CPR and Intubation

[croaker260]

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.

Actually there is decent research (and more every year) that the length of inturuption and ROSC have an asscoaition that is measured in seconds. There is a significant difference in time to Defib of 5, 10, and 15 seconds and resultant ROSC....... If I understand your statement correctly I think that can be extrapolated over to any inturruption and its effect on coronary perfusion/ROSC.

Edited June 29, 2011 by croaker260

[BushyFromOz]

For some reason, the industry got obsessed for over a decade with getting more ROSC's, government's set it as a KPI and tied funding to it, it made good news stories and made us all feel warm and fuzzy behind the knees.

theres not many people here talking about increasing survival to discharge

Actually there is decent research (and more every year) that the length of inturruption and ROSC have an asscoaition that is measured in seconds.

i'd love to see that, but cant do it form my iPhone, got a link to a study?

Edited June 29, 2011 by BushyFromOz

[croaker260]

For some reason, the industry got obsessed for over a decade with getting more ROSC's, government's set it as a KPI and tied funding to it, it made good news stories and made us all feel warm and fuzzy behind the knees.

theres not many people here talking about increasing survival to discharge

i'd love to see that, but cant do it form my iPhone, got a link to a study?

Yu T, Weil MH, Tang W, et al. Adverse outcomes of interrupted

precordial compression during automated defibrillation.

Circulation 2002;106:368-72.

and

Eftestol T, Sunde K, Steen PA. Effects of interrupting precordial

compressions on the calculated probability of defibrillation success

during out-of-hospital cardiac arrest. Circulation 2002;105:

2270-3.

Also, I just read an article discussion on a newly released study that showed similar results on survival to discharge.

[BushyFromOz]

Sweet, ill try and find em when i get off shift.

thanks man.

[Bieber]

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.

Well, I would define a "good airway" as one that provides a definitive route for ventilation and a minimum risk of aspiration. If the airway's not doing either of those, it's no good; but if it is, there's no need to replace it unnecessarily. I agree with you that the mortality rate for aspiration is unacceptably high, and if we need to change airways to decrease that risk, then we need to change airways to decrease that risk. I'm not too familiar with the statistical effectiveness of some of these blind airways at preventing aspiration, though.

Actually, it looks like a few people have posted some studies on blind airways in this thread. Let me read them and I'll get back to you, Dwayne!

[tniuqs]

Quoting : usalsfyre

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. WOW ? 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.

The term "Lung school" is an attempt to illustrate that a point not all those with more in depth education in the specialising in airway management are arrogant .. I am rather well versed and experienced and the problems and prevention of associated micro aspiration. <insert noises of back slapping>

Question is in the USA is that health insurance with your HMO deciding that VAP are non-insurable is that what you wish for ? To prove that Rescue Airways have a higher incidents of VAP, most seriously, I would be very cautious in what you ask for, if you continue to go with "rescue airways as initial "go too". In passing do you believe for a milisecond that the developers of these plastic replacements for lack of ability or practiced skill would even fund such a study ? MEH .. pass the crack pipe.

So yes I agree, a bronchoscope is the REAL rescue device, but it's not the common rescue device in certain settings.

Well a bronchoscope is in every ER that I work, but now lets factor in the possible medical legal ramifications and just to think out of the dogmatic follow the AHA / EMS box for a bit, the glide slope (no I have no monetary investment) but is mentioned in many EMS journals and even in Bledsoe's Critical Care Books just saying, is this a bad thing or possibly a future standard as is ETCO2 ?

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.

Apples to apples .. ok I will bite is EMS not part of Health Care ? In fact you are very correct a Trach is always topic at rounds and on every patient, the criteria being ventilated greater than 7 days, its far more comfortable with less sedating medications required to complicate the "root cause" of admission. Trach in the field with the typical "Paramedic Edjumication" is a blood bath in most cases <seen that been there have the blood soaked T shirt> but in the historical past the Rescue Airway of choice. But ok compare these "bridging" devices on a personal level, if it was a "me" perspective .. just wake up with one of those in your gullet and its a no brainer the complications of self extubation +++. So should we not as EMS providers be concerned at the longer term comfort of our patients or just as in the past typical drop and run ? Patting ourselves on the back that we had a cardiac "save" and then perhaps seeing that patient in the grocery store and being oblivious to what followed for them as humans beings ?

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

Exactly .. why subject a patient to yet another invasive procedure and subsequent sequelae, my point in entire point in fact.

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.

Sounds a bit like some excuse's to me why not place the best of the best ? ... or am I reading this wrong ? Seriously are you saying a practised provider shooting a ETT is more complicated than an LT or Combi ? <cough> Then if you can't get a line in do you use these tubes for med administration, perhaps another plus to the ETT ?

In regards to the Cherry Study you mention, it is EBM quoted by AHA, oddly that fail to note in the any of the AHA research data. Therefore I introduce the new fangled "airflow restrictors" designed only to be used with ETT with good EBM that they maintain a positive pressure "transthorasic" during compressions, after all maintaining CPP is directly related to the newest of outcome ROSC studies, the very reason for changes 30:1 in fact.

