

Intubation, in particular RSI, is something we should not get rid of from the Paramedic box of tricks but we must use it wisely.

[croaker260]

Why was it more difficult and what made it a mess? Sincere questions....

Though I agree that in the vast majority of arrests that just about any airway will do, we don't really do medicine for the majority do we? We plan for worst case scenario. The over bagged 300lb'er that is going to belch his stomach contents all over the place, the ROSC that is going to vomit, etc. The problem I have with your statement is that by the time you realize that it's not 'working' you will have aspiration and you just can't unring that bell.

And I've always wondered, as I've never used the King/LMA, other than inserting a few LMAs in the OR, how well they withstand compression pressure at the seals. Intuitively it doesn't appear that they would do well.

Dwayne

Note: Posting at the same time as Bernhard, similarities are accidental.

1- The King, Combitube, PTL, etc are all less than gentle/delicate insterion proceedures. Therefore even on the best days there is tissue swelling. On the worse days the MD forgets to deflate the cuff before pulling it.

2- Ive used both the King and before that the Combi during arrests...they seem to do well. I will admit that I have never hooked on up to a ventilator AND CPR both....

In the setting of cardiac arrest I don't see the point in intubating the patient really, some still do here but thats more old dog syndrome.

Intubation, in particular RSI, is something we should not get rid of from the Paramedic box of tricks but we must use it wisely.

Food for thought...ETT with or without RSI is a perishable skill, that requires continous performance to maintain.... If the only time we ever intubate are RSI, the skill will perish. Not saying this is the main reason to ETT durrring arrest, but with the advent of CPAP we just dont tube as many people anymore. If we arnt careful, the best of us will become unskilled....Bad ETT success rates will be a self fulfilling prophecy.

[chbare]

Bottom line guys: properly performed CPR that is uninterrupted is the primary intervention during CPR. Therefore, stopping compressions to perform a procedure that is of little to no benefit in the arrest patient is not warranted IMHO.

Regarding supraglottic airways: I think it would take an exceptional amount of intestinal fortitude or perhaps ignorance to pull a perfectly functional airway and replace it with an airway that may or may not be successful. If things go wrong and you are unable to intubate and effectively oxygenate/ventilate, you will have to explain why you pulled a functional airway in the first place. Sometimes the enemy of good is better... If something is working good, trying to replace it with something better may be met with disastrous results.

Take care,

chbare.

[JakeEMTP]

Agree with CHbare and Kiwi here. If I can ventilate the pt. well with a King, I won't pull it. Even the AHA says an airway is nice but chest compressions are paramount. As long as you have an airway, carry on with compressions please.

The LMA was designed for and works beautifully in the OR. It has absolutely no place in an ambulance. Unless of course you have a dedicated LMA "puter back inner". Used one once and promptly through the other one in the trash.

[tcripp]

Okay - so my interpretation for anyone who said, "we should provide uninterupted compressions while intubating" does so - which answers my original question.

Thanks, everyone, for your input.

[fiznat]

I usually try to do it while compressions are still going. If I'm having trouble I'll have my partners pause for just a second.

The bougie has been really helpful in maximizing my success. I pre-load the tube with a bougie instead of a stylet and let it protrude a few inches beyond the end. $$$

I like intubating codes because it is a definitive airway that does a reasonably good job at protecting the lungs from blood and vomit. That, and I like to take every opportunity I can to practice the skill. I won't sacrifice time or compressions to struggle with the tube, but when I can I like to intubate.