# No ETI.



## NomadicMedic (Feb 9, 2019)

I want my providers to stop intubating arrests, and you’d think I asked them to cut off their own foot. 

How many services are using SGAs as the first line airway for “normal” adult arrests?


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## DesertMedic66 (Feb 9, 2019)

For my flight agency ETI is still recommended however we can delay until after ROSC. 

For my ground agency we do whatever we can do without stopping compressions. If we can get the tube then great. If we can’t then we will go the King route.


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## PotatoMedic (Feb 9, 2019)

Our medical directors prefer SGA in cardiac arrest but we can still intubate as long as all other treatments are not delayed or stopped.


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## cruiseforever (Feb 9, 2019)

When we started the to use the I-Gel our ET use has decreased a lot.  I think the biggest reason for that is our first responders usually have an I-Gel placed.  If the airway is good we leave it alone.


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## NomadicMedic (Feb 9, 2019)

Unfortunately our guys can't get a tube without stopping compressions most of the time. I have to go back to code review data to show them that the stopped for 40 seconds to get the tube and they're just gobsmacked. They can't understand that I can playback the entire code and correlate inventions with the timeline. 

I've recently become fascinated with the concept of cognitive offloading for paramedics and making the process of cardiac arrest resuscitation as easy as possible. An early igel and IO in the tibial plateau make the mechanics of an arrest much easier and allow the focus to remain on compressions, electricity and looking for reversible causes.


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## RocketMedic (Feb 9, 2019)

Although I am broadly supportive of the concept of minimizing time without compressions, I think that wholesale abandonment of ETI for arrests is a bad plan. Some airways are not amicable to SGA placement, especially in pediatric patients or trauma victims. Not all arrests are identical, and allowing the paramedics on-scene to determine what the best airway solution is is a better tack than wholesale bans.


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## DrParasite (Feb 9, 2019)

Wake EMS does for all cardiac arrests.  SGA is the primary attempt.  If you get ROSC and want to intubate afterwards, it's paramedic discretion.

however there are situations where ETI is better than a SGA.


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## Gurby (Feb 9, 2019)

NomadicMedic said:


> Unfortunately our guys can't get a tube without stopping compressions most of the time. I have to go back to code review data to show them that the stopped for 40 seconds to get the tube and they're just gobsmacked. They can't understand that I can playback the entire code and correlate inventions with the timeline.
> 
> I've recently become fascinated with the concept of cognitive offloading for paramedics and making the process of cardiac arrest resuscitation as easy as possible. An early igel and IO in the tibial plateau make the mechanics of an arrest much easier and allow the focus to remain on compressions, electricity and looking for reversible causes.


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## NomadicMedic (Feb 9, 2019)

You’ll notice I said a “normal” adult arrest. Not a trauma arrest. Not a pedi code... the run of the mill cardiac arrest. 

I firmly believe that a systematic approach to arrest resuscitations will make for a more organized code and will eliminate the tunnel vision and general loss of focus that always happens and everyone denies.


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## akflightmedic (Feb 9, 2019)

Ahhhh, but let's delve into the psychological aspect which you touched on (cognitive dissonance). First, you are removing one of the skills which is a hallmark of paramedicine...I mean anyone (read any level) can do a SGA, so admit it or not there is that "destruction" of a hierarchical intervention which separates the levels.

The other aspect is not realizing/acknowledging how much time it takes us to successfully insert a tube. We are seasoned, experienced, have dropped 100s of tubes, that small amount of time (if any at all) has zero outcome/bearing on the overall treatment of this patient. Because ultimately the patient will need the tube anyways so might as well do it now and statistically I am counting the negative outcomes, perceptions, statistics as opposed to the positive.

I am not afraid to admit it, many times I have worked codes with the mindset of "knowing" what the outcome is going to be regardless of what I do. Do you think psychologically this may also contribute to choice of airways, lack of time awareness/accountability, and overall general team attitude? I think so...it is very hard to maintain that green EMT, gonna save them all, go for the gusto positive attitude we all once held.


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## Tigger (Feb 9, 2019)

The systems I've been exposed to that were successful in this took it out of the paramedics hands and emphasized that an iGel be placed as the first line airway in cardiac arrest. As such, EMRs and EMTs now just shove an iGel in as soon as they have more than one provider on scene and passively oxygenate. In the city the fire crews were afraid of intubating so that wasn't an issue.


