Mounting evidence against intubating cardiac arrest patients...

[ChaseZ]

Have you guys actually ever worked an arrest, and had copious amount of vomit coming up the airway from compressions ? How in the hell could you suggest that an unsecured airway is ever a good thing. I don't care what one study suggests, anyone who has actually worked in the field knows that this is a bunch of crap. As stated earlier, I am sure that I can produce a study that shows anything I want it to.

So much fail in this post.... I am sure you could produce a study showing anything you want but producing one that holds up against academic scrutiny and is publishable in a scientific journal is another story. Wouldn't it be nice if paramedics were required to take statistics, research, and EBM courses.

The risk of aspiration using a LMA w/ PPV is fairly low and is a good compromise to ETI.

What do you think happens to the gross or micro-aspirate that pools around the ET cuff?

[mobey]

Have you guys actually ever worked an arrest, and had copious amount of vomit coming up the airway from compressions ? How in the hell could you suggest that an unsecured airway is ever a good thing. I don't care what one study suggests, anyone who has actually worked in the field knows that this is a bunch of crap. As stated earlier, I am sure that I can produce a study that shows anything I want it to.

Just so you are clear about what anecdotal evidence means....

In contrast to your post, I have never worked a code with copious amounts of vomit. So shall we conclude that in your response area we should intubate, and in my response area we should not intubate?

[systemet]

Wouldn't it be nice if paramedics were required to take statistics, research, and EBM courses.

I just want to point out that some of are / were, even some years ago.

[island emt]

when I took statistics, we used an abacus

[systemet]

I have major concerns regarding bias potential of the study presented.

1) Proficiency of the intubator. Are the providers included all bark and no bite so to speak (i.e. great didactic without any practical experience).

This is a valid question. They identify in the study abstract that SGAs have been used prehospitally there since 1991. ETI was then introduced for some practitioners in 2004, with a 62 hour didactic component, and 30 tubes in the OR. They discuss whether this is adequate training in the discussion, and state that it exceeds "national curriculum requirements" in the US (apparently only 5 tubes?), and in the UK (25). They quote a study that I haven't read, suggesting that 20 OR tubes are the sort of minimum number to hit a 90% success rate for paramedics. I find this numbers to be a little suspect, but I haven't bothered to actually read the sources, so I should probably reserve comment.

2) Techniques used. Was CPR interrupted for airway placement? Was airway placement given greater priority than treatable causes at any point?

This just wasn't described, which I think was a problem with ROC-PRIMED as well. They also seem unclear on whether some of the SGA group are patients whom they initially attempted to intubate with ETT, and then went to SGA as a rescue. Obviously these patients may have been exposed to greater and more numerous periods of interrupted CPR than a primary SGA group.

3) Algorithm bias. As previously mentioned early ROSC is a well-known indicator of likely survival to discharge. If ROSC comes early in the resuscitation it's less likely that the patient be intubated. It must therefore be considered that intubation could be an incidental finding in failed survival to discharge as opposed to a causal factor.

This is possible. The BVM only group showed a more rapid ROSC versus the advanced airway group. I don't think that the difference was statistically significant, but if there's a group of rapid ROSC, high risk for survival patients hidden amongst a bunch of noise it could skew things.

As for supra-glottic devices, the very design of them should be suspect to anyone with knowledge of vascular anatomy. The early evidence gathered thus far indicates they impair cerebral circulation. Shocker! Let me tamponade your throat and see how long you stay conscious. These devices by nature of design have the potential to do exactly that from the inside out. Not exactly ideal for an already circulation starved brain.

In pigs. The very limited evidence suggests that it impairs cerebral circulation in pigs. The only evidence of detriment in humans is the post hoc analysis of ROC-PRIMED, an analysis that's contradicted by this much larger, more recent study, which shows an equal detriment to both.

Does anyone have access to the whole study, since it's hard to judge a study simply by the abstract

If anyone wants a copy, pm me with an email, and I might be able to point you in the right direction.

Edited February 6, 2013 by systemet

[mikeymedic1984]

Oh Lord, to be young and gullible again. Scientific studies are no more unbiased than what you politicians tell you. Studies are funded by someone, and often the outcome of the study slants towards whatever drug or technology that the company that donated the money wanted it to produce (not always, but often). AHA has put out numerous scientific studies over the years (I have been at this almost 30), changing the ACLS drugs to whatever was deemed to be the drug of choice after the last ACLS book expired. Guess what, cardiac arrest survival rates have not changed any despite all of those expert scientific studies and STATISTICS that suggested that the old way was stupid and that the new way will save everyone.

ACLS has to change the curriculum every few years to sell more books to us, and that is all this is about. In a controlled setting like an OR, and for a short period of time, a supraglottic airway is sufficient, but in the field, the ETT is king. And to correct the rookie who stated that vomit in the airway is due to over inflating the stomach, I have worked two arrests at buffet restaurants this year (2013) where the vomit was in the airway before CPR was started, not to mention the numerous GSWs to the face (or other facial/head trauma) that put tons of blood in the airway.

