Intubation in Cardiac Arrest - Spin Off From Pain Mgmt EMTB

[Asysin2leads]

I'm on the fence about whether ETs in cardiac arrest could be replaced with supraglottic airways or not. I guess I would say, probably. However, so long as there are patients that require immediate intubation, such as asthmatics or COPDers or CHFers, or those with maxillofacial injuries, then intubation should be a skill practiced by paramedics.

I think the key is that intubation should stay in, but the way we think about intubation should change. Those intubations we brag about, the one under the bus, on fire, in the snow should become a thing of the past. Intubation should be considered a surgical technique, not a rescue technique. That is, it should only be performed in a relatively stable environment, like the back of the ambulance. That's my take on it.

[Kiwiology]

However, so long as there are patients that require immediate intubation, such as asthmatics or COPDers or CHFers, or those with maxillofacial injuries, then intubation should be a skill practiced by paramedics.

Intubating an asthmatic patient is fraught with danger and can bring on the seriously bad ju ju very easily including y'know, death

I think the role for intubating a patient without RSI in the pre hospital field is extremely limited to probably non existent; there is significant opportunity to improve outcomes in brain injured patients who have poor airway and/or breathing with RSI and there are only a small number (like 3 or 4) places in the world that are doing it adequately enough which is sad because its missed opportunity

[croaker260]

Intubating an asthmatic patient is fraught with danger and can bring on the seriously bad ju ju very easily including y'know, death

I cant say this is a good reason NOT to do it, because the same could be said of 80% of our interventions. It does seem to e a call for better training.

for example: IF you have a patient in respiratory failure who is an asthmatic, your providers should be able to chose from several interventions based on a risk / benefit clinical analysis, and chose the right one. IF that HAPPENS to be intubation, then they should have been primed with the right education/training to monitor for adverse hemodynamic effects and adverse barometitric sequela (ie. Tension Pneumothorax).

THT is a better approach than saying asthmatics should not be intubated (if I understood your statement correctly....)

I think the role for intubating a patient without RSI in the pre hospital field is extremely limited to probably non existent; there is significant opportunity to improve outcomes in brain injured patients who have poor airway and/or breathing with RSI and there are only a small number (like 3 or 4) places in the world that are doing it adequately enough which is sad because its missed opportunity

I can see your point, but I cant see why we would RSI and intubate live people with potentially complex pathology.... but not intubate dead floppy people who are as stable as stable gets.

It comes back to my original post on intubating dead floppy people in arrest.....I still think that IF you are still STOPPING CPR AT ALL to intubate, you are indeed doing them a diservice. BUT...if we change our "style" and "approach" and intubate during CPR...there is NO reason why intubation is any worse (and some may argue BETER in the long term...) than other supra-glottic airways.

Put another way…….

The ONLY two advantages supraglotic airways have over ETT is ease of placement and not interrupting CPR. If you don’t interrupt CPR to intubate and are proficient in your ETT skills, then those "benefits" are negated, and since the ETT isolates the airway better…it now becomes superior airway control.

If you CANT intubate during CPR for what ever reason...or you are not proficient..then the supra-glottic airway is a better choice.

Simple, huh?

Edited April 10, 2012 by croaker260

[Kiwiology]

I cant say this is a good reason NOT to do it, because the same could be said of 80% of our interventions. It does seem to e a call for better training.

I don't think intubating an asthmatic patient is the best idea and several Consultants I've talked to agree.

Asthma is not an oxygenation problem it is a ventilation problem; an endotracheal tube is going to offer no real advantage to an asthma patient in the pre hospital environment than an LMA or indeed no adjunct whatsoever and very careful hand ventilation with a very prolonged expiratory phase.

Anaesthetising, paralysing and intubating such a patient carries far great prehospital risk and is not something I would do.

I can see your point, but I cant see why we would RSI and intubate live people with potentially complex pathology.... but not intubate dead floppy people who are as stable as stable gets.

Dead floppy people with traumatic brain injury do not become less dead and floppy because they are intubated in the pre hospital environment; there is no evidence whatsoever that points to intubation being of use.

There is a small number of extremely recent, extremely well controlled studies that show improved outcomes for patients intubated using RSI in the pre hospital environment

It comes back to my original post on intubating dead floppy people in arrest.....I still think that IF you are still STOPPING CPR AT ALL to intubate, you are indeed doing them a diservice. BUT...if we change our "style" and "approach" and intubate during CPR...there is NO reason why intubation is any worse (and some may argue BETER in the long term...) than other supra-glottic airways.

There is no evidence that intubation in CPR is beneficial, intervention without evidence should be dismissed without evidence

The ONLY two advantages supraglotic airways have over ETT is ease of placement and not interrupting CPR. If you don’t interrupt CPR to intubate and are proficient in your ETT skills, then those "benefits" are negated, and since the ETT isolates the airway better…it now becomes superior airway control.

Again, there is no evidence that intubation is better for the patient, intervention without evidence should be dismissed without evidence

For the unconscious post-cardiac arrest patient yes there is benefit to anaesthetising, paralysing and intubating them to shorten the time it takes to reach the cath lab and it is what we are doing here.

