CPR and Intubation

[tniuqs]

If this is the case...prove it.

Yep, in fact I've flown patients on a vent after a failed ED intubation with a King in place with no problems, we simply placed an OG tube down the LTS-D. Not to mention any ED worth a crap has backup airways in the cart, just like you'll find in OR where the real airway specialist live.

Anyone convinced the alternative airways cause massive tissue damage and are unsuitable for initial airway use needs to look up Dr. Darren Braude's Rapid Sequence Airway system developed at the University of New Mexico. If your routinely tearing up tissue with BIADS, your doing it wrong.

Frankly it always amazes me that AHA or ERC and ever-changing concesis of procedure protocol based on metastudies are the actual authority and gospel according to god himself .. meh. When one should listen to the "real airway specialists" in the OR, have yet to see an LT King in that place maybe a Carlens or 2, and very few LMAs either.

From the link that Chbare so kindly provided:

Advanced cardiac life support before and after tracheal intubation--direct measurements of quality.

Kramer-Johansen J, Wik L, Steen PA.

Source

Institute for Experimental Medical Research, University of Oslo, Ulleval University Hospital, N-0407 OSLO, Norway. jo.kramer-johansen@medisin.uio.no

Abstract

STUDY HYPOTHESIS:

Tracheal intubation should improve the quality of cardiopulmonary resuscitation (CPR) by enabling adequate ventilation without pauses in external chest compressions.

METHODS:

Out-of-hospital cardiac arrests of all causes were sampled in this non-randomized, observational study of advanced cardiac life support in three ambulance services (Akershus, London and Stockholm). Prototype defibrillators (Heartstart 4000SP, Philips Medical Systems, Andover, MA, USA and Laerdal Medical AS, Stavanger, Norway) registered all chest compressions via an extra chest pad with an accelerometer mounted over the lower part of sternum and ventilations from changes in transthoracic impedance between the standard defibrillator pads. The quality of CPR was analyzed off-line for 119 episodes. Numbers and differences are given as mean +/- S.D. and differences as mean and 95% confidence intervals.

RESULTS:

Chest compressions were not given in cardiac arrest for 61 +/- 20% of the time before intubation compared to 41 +/- 18% after intubation (difference: 20% (16-24%)). Compressions and ventilations per minute increased from 47 +/- 25 to 71 +/- 23 (difference: 24 (19, 29)) and 5.6 +/- 3.7 to 14 +/- 5.0 (difference: 8.7 (7.6, 9.8)) respectively. Four cases of unrecognized oesophageal intubation (3%) were suspected from the disappearance of ventilation induced changes in thoracic impedance after intubation.

CONCLUSION:

The quality of CPR improved after tracheal intubation, but the fraction of time without blood flow was still high and not according to international guidelines. On-line analysis of thoracic impedance might be a practicable aid to avoid unrecognized oesophageal intubation, but this area needs further research.

Edited June 28, 2011 by tniuqs

[BushyFromOz]

Whooooa! Hold on there, buddy. Let me get this straight, you're going to decrease your patient's chance of surviving the arrest (assuming that you mean to say you'll stop compressions to get the tube) in order to facilitate post-arrest treatment? I think you're getting way, WAY ahead of yourself there. How about we worry about getting the person back first, and worry about everything else after we've accomplished that?

If you can tube 'em without stopping compressions, by all means, go for it. That's what I'd do. But if you're holding lifesaving compressions in order to facilitate post-arrest treatment, I have a MAJOR problem with that.

Sorry bro, you didn't get it straight, and the throw away line of "worry about getting them back first" is somewhat insulting.

The cardiac arrest management we produce is delivered a a package, one that has been in devlopement for over a decade. What we have now has been trialled piece by piece and our data clearly shows we have excellent ROSC and survival to discharge rates when compared to other services. In melbourne, we are currently delivering what is believed to be world leading stats. Over 50% of arrest are ROSC's and over 30% survive to discharge. Significant changes to the way we resource and deal with first response to arrests (which accouns for the 25% of the 30% who survive to discharge) as well as proper airway management, intubation and rapid infusion of normal saline (accouhnts for the other 5%) when given as a package give our patients MAXIMUM chance of survival if delivered in its entirety, so whats the "major" problem?