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## StCEMT (Feb 10, 2019)

I always intubate arrests, but I make it a point to not stop compressions. Usually I do a pulse check and then intubate once I start the autopulse again. I know I have two minutes and don't have any other tasks that require my attention within that time aside from 1. Final prep 2. Intubate 3. Verify tube placement. Two minutes is plenty of time for me to do that.

Like I said though, I make it a point to not stop compressions to intubate. I properly prep my patient and have had no issue getting a ETT placed ever since I restructured my approach to intubation.


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## RocketMedic (Feb 10, 2019)

Another consideration here is that arrests make up the majority of field intubations. By removing intubation from most arrests, you are also removing significant opportunities for it that may not be replicable with alternative training. The science has shown it doesn’t matter to outcomes of arrests when done to a highstandard and that it can be harmful, so I’m not sure if it ought to be done in the course of an arrest, but I do know that there are cases where emergent intubation is needed and a firm competency built on both training and experience is necessary to succeed. 

I generally like the initial use of an SGA, but have discovered that time-critical situations (MI discovered post ROSC) tend to get bogged down by a perceived need to intimate with an ETT. I reckon the best answer is actually less focus on the tool and more on the objective.


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## NPO (Feb 12, 2019)

We intubate our cardiac arrest, but we don't do it until the 3rd round, or adequate personal are available and other tasks are complete.

Prior to intubation we use a nasal cannula at 10LPM for passive apnic oxygenation. We switched to a NC from a NRB because it allows for continued passive oxygenation during intubation.

Personally, this is my favorite way to use airway/ETI in cardiac arrest. There are undeniable benefits to ETI over SGA. I'm aware of the studies. I'm talking beyond simple outcome numbers. I'm talking about true definitive  airway, prover skill with ETI for the times when ETI is truly needed, cognitive offload by not making the SGA vs ETI decision, etc... The-prioritization of ETI is critical unless it's a respiratory call.

With the King Vision we can intubate during Lucas CPR, and have an above-standard (but not where I'd like to see it) first pass success rate.


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## StCEMT (Feb 13, 2019)

If you are seeing problem areas with how the arrests are done, with intubation in particular, why not overhaul it and implement training?

I went from a absolute **** first pass success rate to confidently getting one successful intubation after the other by being proactive and figuring out things I was not doing right. I want to say I had a good two month gap between my last intubation and the one before that. But I have ingrained in myself a specific approach that worked for me and even with such a gap, I reverted right back to it, and was able to get it on the first time despite having to take a little more time than normal (still within the 30 second window we like to use).  You have Williamson county who had their airway management methods restructured by their OMD and had a significant improvement. I'm sure there are other areas that have improved their approach and also their success as a result.

We are perfectly capable of being successful at intubating, but I think there is a large failure in leadership to make that happen. Yes, we still need to be proactive on our own, but so do those managing us. From personal experience, my employer doesn't do a damn thing to train us. The closest I get is the alphabet soup refreshers and even the equipment is so mismatched compared to our actual set ups that I don't take it serious. That is a failure of my leadership to provide resources to make us more successful. Give your employees training. Set the new standard. Explain why. Show the numbers of their success and what happens to circulation without compressions. Educate them on how they can be better then empower them with the tools and resources they need to be better.

That's also a bit of a personal soap box though from being disgruntled with my employer. I fully believe that EMS agencies need to hold their employees to a high standard, but make sure they give the employees everything they need to maintain that standard.


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## Carlos Danger (Feb 13, 2019)

RocketMedic said:


> Another consideration here is that arrests make up the majority of field intubations. By removing intubation from most arrests, you are also removing significant opportunities for it that may not be replicable with alternative training. The science has shown it doesn’t matter to outcomes of arrests when done to a highstandard and that it can be harmful, so I’m not sure if it ought to be done in the course of an arrest, but* I do know that there are cases where emergent intubation is needed and a firm competency built on both training and experience is necessary to succeed.*



But the problem with that (and I'm talking about airway management overall, not just in the context of medical arrests) is unless you are doing a lot of arrests, it's probably not enough practice to make a difference. 

Remember the learning curve for airway management is steep at first (50-100 tubes) but then it flattens out. Which means once you gain a basic level of competence (able to tube most arrests without difficulty), you are good to go with the exception of the most difficult airways, which require A LOT of experience to be able to consistently manage well.


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## DrParasite (Feb 13, 2019)

Part of the issue with paramedics being unable to intubate on the first time if they don't do it enough.  the studies, particularly out west, support that thinking.   If you have a medic who hasn't intubated a live person in over a year, can you really fault them for not being proficient in it?