[croaker260]

Again, there is no evidence that intubation is better for the patient, intervention without evidence should be dismissed without evidence

Three comments (respectfully) :

1- As an well respected doc told me: Lack of evidence is NOT evidence against.

2- Your argument Intubation in CPR holding no merit does not consider aspiration as a co-mobid factor. There is clear evidence that patients that develop aspiration pneumonia have a higher mortality than those who dont. A simple cause and effect shows that prevention of aspiration is esential. Therefore, when you consider the increased mortality with aspiration, some form of advanced airway control becomes mandatory. If we both agree that an advance airway should be placed of some type, the only question is WHICH option. ETT or another airway. We are talking about choices here. If we dont agree on this key point, then we may never agree.

3- Your argument against ETT only holds merit if you are not going to place ANY advanced airway. If you are going to place an advanced airway, then my argument comparing them still holds water. Please remember we are talking about the Cardiac arrest patient. Nothing more, nothing less.

The discussion re: asthma, post arrest, etc are separate (and good, I will admit) discussions but not what the thread is about.

ETT is less a potentially less traumatic, more cost effective, more secure airway that offers options in ventilator management that simple supra-glottic airways do not offer. It is an airway whose faults are not in the intrinsic design of the tube itself, but rather in how we as providers are using it.

Remember: All of the adverse effects of the ETT in arrest come NOT from the type of airway, but from multiple attempts, prolonged and difficult placement, unrecognized esophageal placement, and stopping CPR to place ETT. Resolve these issues, the game changes.

IF (big "IF"..) we change the way we use the ETT, then the previous evidence will no longer applies, and the previous detractors no longer apply, and then its efficacy over other supra-glottic airways is clear.

IF we dont change the way we use ETT, then you are right, supra-glottic airways are a better choice.

All of the above assumes three things... 1- We are talking about an arrest patient 2- We don’t stop CPR to place ETT, 3- You are proficient enough to reasonably expect to get it on the first attempt. If these three factors don’t apply, then supraglottic airways may be a better choice.

[Kiwiology]

1- As an well respected doc told me: Lack of evidence is NOT evidence against.

Correct evidence of absence does not extrapolate with absence of evidence however we should really have evidence something is beneficial before we decide to do it (or keep doing it in the case of things where we had no evidence to begin with)

If we both agree that an advance airway should be placed of some type, the only question is WHICH option. ETT or another airway. We are talking about choices here. If we dont agree on this key point, then we may never agree.

There is no evidence showing that placement of an advanced airway improves neurologically intact survival in patients who suffer a cardiac arrest and evidence showing no difference in survival between intubation and the LMA.

Furthermore, there is evidence showing that delayed ventilation and avoidance of hyperventilation improve neurogenic outcomes in cardiac arrest patient (1, 2)

So that begs the question of why people bugger around trying to tube a cardiac arrest? Because it makes theoretical physiologic sense and because it's tradition.

3- Your argument against ETT only holds merit if you are not going to place ANY advanced airway

I wouldn't loose any sleep if that was the case

My limited resuscitation order is getting updated to include no intubation, no adrenaline and no ventilations until after ROSC or 5 cycles of CPR

(1) Kellum MJ, Kennedy KW, Ewy GA. Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest. Am J Med 119:335–40, 2006.

(2) Aufderheide TP, Lurie KG. Death by hyperventilation: A common and life-threatening problem during cardiopulmonary resuscitation. Crit Care Med 32:S345–51, 2004.

[croaker260]

OK, I see your approach now. Not saying I nessessarily agree with it...just understand your point a little better. Here in the US we have too many cook book medics using the supra-glottic airways just because its eaier and the AHA says its ok, without any realy understanding of why or why not to chose one over the other.

I am familier with your studies cited. Again this comes down to HOW you use your advanced airway of choice.

At my service we are specifically using very close monitoring of ETCO2, resp rates, and early use of vents (as in on scene) to mitigate the hyperventilaion issue. I am not saying it doesnt still happen, just that it happens a lot less.

I still belive that the risk of aspiration mandates the early use of an advanced airway, as long as you dont compromise CCR/CPR.

We are also improving our focus on compressions, incuding starting the use of lucas here in a month to keep compressions strong. Though here in America we are still hammering EPi early in arrest.

Quick question: when you say 5 cycles...do you mean 2 minutes, or 10 minutes?

.

Edited April 11, 2012 by croaker260

[Kiwiology]

The Clinical Management Group are on record here stating adrenaline is probably going to be removed at the next guidelines update (September 2013)

[croaker260]

I take it that the Clinical Management Group are part of your clinical guideline development committee or something similar?

ALso, you didn't answer my question re: CPR

[Kiwiology]

Quick question: when you say 5 cycles...do you mean 2 minutes, or 10 minutes?

10 minutes; the original study used 12 minutes

I take it that the Clinical Management Group are part of your clinical guideline development committee or something similar?

Yes, and I should say that its now called the National Ambulance Clinical Working Group and contains an Anaesthetist, an Intensive Care Medicine Specialist, two Emergency Physicians, a GP who is the Director of Defence Health and a bunch of other clinical people.

Last year we went to issuing national Guidelines for civilian Paramedics and the Defence Force Medics