Edited June 29, 2011 by BushyFromOz

[DwayneEMTP]

...I completely agree with you that a good airway should not be replaced "just because", unfortunately the standard around here seems to be that if we haven't gotten a tube on scene then it must be replaced.

Please define 'good airway.' Just so's we know that we're talking apples to apples.

If your patient aspirates, have you then given good patient care because you started with a 'good airway?' What would you suppose the recovery rate for an aspirated ROSC would be? I don't have studies but I've had two anesthesiologist tell me that the permanent morbidity and/or mortality rate for significant aspiration is above 90%. If we use that value as factual, which I am not claiming to be true, would that change your definition of a good airway?

In my mind this definition isn't complete simply because we've verified that the airway will in fact move air. Just sayin'...

Dwayne

Edited to add the word 'significant' in italics above.

Edited June 29, 2011 by DwayneEMTP

[Bernhard]

Frankly it always amazes me that AHA or ERC and ever-changing concesis of procedure protocol based on metastudies are the actual authority and gospel according to god himself .. meh.

That said together with the ongoing citation of studies wonders me a bit...

When one should listen to the "real airway specialists" in the OR, have yet to see an LT King in that place maybe a Carlens or 2, and very few LMAs either.

Here, since some years, it's very common to have a larynx mask in the OR (applied by real anesthesists).

I see the LT as a replacement for the simple face mask when bag valving in the first place - it's fast enough to apply, needs not so much further attention and makes one hand free.

Secondly it has the advantage to provide a very safe airway almost the same as with an e.t. tube (according to scientific study surveys), making the e.t. unnecessary in many cases. The LT is far faster to apply, doesn't need assistance (cricoid pressure, handing the tube over), no additional fumbling with stylet/lubrication and it's safe enough if applied correctly (which is simple). It's in place when others still try to get a view on the vocal cords.

Sure, I have my e.t. tube as the tool, if LT is not working or not indicated (i.e. in massive oropharyngeal bleeding). I recall two cases last year, where the LT didn't fit - it then was a mess with the e.t. either...(each involving more than one experienced provider, including anesthesists).

I simply prefer the right tool for a situation, based on acceptable/adequate effectiveness, time needed (the faster the better) and risks involved (the less risks, the better). To propagate "one solution for every situation" is too short sighted, I think.

[chbare]

Again, I have to point to the best guidelines available. We can complain about AHA and worry about aspiration; however, a "gold standard ETT airway" remains a low priority in the arrest patient when looking at other interventions such as compressions. Since this thread is about stopping compressions to intubate, I will continue to say that stopping a primary treatment modality to do something less important is not a good idea. Post arrest with ROSC, we can have a discussion, during an arrest, the priority remains pretty clear.

Take care,

chbare.

[BushyFromOz]

Collectively weve spent billions of dollars on trying to find ways to bring dead people back to life and the document that demonstrates "best practice" is still a flipping "guideline"

We routineley have to break CPR for very short periods of time, during defibrillation, rhythm checks etc. We all know that problems of working an arrest in confined spaces because you were unable to move the patient to a better area within a reasonable timeframe (for some reason my arrests never happen in the middle of the backyard or loungroom floor or on a hospital bed). In the overall picture, would not performing 10 or so compressions or a rhythm check lasting an extra 6 seconds so the vocal chords stop bouncing enough to pass the tube through them matter?. Given all the variables of out of hospital arrests would it really matter that much or even be measurable?

Not advocating it, just playing devils advocate.

