Mounting evidence against intubating cardiac arrest patients...

[chbare]

Is beginning to include supraglottic airways.

http://jama.jamanetwork.com/article.aspx?articleid=1557712#qundefined

Thoughts?

[scubanurse]

It's interesting. I could be wrong, I scanned the paper and I'm pretty tired right now, but I didn't see much data as to whether or not the intubation was successful on the first attempt, how long it took to intubate, and proficiency of the prehospital provider. This would hold a lot more weight if they were anesthesiologists in the field intubating or less if they were paramedics with barebones experience.

But then, maybe that variable is irrelevant. That was just what first popped in my brain after looking at the data.

[BAYAMedic]

http://www.ncbi.nlm.nih.gov/pubmed/16740355

Reading this peer reviewed article, it seems EMS is in its infancy in Japan. I would be interested to compare the educational benchmarks between a the two countries ALS provider performing the intubation.

BAYAMedic

[island emt]

In reading through lots of studies recently it would seem that the current AHA recommendations are on target in moving airway far down the algorithm of cardiac resuscitation.

The studies quantify the need for continuous cardiac compressions with full release of pressure on the up stroke to allow the heart to refill and this seems to move enough air

to make intubation unnecessary.

[scubanurse]

My concern with this is how much air is getting into the stomach. If we are doing effective ventilations, we could still be filling to stomach with air. The more air that enters the stomach the more it will push up on the diaphragm decreasing the space for the heart to fill completely. Similar concept as when a pregnant woman arrests. If baby is above the belly button there is a perimortem c-section performed to increase the efficacy of the chest compressions.

If intubation can be done successfully, or any other advanced airway for that matter, without stopping chest compressions wouldn't it still be prudent to secure the airway?

[triemal04]

For any paramedics who are truly proficient at intubating, this is something to be concerned with. Not because of the science behind it or how the "study" was performed, but because it has been published in JAMA. A very insignifigant medical journal...

Having met and talked to a couple of Japanese paramedics and paramedic students, while this is applicable to the US system, it's not the a perfect match. Japan gives their paramedics more didactic hours than any school I've ever heard of; as far as science and theory go, they are sound and would run circles around the average paramedic. As far as physically performing clinical skills...let's just say that the clinical hours don't add up to the didactic. In essence, you have people with minimal training in intubation attempting to intubate in the worst conditions possible.

Which really isn't all that different than the average US paramedic trying to intubate a cardiac arrest patient.

When you compare this to other similar studies (data gained from PRIMED for example) what you really start to see is a much better point: if people are not truly proficient at intubation, then they should not be intubating patients. Ever. And the average US paramedic, sad to say, is far from proficient. It's not a hard thing to understand; if you aren't good at a skill that has the potential to stop chest compressions (one of only 2 things that we know truly work for cardiac arrests) you probably shouldn't be doing it. If you aren't good at something that, if done wrong, will decrease if not remove your ability to ventilate a patient (even if the need may be quite small in an arrest) then you probably shouldn't be doing it.

I haven't been a paramedic for a super long time, but the longer I do this, the more I read and learn, the more I do start to believe that intubation should be removed from the skillset of the vast majority of paramedics out there. Until both the educational system and EMS delivery model change, that is really the only thing to do.

[ERDoc]

Similar concept as when a pregnant woman arrests. If baby is above the belly button there is a perimortem c-section performed to increase the efficacy of the chest compressions.

I'm not trying to nitpick or go off topic here, but your reasoning is a little off. A perimortem c-section is done when the baby is above the belly button because the belly button represents 20 weeks and the baby is possibly viable at that point. The c-section is done to rescue a possibly viable baby. It does help the mother also by relieving intraabdomenal pressure.

[scubanurse]

My bad then. I was going off what our lecture and maternal/fetal textbook said... Thanks

[HellsBells]

I wonder why the outcome was worse in pts with an advanced airway. Is this related to interruption of compressions to secure an airway?

[Arctickat]

I don't get it really. Why do we need to stop compressions to intubate? I mean, I used it stop them years ago but then I thought..."Hey, why am I stopping when I can still see all my landmarks?" so I decided to give it a go. Since then I've only stopped compressions a couple of times, and only for about 3 - 5 seconds to pass the tube. I still intubate farther down the algorythm than the old days, but stopping CPR to do it just isn't always a requirement.