Straight to advanced airway on code?

[lsmft]

I'm just wondering if you all have any thoughts on this rather narrow series of events: Say you're on scene, pt's airway is patent and have gag, and either while transporting or on scene they code and or lose their airway. Personally I feel it is a waste of time to drop an npa/opa especially if they've just coded in front of you. I'd rather go for my advanced airway (combi/king/lma.)so we can do synchronous respirations. Unfortunately protocols differ from my opinion.

Any experiences / thoughts.

 

[STXmedic]

Hope you have an extra set of hands in the back

I think it kind of depends on how far out you are. If you're rural and still have a long transport left, I'll personally drop a tube. Hell, might even pull over and work the code there if it's still considerably far from the hospital.

If you're going to be at the ED in a relatively short amount of time, and bagging with an OPA/NPA is effective, I'd just stick with that.

 

[Brandon O]

I'm just wondering if you all have any thoughts on this rather narrow series of events: Say you're on scene, pt's airway is patent and have gag, and either while transporting or on scene they code and or lose their airway. Personally I feel it is a waste of time to drop an npa/opa especially if they've just coded in front of you. I'd rather go for my advanced airway (combi/king/lma.)so we can do synchronous respirations. Unfortunately protocols differ from my opinion.

Any experiences / thoughts.

Consider two things:

1. What do you believe to be the etiology of arrest? Did they become increasingly hypoxic and then code (although in this case we can probably ask why you weren't addressing the problem earlier)? In that case it would make sense to address oxygenation first. Or do you think it's a primarily cardiac problem? In that case I would start with compressions, or preferably just push a button because you've already hooked them up. Don't let them become increasingly ischemic while you fiddle with ways to address their non-problematic oxygenation status.

2. What device do you actually need to manage the airway? Are they unmanageable with the BVM? In particular, if you're simply going to zap them and hopefully have them breathing spontaneously within a few seconds, do you really need to bother putting a tube in?

All of this will obviously be wrinkled by the fact that, if transporting, you may be the only provider back there, in which case you'll need to prioritize.

 

[lsmft]

Definitely assuming we got 2 in the back if transport. Otherwise yeah it is pointless to go advanced unless the adjunct can't do the job.

 

[Brandon O]

Definitely assuming we got 2 in the back if transport. Otherwise yeah it is pointless to go advanced unless the adjunct can't do the job.

Just remember, have a reason for everything you do. Don't feel like you have to immediately jump to "airway" just to check it off a list; think about what's wrong and what the specific patient needs, and prioritize based on that. (Heck, even the formal AHA guidelines say C before A now, but don't think guidelines, think physiology.)

 

[medicdan]

The ONLY two interventions proven to provide any improvement in cardiac arrest are compressions and defibrillaton. NOT intubation or ventilation. Especially with the current CCR projects and research, there are good or better outcomes if intubation or advanced airway protection is deferred to later points in the resusication.

If you can insert an OPA and use an NRB or BVM and achieve chest rise, your time and efforts on scene are much better spent proving high quality compressions, interrogating reversable causes for the arrest, ensuring vascular access and proving medications, etc. If, and only when you have ensured the above, should you begin thinking about an advanced airway, and abort the procedure if it interrupts your compressions or defibillation, because again, those are your priority interventions.

 

[Brandon O]

The ONLY two interventions proven to provide any improvement in cardiac arrest are compressions and defibrillation.

And post-ROSC hypothermia!

 

[lightsandsirens5]

Definitely assuming we got 2 in the back if transport. Otherwise yeah it is pointless to go advanced unless the adjunct can't do the job.

That would be nice...... h34r:

Honestly, the two biggest factors in improving outcome in arrest are compression and defib. Airway should probably take the back seat in a sudden arrest situation. Jump on them compressions and the defib, if indicated, and then start to manage the airway.

As for HOW to go about that. Sounds like greater minds to me have basically covered it already. And I'd say go to the advanced airway 1) once things begin to calm down and get in rhythm, or 2) if you cannot manage them with a simple airway+BVM.

 

[lsmft]

Just remember, have a reason for everything you do. Don't feel like you have to immediately jump to "airway" just to check it off a list; think about what's wrong and what the specific patient needs, and prioritize based on that. (Heck, even the formal AHA guidelines say C before A now, but don't think guidelines, think physiology.)