[chbare]

Collectively weve spent billions of dollars on trying to find ways to bring dead people back to life and the document that demonstrates "best practice" is still a flipping "guideline"

We routineley have to break CPR for very short periods of time, during defibrillation, rhythm checks etc. We all know that problems of working an arrest in confined spaces because you were unable to move the patient to a better area within a reasonable timeframe (for some reason my arrests never happen in the middle of the backyard or loungroom floor or on a hospital bed). In the overall picture, would not performing 10 or so compressions or a rhythm check lasting an extra 6 seconds so the vocal chords stop bouncing enough to pass the tube through them matter?. Given all the variables of out of hospital arrests would it really matter that much or even be measurable?

Not advocating it, just playing devils advocate.

Who knows. Certainly, the guidelines do cover pausing for intubation and it's not forbidden.

Tae care,

chbare.

[tniuqs]

'Bernhard'

That said together with the ongoing citation of studies wonders me a bit...

Here, since some years, it's very common to have a larynx mask in the OR (applied by real anesthesists).

I see the LT as a replacement for the simple face mask when bag valving in the first place - it's fast enough to apply, needs not so much further attention and makes one hand free.

Secondly it has the advantage to provide a very safe airway almost the same as with an e.t. tube (according to scientific study surveys), making the e.t. unnecessary in many cases. The LT is far faster to apply, doesn't need assistance (cricoid pressure, handing the tube over), no additional fumbling with stylet/lubrication and it's safe enough if applied correctly (which is simple). It's in place when others still try to get a view on the vocal cords.

Sure, I have my e.t. tube as the tool, if LT is not working or not indicated (i.e. in massive oropharyngeal bleeding). I recall two cases last year, where the LT didn't fit - it then was a mess with the e.t. either...(each involving more than one experienced provider, including anesthesists).

I simply prefer the right tool for a situation, based on acceptable/adequate effectiveness, time needed (the faster the better) and risks involved (the less risks, the better). To propagate "one solution for every situation" is too short sighted, I think.

The studies in Seattle and Vancouver (Can) are very clear no matter what EMS believes the most positive outcomes are decided well before our arrival in Out of Hospital Arrests therefore teaching the public to perform CPR is the real deal, that said with rapid ALS back up. This almost uninterrupted compressions by teams in the field or in hospital even with the old standards are fairly constant (see Brindley et all) No matter how much physical effort, electricity, or drugs .. Dead is Dead .

Kudos to tripp for her query it clearly demonstrate's that she is an excellent provider.

FIRST GET GOOD .. THEN GET FAST

last but not least PRACTICE MAKES PERFECT !

< reason for edit> dang quotes again .

Edited June 29, 2011 by tniuqs

[HERBIE1]

Maybe a slight detour, but I will back up a bit. Anecdotally, the majority of my full arrest saves have been WITHOUT an ET tube. We've been on a roll lately- the last 3 arrests we had were saves with a ROSC, and so far, 2 of them have survived to discharge with no deficits. All were intubated AFTER ROSC. With proper CPR and good ventilations, I think the ET is superfluous in the initial stages of a resuscitation. .New CPR standards say we need to compress the chest hard and fast and demphasizes ventialtions..

Is an airway and ventilations important? Of course, but here's an example. Last week- call for a person "down" in car. Upon arrival, we see a bystander doing OUTSTANDING CPR with the victim on the sidewalk- compressions ONLY- for about 3-4 minutes per bystanders,.I checked for a pulse, and the patient actually had one, and some preliminary respirations. I profusely thanked the bystander and told him he just saved a life. To make a long story short, we essentially did an ACLS megacode, - multiple defibs, lots of drugs, but the person survived, was making purposeful movements and fighting the tube. Before we left the ER, the patient was enroute to tthe cath lab for his STEMI- unknown outcome.

Point being, we make a big deal out of toys, procedures, and forget the point of all this.

Simple answer- do NOT interrupt CPR just to intubate. Good, solid BLS care is what saves folks, and the toys and meds we use are what keeps them alive for definitive care.

[usalsfyre]

Wow...

