Intubation in Cardiac Arrest - Spin Off From Pain Mgmt EMTB

[mikeymedic1984]

I am sorry, the whole "you have to have a scientific study to prove something" is bizarre to me. I agree if you are introducing a new product, then it should be thoroughly tested, but intubation has been around for decades, and if it were useless or dangerous it would have been discontinued by now. And when you do convert any cardiac arrest patient, what proof do you have that the conversion was due to CPR, Good Ventilation, a certain drug that had just been pushed, or the combination of all ???

Just because a blind man can not see that there is a pink flower in front of him, does not mean pink flowers do not exist.

[chbare]

This whole scientific study business is what drives medicine. Unfortunately, the scientific method is often neglected or not even covered in many EMS educational programmes. Just because something has been around for a while does not make said concept a "golden standard." Part of any theoretical framework for scientifically based concepts is a concept known as falsifiability. That means the concept can always potentially be dis-proven. Even the most important and well tested theories are still being examined with new tests to see if they hold up. Many concepts such as aggressive fluid resuscitation have changed due to the availability of new evidence.

We need to be dynamic in medicine and be aware that the latest and greatest idea can potentially be falsified by well obtained and reproducible evidence. I do not think the underlying argument from many of us is that endo-tracheal intubation is useless. However, there exists a large body of evidence that suggests the role of intubation in many situations is not necessarily that of a golden standard. Also, there is little doubt that intubation among many other modalities is inherently dangerous. Intubation gone wrong is a sure fire way at getting a clean kill so to speak. The bigger debate IMHO is in some situations, do the risks of intubation outweigh the possible benefits?

Regarding your question about CPR, medications and so on, I strongly encourage you to read the link that I posted to the American Heart Association's science based journal called Circulation. In this journal, the AHA makes consensus statements based on the current literature. In addition, the AHA uses a multinational team of providers to re-examine the evidence over the course of several years, culminating in a new consensus every 5 years. You can then look at the literature the AHA used to come to their consensus. After reading through those studies, you can make up your own mind about what is helpful. However, the literature is often technical in nature and requires a good understanding of statistical and data collection/interpretation methods. In other words, quantitative literacy. Does the process contain possible pitfalls and flaws? Yes; however, going away from the scientific method means we regress back to relying on anecdotal stories and faith. Neither of which can be reliably tested and falsified under most circumstances.

Please do not take the tone of my post as an attack or aggression. I simply want to present decision making in a new light. My objective is to clarify and perhaps educate and not attack personally. I just want to be clear about my motivation here.

[Kiwiology]

Excellent post, I will add more after I get some sleep otherwise if I do it now I might die from my brain shutting down

[ERDoc]

The thing with medicine is that there are so many studies that need to be done to justify everything we do that we could never possibly do all of them, not to mention the impossibility of funding them. When there is no evidence, the gold standard becomes what has always been done. Take the work up of pulm emboli. The gold standard was always angiography because that is all we had. Then along comes this new technology called a CT scanner. Several well designed studies later and CT has become the gold standard. The same thing goes with intubation. ETI has always been the way it's done so it has by default become the gold standard. It will be the gold standard until it can be adequately shown that there is something superior or that it truly does harm.

[Kiwiology]

I reasonably think there is enough evidence to conclude that intubation is not the best idea anymore; in fact I hypothesise that it is physiologically plausible that the need for ventilation in cardiac arrest is minimal; the cardiocerebral resuscitation presented by Ewy et al strongly suggests the body has adequate oxygen reserves for up to ten minutes following cardiac arrest and that if we don't cram oxygen down their gob that patients have a higher rate of survival to hospital discharge.

Locally it is believed that ventilations are not a priority and that if ventilating the patient interferes with CPR don't do it

[ERDoc]

I agree with you about the need for ventillation as I think most of the recent studies show that maintaining coronary perfusion pressure is the name of the game. However, you still need to protect the airway and the only secure device is the ET tube. It may not change neurologic outcomes but does it decrease the aspiration rate? I don't beleive there are any good studies that look at this. If you do get ROSC but have an airway full of lunch you have put the ICU and pt well behind the eight ball. That may not matter in the field but it will in the hospital. Until there is a good study that securing an airway is harmful, I'd argue that it should still be done, but not at the expense of maintaining good CPP, in other words we need competent providers who can tube while compressions are ongoing.

[Kiwiology]

Good point, and you know if we don't ventilate the crap out of people we're going to lower the chance of distending the stomach and having lunch come back up at you

[ERDoc]

Even without aggressive bagging, you can still aspirate. I think you got a pretty good flogging over this on the anesthesia fourms on that other website. I think the real issue with this whole thing is the provider. There is such a huge variation in the skills/training/education of prehospital providers throughout the country/world that you will not be able to do a truly adequate study. Physicians are pretty much trained to the same standards, but the same is not true in the prehospital environment.

[Kiwiology]

LOL funny ... what I said was it's not a good idea to knock crook people down a couple levels with some midazolam and try to tube them

And yes you can aspirate without being ventilated

I'm still not keen on intubating people in cardiac arrest and wouldn't consider it until well into the resuscitation attempt or ROSC has been achieved

[ERDoc]

This is the beauty of medicine. There is more than one way to do it. I do agree with some of the points you bring up over there. I think the danger of sux has been overestimated in the inpt setting. I also feel the same way you do about RSI. If they are still breathing, they are getting paralyzed. If I paralyze someone I'm going to sedate them regardless of how out of it they are. The more optimal I can make the intubation conditions, the better. Obviously there are exceptions to this but that is generally the way I look at it.