Sorry, I guess I should have been more clear, I definitely agree with everything you've said so far. But in a multi-provider scene, when you've already got someone on compressions, and they've just gone agonal or apnetic due to the arrest, obviously if you're not already transporting you're about to, but my main though process is, if I've got the hands for cpr, why not give the best patient care and pop in an advanced airway so we can do synchronous respirations/compressions

I guess I am kind of missing the over-arcing point of CAB before ABC, though. Thanks for the input, guys.

To be super clear: this came up when we had 5 emts on scene, so definitely no shortage of hands. It just seemed a little redundant to drop opa/npa.

 

[Brandon O]

Sorry, I guess I should have been more clear, I definitely agree with everything you've said so far. But in a multi-provider scene, when you've already got someone on compressions, and they've just gone agonal or apnetic due to the arrest, obviously if you're not already transporting you're about to, but my main though process is, if I've got the hands for cpr, why not give the best patient care and pop in an advanced airway so we can do synchronous respirations/compressions

I guess I am kind of missing the over-arcing point of CAB before ABC, though. Thanks for the input, guys.

The main point is that compressions have been proven to save lives; intubation and ventilation have been proven, in general, to either have no benefit or to kill (largely, we presume, because it can take away time from compressions). So anytime you're interrupting or delaying compressions/defib for... well, anything else, you'd better have a darned good reason. During high-performance resuscitations in the best systems, you'll have to tackle the compressor or club them with an oxygen tank if you want them to stop pushing while you to fiddle around; it just ain't happening, and that's a good thing. (If you're good, you may be able to intubate during compressions, which would be one compromise... but if hands are limited and it's a choice between that and throwing on pads, start with the pads.)

If you're on scene, no need to rush to transport, either. Again, barring some reversible cause that you can't address (i.e. alien bursting out of chest), it's early, quality compressions and shock that will save your patient, if they're saveable. You can't do those very well if you're focusing on packaging and transport. In fact, if you're already en route, I would probably pull over and have your partner come back to assist you. There's no magic finish line at the hospital; you have access to the good stuff already.

 

[lsmft]

but if hands are limited and it's a choice between that and throwing on pads, start with the pads.)

I definitely agree! I guess my title was very misleading, and I left out the fairly important detail that we had 5 emts on scene. Cardiac was fully taken care of, and we still had 2 people just for airway before we packaged them. Protocol in that case says to pop in the npa/opa and give breaths every 30 seconds. I can prep an lma/king in 30 seconds, so I figure, it's just better to skip the npa/opa and drop the lma so we can start giving them continuous breaths, regardless of how pointless it is.

 

[Brandon O]

An LMA or King might be a nice choice in that case, since you shouldn't need to pause compressions to insert it. Just make sure that the mere fact you have a patent airway doesn't lead to hyperventilation -- a lot of the time folks end up squeezing 40 times a minute just because they stop paying attention once the advanced airway is in. The provider at the head should have no job other than staring at the bag and counting "one one thousand, two one thousand..." (or use a metronome... heck, you can get a metronome app for your smartphone).

There is some tentative evidence that the cuff on devices like the King may compress the internal carotid and reduce cerebral perfusion. But that's very early stuff and probably shouldn't affect your care.

 

[usalsfyre]

There is some tentative evidence that the cuff on devices like the King may compress the internal carotid and reduce cerebral perfusion. But that's very early stuff and probably shouldn't affect your care.

http://www.ncbi.nlm.nih.gov/m/pubmed/22664746/?i=5&from=/22541878/related
http://www.ncbi.nlm.nih.gov/m/pubmed/22541878/
(Two large, multi-center trials suggesting poor outcomes with SGAs. Not exactly tentative evidence)

 

[Bieber]

The ONLY two interventions proven to provide any improvement in cardiac arrest are compressions and defibrillaton. NOT intubation or ventilation. Especially with the current CCR projects and research, there are good or better outcomes if intubation or advanced airway protection is deferred to later points in the resusication.

If you can insert an OPA and use an NRB or BVM and achieve chest rise, your time and efforts on scene are much better spent proving high quality compressions, interrogating reversable causes for the arrest, ensuring vascular access and proving medications, etc. If, and only when you have ensured the above, should you begin thinking about an advanced airway, and abort the procedure if it interrupts your compressions or defibillation, because again, those are your priority interventions.

This.

 

[medicdan]

An LMA or King might be a nice choice in that case, since you shouldn't need to pause compressions to insert it..