Do you have 3 years in "lung school" to spare ? Aspiration = Pneumonitis = Death (the huge majority of ICU deaths say in OD are from aspiration not the drug itself)

If you've spent a few years in "lung school" as you call it then you should know that an ETT is not a device that prevents aspiration whatsoever. Sure, it is a "better" device and reduces the chances, but it's not a secure device. Secondly, find me the study that shows a massively higher level of aspiration with alternative ariways than ETT in the cardiac arrest population.

Firstly in any good ER there is a thing called the bronchoscope the REAL rescue device.

Yes and no. In any tertiary facility...sure. In the local critical access facility we transfer out of routinely, not likely, nor is it likely to find a clinician in the ED with the skill set to use a bronchoscope. Nor are you likely to find anesthesia coverage after hours. So yes I agree, a bronchoscope is the REAL rescue device, but it's not the common rescue device in certain settings.

How much time have you spent in an ICU ?

None lately, but long term ICU ventilation and a bridge therapy while hands are short isn't exactly comparing apples to apples. By extending your logic, we should be traching all these folks anyway, cause that's what they might end up with.

Have you ever observed a patient on a ventilator with an LT King or an LMA ?

See above. The two devices mentioned are not suitable for long-term ventilation.

No problems ? How do you know, do you follow every patient up to door discharge?

No, but when you see the guy in the grocery store a couple of months later it's a pretty good bet he wasn't in the "100%" mortality group.

Your missing the point, subjecting a patient (possibly viable) to yet another procedure because of lack of skill in the first place is just bad medicine

But per your thinking, it's such a quick and easy procedure it should be no big deal right? Even though I only have four sets of hands to provide good quality compressions, secure an airway, obtain venous access (better go ahead and place a PA cath while we're there, wouldn't want to subject the patient to unneeded procedures and they're going to get one of those in ICU too), administer any needed medications, figure out how to remove the patient should we get and ROSC....I'm not placing an LT because I think it's the "best of the best", I'm placing one because it's the reality of care delivery in my environment. I don't believe medicine is different in the field, but you have to acknowledge there are delivery differences at times, this being one of them. As Bernhard noted, the thing is like a "super OPA". I can have my Basic partner place it (as she is credentialed to do) and focus on other more pressing issues.

As far as studies go....meta analysis is considered the best data to make policy off of for a reason. It's VERY easy to cherry pick studies that support your argument otherwise. You posted a study that compared BVM ventilation to ET intubation, in which ET intubation showed to be superior. I wouldn't have disagreed with you. The problem is that's not exactly what we're debating. The other studies you noted showed superior outcomes in the in-hospital environment, where it can be reasonably expected that CPR was started promptly, there will be plenty of hands to work and arrest and resuscitation equipment is close at hand. Not the case in my particular environment. Not to mention not one of those studies looked at ET intubation specifically anyway.

I don't disagree with you about an ETT being a better airway, but again, it's the reality of my certain situation. I have things I need to do other than setting up for and placing a tube in this situation. I will pull the King and place a ETT when I get an ROSC, if the patient appears amicable to intubation. Yes it's another procedure, but it facilitates later care and is a better airway. The patient is usually well preoxygenated, and once I've got two or three minutes it's not a big deal. I've yet to encounter airway trauma from one of these devices, but we train on their correct insertion and I'm pretty maniacal about making sure they go in right (dear God don't hold the sucker down while you inflate the bulb). If it looks like the patient is going to be a difficult airway, then I will wait to a more appropriate setting. We manage aspiration fairly well as all of out King LTs have an OG placed almost concurrently hooked to suction until we stop having gastric contents come out.

Please don't take offense to this...but as far as pissing the RT off? I really don't give a crap. Again, no offense but that's why your there. I've pissed nurses and ancillary staff off more than I can remember, usually because I've done something they're not used to. However I can count on one hand the number of times I've pissed off a physician (usually over pain management) and I've never pissed off any of the medical directors I've worked for.