This was also the area that you will have 6 to 8 paramedics on the scene of an arrest (3 on the engine, 2 on the ambulance, maybe a supervisor or a second truck), so 6 paramedics, 1 tube, you see the issue.

Compare that to my days back in NJ, where paramedics would tube 1 patient every 2 weeks (and some people it was 2 patient's a week on a bad week)... every cardiac arrest was intubated, and many were intubated in the awkward position with paramedics getting on some super sketchy floors..  1 patient, 2 paramedics, who only handled ALS patients.....  see the difference?

If you are going to remove ETI, and use SGA as the first line or airway management, how proficient will your crews be when they get a bad airway burn who needs an ETI ASAP, or a patient where the SGA isn't working well enough, or pick another person who needs an ETI vs a SGA?  Remember, if you don't use a skill, you do lose it, as the studies have shown.


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## Summit (Feb 13, 2019)

Medics need experience to competently ETI when needed.

But arrested patients are not practice dummies. If you are stopping compression to tube, you are doing a disservice to the arrest.

So either SGA or practice enough with manakins receiving compressions and scheduled OR rotations to be able to ETI arrests and handle those times when you need ETI.

If medics get enough skills practice and experience, then maybe too many people have the skill and it should be specialized rather than all medics.


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## Aprz (Feb 13, 2019)

I think if you do not interrupt compressions to intubate, you should be fine. In my county, they forced us to attempt intubation first before sticking to a rescue or BLS airway. They said our success rate for intubation dramatically deteriorated when started following the "if BLS is good, no need to use a King or intubate" thing. In my experience, I felt a lot of providers would say the BLS airway was good even though it wasn't.


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## CWATT (Feb 13, 2019)

MD Ambulance (a subsidiary of Medavie) in Saskatoon, Saskatchewan, Canada conducted a ‘compression only’ pilot program last year.  I believe it was only using OPA + N/C O2 for cardiac arrests (although I was told it did not preclude practitioners from performing SGA or ETI).  Either way, just explain the following logic to your members: 

-Passive O2 flow down it’s concentration gradient from the mouth to the alveoli is 250ml/min
-Normal O2 consumption for an average adult is appx. 250ml/min.
-In theory, if you stod with your mouth open, it should provide sufficient O2 for normal life-sustaining processes
-Supplimental O2 via N/C is superlative.  
-However, CO2 needs to be eliminated through ventilation.
-During CPR the expansion and contraction of the thoracic space creates ventilation.
-During a cardiac arrest the heart is pumping 0%.
-No blood is being circulated through the pulmonary circuit
-The ventilation/perfusion ratio is 100:0
-The goal of CPR is to pump blood.  
-At best, we can achieve 20% normal perfusion (evidenced by the ‘goal of therapy’ being an ETCO2 >10mmHg)

Conclusion — during optimal CPR the V/Q (ventilation/perfusion) ratio is still heavily in favour of ventilation and we are already providing additinal O2, so the last thing we need is MORE ventilation.  The focus should therefore be on perfusion.  If your protocols still utilize 30:2 so be it, but recognize the important component of CPR is chest compressions (perfusion) and not ventilation because the ventilation you are creating with compressions is already exceeding the perfusion to the lungs.  So an ET-tube is not an intervention that is going to provide any life-sustaining benefit to the patient and any delay initiating this treatment will have a negative effect against their outcome.


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## aquabear (Feb 14, 2019)

For our agency, endotracheal tube placement is the "preferred airway device." We also approach intubation differently than most ground EMS agencies (only using VL, utilizing a bougie every time, regular ETI and SALAD training, not stopping compressions during attempts) and as a result, we consistently have a FPS rate greater than 90%.


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## MSDeltaFlt (Mar 19, 2019)

I am an old school medic and I do love dropping a tube and getting an EJ.  That being said I also believe the national standard of care for the standard adult cardiac arrest is SGA's and IO's.  And here's the reason why, in my honest and humble opinion (granted opinions are like butt holes, everybody's got one and most of them stink).  You can't kill a dead man.  And the odds of getting said dead man back are not in your favor.

The goal is early defibrillation and quality chest compressions.  And chest compressions are like Pringles - once you pop you just can't stop.  That is until the patient is not responding.

So, drop your King, I-Gel, Combi, whatever and drill them and keep going.  If you get ROSC get your ETT if you can.  If you don't get ROSC work it and call it.

Dead is dead.  There has been only one person in history that wasn't God to walk on water and he didn't make it very far.  

Do the best you can and let it go.