Why do you need to stop compressions to intubate? You may need to in order to auscultate LS, but thats a different story.

 

[medicdan]

Sorry, I guess I should have been more clear, I definitely agree with everything you've said so far. But in a multi-provider scene, when you've already got someone on compressions, and they've just gone agonal or apnetic due to the arrest, obviously if you're not already transporting you're about to, but my main though process is, if I've got the hands for cpr, why not give the best patient care and pop in an advanced airway so we can do synchronous respirations/compressions

I guess I am kind of missing the over-arcing point of CAB before ABC, though. Thanks for the input, guys.

To be super clear: this came up when we had 5 emts on scene, so definitely no shortage of hands. It just seemed a little redundant to drop opa/npa.

The research shows the opposite in some ways... Performing chest compressions does create some positive and negative pressure in the thorax, which brings air in and out, perhaps our goal should just be to provide oxygen for that gas coming in (OPA + NRB?)

Our goal should absolutely be the constant compressions, but as previously said, we need to make sure we aren't delaying them in the process (to insert an advanced airway, etc. )

I definitely agree! I guess my title was very misleading, and I left out the fairly important detail that we had 5 emts on scene. Cardiac was fully taken care of, and we still had 2 people just for airway before we packaged them. Protocol in that case says to pop in the npa/opa and give breaths every 30 seconds. I can prep an lma/king in 30 seconds, so I figure, it's just better to skip the npa/opa and drop the lma so we can start giving them continuous breaths, regardless of how pointless it is.

I'm a little confused how 5 EMTs on scene could help with advanced airway management.... If you have two focused on just the head, I'd prefer one get a great mask seal while the other bags and keeps time for the rest of the team... Remember, we want responsible bagging.... Or interrogating reversible causes of arrest, etc.

 

[Brandon O]

Why do you need to stop compressions to intubate? You may need to in order to auscultate LS, but thats a different story.

Well, some medics don't, but some do, or think they do.

 

[Brandon O]

http://www.ncbi.nlm.nih.gov/m/pubmed/22664746/?i=5&from=/22541878/related
http://www.ncbi.nlm.nih.gov/m/pubmed/22541878/
(Two large, multi-center trials suggesting poor outcomes with SGAs. Not exactly tentative evidence)

I actually tend to agree, but I don't think the evidence is conclusive yet -- at least not enough to indict a specific negative mechanism (whether cuff pressure or whatever else), which is the real question, so we can focus on avoiding it.

 

[lsmft]

The research shows the opposite in some ways... Performing chest compressions does create some positive and negative pressure in the thorax, which brings air in and out, perhaps our goal should just be to provide oxygen for that gas coming in (OPA + NRB?)

Yeah, but a BVM with 15+lmp gives ~100% o2, I fail to see how an NRB with essentially the lowest form of blowby could even come close. Not to mention when you take dead space into consideration, there is hardly any alveolar vent from compressions. Yeah, sure, it's adequate if you're solo. But when you have a surplus of hands, I'm talking optimum pt care.

Our goal should absolutely be the constant compressions, but as previously said, we need to make sure we aren't delaying them in the process (to insert an advanced airway, etc. )

Obviously, but how long does it take to put in an lma? 5-10 second max, and that's assuming you even have to have them stop compressions.

I'm a little confused how 5 EMTs on scene could help with advanced airway management.... If you have two focused on just the head, I'd prefer one get a great mask seal while the other bags and keeps time for the rest of the team... Remember, we want responsible bagging.... Or interrogating reversible causes of arrest, etc.

sure, one could get good seal, and the other bags. That's standard procedure if you've got 4 spare hands. But again, I fail to see how 30/2 or 15/2 is comparable to synchronous, regardless of seal. Also person doing compression keeps the time, always, not the person bagging. They can be off in their own world with whatever mantra works for them, but compressor keeps team time.

 

[Aidey]

Yeah, but a BVM with 15+lmp gives ~100% o2, I fail to see how an NRB with essentially the lowest form of blowby could even come close. Not to mention when you take dead space into consideration, there is hardly any alveolar vent from compressions. Yeah, sure, it's adequate if you're solo. But when you have a surplus of hands, I'm talking optimum pt care.


.

Do some research on apenic oxygenation and hyperoxia in cardiac arrest patients. Sometimes the maximum amount of oxygen possible isn't optimum patient care.