Although this lack of ventilation trend does have an end point if one understands the relationship of PaCO2 to PH and even factoring in permissive hypercapnia and hypo-oxygenation as protective mechanism's at the cellular level. I predict that as in most things "trendy" resuscitation medicine we will eventually reverse some of "todays" opinions.

Frankly: It was the first link in chbare's I clicked upon to actually inform myself the studies used to make up general AHS guidelines ... one must ask themselves this question:

Do we blindly follow so called EBM statistical meta studies in their entirety or go with what actually works well a proven standard in medical practice but <gasp> requiring some practice ?

If you can't see the cords with compressions heck stop for 5 seconds, with the L-scope in situe, easy peasy.

I can tell you of MANY Paramedics that do it "by the book" and never had a "save" and those that(I guess could just be called "lucky" ) those that actually practice medicine. Noo 2 arrests are the very same.

In passing my personal favourite "back up rescue airway" when needed as in facial smash or hanging is a bougie used as a stylet and a retrograde intubation and in > 30 years only needed it once, lucky me never had to resort to the plastic monstrosities.

thus end's coffee driven ramblings.

Edited June 30, 2011 by tniuqs

[DwayneEMTP]

Well, I would define a "good airway" as one that provides a definitive route for ventilation and a minimum risk of aspiration. If the airway's not doing either of those, it's no good; but if it is, there's no need to replace it unnecessarily. I agree with you that the mortality rate for aspiration is unacceptably high, and if we need to change airways to decrease that risk, then we need to change airways to decrease that risk. I'm not too familiar with the statistical effectiveness of some of these blind airways at preventing aspiration, though.

Actually, it looks like a few people have posted some studies on blind airways in this thread. Let me read them and I'll get back to you, Dwayne!

Yeah man, as chbare pointed out I'm afraid I went off track with the 'x airway vs z airway' argument. I have no doubt that interrupting compressions for nearly any reason decreases you chances of ROSC. And I don't have any significant studies to show that ETT is superior to all other airway applications. I guess that that has just seemed intuitively reasonable to me. This thread has certainly kicked sand in the face of my intuition, I'll tell you that. :-)

I've obtained ROSC in over 50% of the arrests that I've chosen to work, and as much as I'd love to brag about that, have yet to have one walk out of the hospital that I'm aware of...

What a great debate this is proving to be by a bunch of really smart, committed folks. You all are a gift.

I would love to see the studies should you happen to find any on the rates of arrest aspiration as well as head to head comparisons of aspiration risks/rates between the more common devices. In the last 10 weeks I've been home 7 days so it will be at least a week before I'll be spending any time Googling studies as opposed to...say...fulfilling more recreational home based responsibilities.

Thanks for participating all!

Dwayne

[tniuqs]

I would love to see the studies should you happen to find any on the rates of arrest aspiration as well as head to head comparisons of aspiration risks/rates between the more common devices.

As would I ... BUT just what producer of all these airways would take the financial risk undertaking such a study and in a passing comparison (what came first the chicken or the egg, aspiration debate) Did the patient aspirate prior to arrival or post compressions, some things in fact just cannot be studied.

In a hospital arrest the ETT is the golden standard so why should the field be any different like really ?

I see a very disconcerting "trend" in EMS these days (perhaps I am getting old a dogmatic in my perspective) but using "techno-wizardry" to solve problems instead of education, ongoing and realistic con-ed and practice of procedures. I was most literally one of the first in my hood to be permitted to intubate and loosing that accepted standard of care is a huge step backwards this is of great consternation to me personally.

Very seriously I became a Paramedic to:

1- Definitively Protect Airways.

(after the EOA was pulled because of the perceived complications of oesophageal varices )

2- Take away the pain.

I became an RRT to take some of the tubes OUT and a far more difficult a job overall.

Quote Dwayne: fulfilling more recreational home based responsibilities.

You know the thread is concluded when Dwayne goes to the sex place. Is this code for "getting naked and sweaty at home with the better half ? " .... my bad ?

cheers

[chbare]

Unfortunately, I am finding a fair amount of cherry picking and dogmatic arguments here. The issue simply cannot be resolved by stating you are for or against a specific modality followed by a link to the evidence. The evidence may suggest one thing, only to contain caveats. At this point, after looking at the evidence, it seems three (Bag mask ventilation, Supraglottic airways and ETT) modalities are roughly, equally efficacious when you appreciate the big picture.

So, going back to the original question, I would argue going with the modality that would result in the least amount of interruption of compressions would be the optimal action. Clearly, that action can take on a number of interventions and very well may be situation and provider dependant.

Take care,

chbare.

[Medic Baby 171]

I generally don't stop compressions while I'm intubating, however...IF and only IF I cannot visualize vocal cords properly, and cric pressure doesn't help...THEN I will stop compressions. I stop compressions as a last resort.