[ERDoc]

Oh Lord, to be young and gullible again. Scientific studies are no more unbiased than what you politicians tell you. Studies are funded by someone, and often the outcome of the study slants towards whatever drug or technology that the company that donated the money wanted it to produce (not always, but often). AHA has put out numerous scientific studies over the years (I have been at this almost 30), changing the ACLS drugs to whatever was deemed to be the drug of choice after the last ACLS book expired. Guess what, cardiac arrest survival rates have not changed any despite all of those expert scientific studies and STATISTICS that suggested that the old way was stupid and that the new way will save everyone.

ACLS has to change the curriculum every few years to sell more books to us, and that is all this is about. In a controlled setting like an OR, and for a short period of time, a supraglottic airway is sufficient, but in the field, the ETT is king. And to correct the rookie who stated that vomit in the airway is due to over inflating the stomach, I have worked two arrests at buffet restaurants this year (2013) where the vomit was in the airway before CPR was started, not to mention the numerous GSWs to the face (or other facial/head trauma) that put tons of blood in the airway.

And your 30 years means nothing when you have no idea how science and medicine work, which you have shown in this post. Your attitude of "This is the way we've always done it so it is the way it should always be," is what seperates EMS from medicine. There is a reason we don't do labotomies and blood letting any more and the reason is because of rigorous scientific studies. You are a danger to your pts until you accept this and change it.

As for the comment about science being as biased as politicians, I only have this for you:

[ChaseZ]

Oh Lord, to be young and gullible again. Scientific studies are no more unbiased than what you politicians tell you. Studies are funded by someone, and often the outcome of the study slants towards whatever drug or technology that the company that donated the money wanted it to produce (not always, but often). AHA has put out numerous scientific studies over the years (I have been at this almost 30), changing the ACLS drugs to whatever was deemed to be the drug of choice after the last ACLS book expired. Guess what, cardiac arrest survival rates have not changed any despite all of those expert scientific studies and STATISTICS that suggested that the old way was stupid and that the new way will save everyone.

ACLS has to change the curriculum every few years to sell more books to us, and that is all this is about. In a controlled setting like an OR, and for a short period of time, a supraglottic airway is sufficient, but in the field, the ETT is king. And to correct the rookie who stated that vomit in the airway is due to over inflating the stomach, I have worked two arrests at buffet restaurants this year (2013) where the vomit was in the airway before CPR was started, not to mention the numerous GSWs to the face (or other facial/head trauma) that put tons of blood in the airway.

I may be young, hell you have been doing this almost a decade longer than I have been alive, but I am not gullible and most certainly not uneducated. But years of experience does not automatically make you an expert. Doing something wrong for 30 years does not really mean much.

Yes, there are some studies that are biased either overtly or through less obvious statistical trickery but for those of us who actually understand research and statistics they are easy to spot.

Medicine is dynamic and ever changing. Many things we swore by years ago have been found to be ineffective or even harmful but that does not in anyway discredit new research and changes. We learn and improve with time.

Actually, In hospital cardiac arrest survival rates have been rising over the past few years. Prehospital cardiac arrest survival rates are tricky and involve many factors outside the control of EMS. We know that early CPR and defibrillation are they key to survival. Regardless of how good our interventions are they are not going to bring back a guy who has been pulseless with no CPR for 10 mins.

If you truly believe that the only reason ACLS changes is to sell books than there is no point in trying to argue with you and I sincerely hope you retire very soon.

Why are you correcting "the rookie"? First of all I am pretty sure he is not a rookie. He is not wrong, that is one of the reasons a patient may vomit during CPR. Obviously not the case in a patient who has vomited prior to arrival but that does not mean it is not correct. Why do you keep using the same anecdotal flawed logic.

And I think everyone will agree that advanced airways are necessary in those rare incidences of excessive blood or vomit in the airway. The study's main focus is uncomplicated cardiac arrests, the most common.

Edited February 6, 2013 by ChaseZ

[island emt]

And to correct the rookie who stated that vomit in the airway is due to over inflating the stomach, I have worked two arrests at buffet restaurants this year (2013) where the vomit was in the airway before CPR was started, not to mention the numerous GSWs to the face (or other facial/head trauma) that put tons of blood in the airway.

In 42 years in the business, [ I guess that makes me a rookie} I have seen many times where we arrive and bystanders or family members have started CPR and all of their breaths went directly into the stomach.Put your hand on the distended belly and the fountain starts gushing.

I've also worked many codes with no vomit produced.

Working a couple of whales at a buffet restaurant , I would expect lots of vomit by the fact that they are lying supine with a full gut. Nothing earth shattering in the news department there.

No one is arguing whether an ETT will give control of the airway.

The argument is based on whether or not an advanced airway is having a positive outcome with Cardiac arrest patients. The AHA guidelines are moving respirations and airway way down the algorithm for a reason.

Because the science is being tested and found to not be all that beneficial in resuscitation & survival with a positive outcome.

You can argue all you want that it should be done this way because thats how it's always been done.

It won't make it right and may be detrimental to our patients.

[ERDoc]

Has anyone seen my MAST pants?