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## E tank (Mar 19, 2019)

CWATT said:


> Conclusion — during optimal CPR the V/Q (ventilation/perfusion) ratio is still heavily in favour of ventilation and we are already providing additinal O2, so the last thing we need is MORE ventilation.  The focus should therefore be on perfusion.  .



Just a point of order, if you'll forgive the hair splitting...ventilation is a function of CO2 elimination, which requires, by definition, cardiac output.

So, that the bag is being assiduously  squeezed is no indicator of adequate "ventilation". That said...who cares? Acidosis from accumulated CO2 is pretty well tolerated by almost everyone, with a couple of notable exceptions.

But the squeezing the bag is better than apneic oxygenation and improving O2 delivery through bag squeezing  is a good goal (understanding that while true ventilation while doing this may be a bridge too far, oxygenation is not).

And when we say perfusion, while we immediately think blood flow, the critical element is the oxygen in the flowing blood.


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## Tigger (Mar 19, 2019)

MSDeltaFlt said:


> I am an old school medic and I do love dropping a tube and getting an EJ.  That being said I also believe the national standard of care for the standard adult cardiac arrest is SGA's and IO's.  And here's the reason why, in my honest and humble opinion (granted opinions are like butt holes, everybody's got one and most of them stink).  *You can't kill a dead man.*  And the odds of getting said dead man back are not in your favor.


I think this mindset has hindered resuscitation care. If we examine every treatment under the premise of "it won't hurt because they're dead," we're potentially setting our patients up for poor neurologic outcomes, which should be the primary goal of all cardiac arrest management.


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## MSDeltaFlt (Mar 20, 2019)

*AHA Releases Latest Statistics on Sudden Cardiac Arrest*
Submitted by SCAFoundation on Thu, 02/01/2018 - 6:16pm


SCA News







There are more than 356,000 out-of-hospital cardiac arrests (OHCA)[1] annually in the U.S., nearly 90% of them fatal, according to the American Heart Association’s newly released _Heart Disease and Stroke Statistics - 2018 Update_. According to the report, the annual incidence of EMS-assessed non-traumatic[2] OHCA in people of any age is estimated to be 356,461.
There are a number of ongoing challenges to understanding the epidemiology of cardiac arrest in the U.S. Despite being a leading cause of death, there are currently no nationwide standards for surveillance to monitor the incidence and outcomes of cardiac arrest. Thus, registries and clinical trials are used to provide best estimates.[3]
Following are highlights from the report:
Adults

Estimates suggest the incidence of OHCA among adults is 347,322.
Overall, survival to hospital admission after EMS-treated non-traumatic cardiac OHCA was 29%, with higher survival rates in public places (39.5%) and lower survival rates in homes/residences (27.5%) and nursing homes (18.2%)
Survival to hospital discharge was 10.8% among adults (9% with good neurological function).
Large regional variations in survival to hospital discharge (range, 3.4%-22%) and survival with functional recovery (range, 0.8%-20.1%) are observed in 132 counties in the U.S. Variations in the rates of layperson CPR explained much of this variation.
Among adults treated by EMS, 25% had no symptoms before the onset of arrest.
The majority of OHCA’s occur at a home or residence (68.5%), followed by public settings (21%) and nursing homes (10.5%).
Cardiac arrest was witnessed by a bystander in 37% of cases, and an EMS provider in 12% of cases. For 51% of cases, the collapse was not witnessed.
Among EMS-treated OHCA patients, 19.8% had an initial rhythm (Ventricular Fibrillation or Ventricular Tachycardia) that is shockable by an automated external defibrillator (AED).
Among 10.9 million registered participants in 40 marathons and 19 half-marathons, the overall incidence of cardiac arrest was 0.54 per 100,000 participants. Those with cardiac arrests were more often male and were running a marathon versus a half-marathon. Among runners with cardiac arrest, 71% died; those who died were younger (39+9) than those who survived 49+10).
Dead is dead.  And it is usually final.  Don't waste time trying to get the ETI and EJ.  If you can great but dont' waste time.  Quality chest compressions and early defibrillation are key.  Drill them and get your SGA.


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## NomadicMedic (Mar 21, 2019)

As an aside, the PA ALS 2019 protocol revisions remove routine intubation from the standard arrest protocol. 

Looks like I'm not crazy.


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## EpiEMS (Mar 21, 2019)

NomadicMedic said:


> As an aside, the PA ALS 2019 protocol revisions remove routine intubation from the standard arrest protocol.
> 
> Looks like I'm not crazy.



Wouldn't be surprised to see this happening nationally - my protocols have said that ETI and SGAs are equivalent in the setting of OOCHA for a couple of years now.


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