Intubation in Cardiac Arrest - Spin Off From Pain Mgmt EMTB

[mikeymedic1984]

Ok, I will play along, what would you consider the gold standard then ? If I go to the ER and arrest, will they intubate me ? What about ICU or OR ? Granted, if I am having a short procedure, they may choose to use some other temporary form of airway management, but if I am in respiratory arrest for any long period of time, I bet I wake up with a tube and a ventilator. You could make the arguement that the Paramedics are the problem, not the procedure (I think Doc suggested that earlier), but I still think the industry experts would say that intubation (when done right) is the superior method. But hey, I do not pretend to know everything, please feel free to educate me to your position.

[ERDoc]

Yeah, in the US it is a damned if you do, damned if you don't situation. I had a SICU attending who was successfully sued after he cared for a pt that had a prolonged code in the OR due to an unnoticed knicked artery and was brain dead upon arrival in the SICU. He never saw the pt before she was brought to the SICU but he was found at partial fault for her death. I don't know the amount, but such is the state of medicine in the US.

As for the question about comparing methods, as long as you have IRB approval and are carrying out the study appropriately with oversight you should be covered from any lawsuits. I said should because, hey, this is the US and we all want the winning lottery ticket.

[chbare]

Ok, I will play along, what would you consider the gold standard then ? If I go to the ER and arrest, will they intubate me ? What about ICU or OR ? Granted, if I am having a short procedure, they may choose to use some other temporary form of airway management, but if I am in respiratory arrest for any long period of time, I bet I wake up with a tube and a ventilator. You could make the arguement that the Paramedics are the problem, not the procedure (I think Doc suggested that earlier), but I still think the industry experts would say that intubation (when done right) is the superior method. But hey, I do not pretend to know everything, please feel free to educate me to your position.

I thought we were talking about intubation and cardiac arrest? Once we change the boundary conditions of the context within this thread, we can inject many other arguments. However, in the context of a person in cardiac arrest without ROSC, I cannot appreciate consistent levels of evidence that say intubation should be considered a "gold standard.

[Kiwiology]

A Japanese study from 2011 that showed no difference in neurologic outcome between endotrachial intubation and supraglotic airways. It did show that early airway management improves neurologic outcome. Some criticisms I have is that is does not have a study arm that did not receive advanced airway management.

I think it was an appropriate design for one group to receive intubation and the other a supraglottic airway.

There is also another excellent Japanese study from last year which shows worse outcomes for patients who received intravenous adrenaline in cardiac arrest.

Looks like those Japanese are good for more than getting me addicted to their raw fish wrapped in sea weed

Kiwi, when you take 40% out of someone's paycheck in the form of a tax, your healthcare is not free. Not saying our method is any better, at least in your world everyone pays something towards their healthcare whereas here, the insured pay for the uninsured.

Our top tax rate is 30% and we only pay that on the portion of income we have over $70,000 for everybody else i.e. those earning under $70k it's 17.5%

I know in the US the income tax rates are quite a bit lower and some states (such as Texas) do not have a state income tax.

I would rather pay a bit extra in tax so that everybody can get the same access to healthcare

Who is seriously calling it a "gold standard?" The paradigm has shifted significantly recently. Many lawsuits that I've seen have been due to endotracheal intubation related issues.

It's more "tradition" but in theory yes intubation is the gold standard i.e. best way to protect an airway but you cannot consider that fact alone in isolation yes it might protect the airway better than an LMA, King LT, EOD, NPA, OPA or dancing around the patient reciting some sort of chant but in the overall clinical context of somebody in cardiac arrest it is not the best way to go.

I had a SICU attending who was successfully sued ...

Oh so that explains why you're now working in the Emergentology department?

Edited April 9, 2012 by Kiwiology

[ERDoc]

I think it was an appropriate design for one group to receive intubation and the other a supraglottic airway.

I think the study was fine for comparing ETI with SGAs but our question is ETI vs no advanced airway, which this study does not answer. Based on that study alone, I would rather intubate a pt then insert a SGA since the airway is more secure.

[Kiwiology]

I think the study was fine for comparing ETI with SGAs but our question is ETI vs no advanced airway, which this study does not answer. Based on that study alone, I would rather intubate a pt then insert a SGA since the airway is more secure.

I certainly think an LMA (or other supraglottic airway) is becoming more recognised as an acceptable alternate to endotracheal intubation in the out of hospital cardiac arrest so this study would support such a notion

This study shows that cardiac arrest patients who received no ventilation whatsoever and just passive oxygenation with an OPA and supplemental oxygen had better outcomes than those patients who received manual ventilation

http://ipep.arizona...._Arrest.pdf.pdf

http://www.azdhs.gov...onMCCMCC385.pdf

So this that in mind if such is true then it sort of makes this intubation argument moot point because even if intubation is the best thing since sliced bread (and I can tell you for a fact it is not, I much prefer going to Chinese bakery and slicing my own bread so it's nice and thick, I also refuse to eat regular crust pizza, it must be so thick I can sink my teeth into it!) um, right, even if this intubation deal is the best thing since sliced bread it doesn't matter because we're killing people by forcing oxygen into their lungs

It was forewarned back in 1994 during Intensive Care Officer training that there is nothing in cardiac arrest proven effective except CPR and defibrillation and somehow the notion has not caught on

I am going to update my limited resuscitation order to include no intubation, no adrenaline and no positive pressure ventilations

Edited April 9, 2012 by Kiwiology

[ERDoc]

I don't disagree with what you say Kiwi, but we were addressing the specific question of intubation vs no intubation and I don't think there is any solid evidence either way. Each study shows something different.

[medicgirl05]

I do not even attempt to intubate most cardiac arrest patients. Due to limited resources and a lack of evidence showing intubation as a superior method of airway management in a prehospital environment I choose to use my resources in other ways. I have had one save, we found the patient in V-fib and after 3 or 4 defibrillations he had ROSC, now he rides his bike around town daily...he was never intubated and suffered no ill effects.

[Lotus]

I've gone into arrests plenty of times without intubation. Im still alive enough to be posting on here

[HERBIE1]

We have certainly beaten this horse to death around here, but anecdotally, I would say AT LEAST 75% of my saves with ROSC AND no neuro deficits have been without ET's. Obviously they were either witnessed arrests or ones where there was minimal downtime and/or someone was doing CPR prior to our arrival. Is there a place for ET's prehospitally? Sure- but then again in our system we do not do RSI's and use no paralytics, so in some cases where a protected airway would be optimal, we simply do not have that as an option.

As the new AHA CPR guidelines indicate, it's now CAB- with an emphasis on quality CPR, rapid compressions, and minimal interruptions(we no longer look, listen and feel, or do multiple pulse checks). The decreased emphasis on ventilations also decreases the importance of advanced airways- at least in the initial resuscitation steps. Energy and medications- as needed- are the new paradigm. Even properly done, pausing CPR to insert an advanced airway is not desirable, and I happen to agree with that notion. I would love to see a study that compared and contrasted prehospital ROSC's based on advanced airways, or simple BLS techniques. I think those numbers would be interesting.