CPR and Intubation

[JakeEMTP]

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.

Yeah Fiz, I should've added if the pt. is fortunate to regain ROSC, I have no problem inserting an ETT. I too like the bougie for tubes.

[Bieber]

If I can't tube 'em through compressions, I'm not tubing them at all. The tube isn't going to save their life, compressions are. And I'm pleased to say that that is the standard of my service (though I won't lie and say I haven't seen exceptions made by some paramedics).

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.

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. I'm not sure how much of that is ER docs wanting to get a tube and how much of that is due to the impracticality of blind airways being used long term.

[BushyFromOz]

this will attract a mortar round or two...

In our case we have what i believe is a legitimate reason to tube each cardiac arrest, and that is our post ROSC management for therpeutic cooling relies on the pt being intubated. We have a proven increase in ROSC and survival to discharge based on the cardiac arrest management we use and to give the pt the maximum chance to survive to discharge, they need to be tubed.

[Bernhard]

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.

To be honest: I don't like this argument. Performing a not really needed task (here: if something easier is available) only because to stay in training? That view would open a lot of more doors to things not really needed to be done.

Training is something to be done in classroom and in hospital when a patient needs the task done in a controlled setting. Experience is something to be gained, when the patient really needs the thing but not just only to get experience points for the provider. Some internship in a hospital may help to get a larger set of patients in such need than on the street.

[Bieber]

this will attract a mortar round or two...

In our case we have what i believe is a legitimate reason to tube each cardiac arrest, and that is our post ROSC management for therpeutic cooling relies on the pt being intubated. We have a proven increase in ROSC and survival to discharge based on the cardiac arrest management we use and to give the pt the maximum chance to survive to discharge, they need to be tubed.

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.

[Bernhard]

The following is from our standards (European Resuscitation Council, Guideline 2010, Section 4 "ALS") - original in german since I couldn't find the full english text, so I (lousily) re-translated it.

"Staff trained in advanced airway management shall intubate the patient without interrupting thorax compressions. A short pause in compressions may be necessary to get the tube into the trachea; this pause shouldn't be more than 10 seconds. To avoid interruptions of compression, alternatively the intubation can be delayed until a ROSC is reached."

"Up to now there is no study that shows a raise in survival rates after endotracheal intubation."

Thus weaking the influence of (e.t.) intubation.

Then there is a chapter on airway management, and there it says:

"Immediate action is needed to control airway and ventilate the lung. Only this prevents secondary, hypoxy generated damages of brain and other vital organs. Without adequate oxygenation it could be impossible to get a ROSC."

"Give oxygen during resuscitation as soon as available".

"Give patients with insufficient or no spontaneous respiration artificial ventilation as soon as possible"

On passive oxygenation (O2 without active ventilation) even in case of non-blocked airway, the guideline states:

"Until there are more results, the passive oxygenation without ventilation of the patient is not recommended as a routine procedure during CPR."

OK, what does this say, at least for european ALS providers (ERC is the european guideline factory)?

• compressions shall not be delayed by intubation
• intubation could even be done after ROSC
• additionally important to compressions is an early and active application of oxygen (i.e. by bag valve)

In several other chapters, the guideline tells something about alternative airways, including larynx tubes etc. which may be easier and quicker to apply than e.t. tubes with the implicit advantage of not needing to interrupt compressions.

That's the way we do it here. However, I'm a bit surprised to read that a larynx tube may be good enough even for automatic respirators and/or "asynchroneous" compressions, since we were told that this always would require an e.t. tube. But the random amount of lost air (if compression and respiration comes at the same time) obviously is not a problem according to the guideline. Good to know, thanks for this discussion making me re-read the guideline much closer.

So, I would suggest to check your actual guidelines (AHA, others?) closely...

[tniuqs]

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

Sure why not, use an LT King ... in a cadaver.

1-The LMA is NOT a definitive airway, it is a device developed for "belly empty" short term OR procedure's.

2- If this "could be" a viable patient then you will be subjecting the "save" to another procedure and piss off an RRT.

3- VAP- Ventilator Acquired Pneumonias (or procedure acquired) are the biggest cause of mortality in the ICU.

4- Using a positive pressure ventilating (plastic brain) without the gold standard ETT (closed system).. is a recipe for DOA.

5- Ever see an ETT "not passed" in every code in hospital ? There is a reason that no LT Kings or vagina on a stick are absent in the code cart.

"Up to now there is no study that shows a raise in survival rates after endotracheal intubation."

University of Alberta Hospital Canada (Dr. Brindley) any mention of LT King or LMA used ? ... nope.

http://ecmaj.ca/cgi/content/full/167/4/343

http://bja.oxfordjournals.org/content/104/4/496.full

http://www.hkmj.org/article_pdfs/hkm0708p258.pdf

Permission to hunt down Wong et all and punch him in the nose ...

Edited June 28, 2011 by tniuqs

[chbare]

http://circ.ahajournals.org/cgi/content/full/122/18_suppl_3/S729

Take care,

chbare.

[Bernhard]

Sure why not, use an LT King ... in a cadaver.

Sorry, ERC guidelines (usually based on a very broad survey of studies) say otherwise...

Not that I don't have seen guidelines change multiple times, but the above are the most recent ones and I'm more or less bound to them.

Additionally my personal experience is the same: a LT is a very sufficient airway and absolute quick & easy to apply. And usually I'm not bad with e.t. either plus was very suspicious about the LT at first. Unless ERC guidelines say otherwise, I take the LT as soon as I would have taken the mask for bag valving.

[usalsfyre]

4- Using a positive pressure ventilating (plastic brain) without the gold standard ETT (closed system).. is a recipe for DOA.

If this is the case...prove it.

5- Ever see an ETT "not passed" in every code in hospital ? There is a reason that no LT Kings or vagina on a stick are absent in the code

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.

Edited June 28, 2011 by usalsfyre