# ET entubation in cardiac arrest victims



## HMartinho (Feb 3, 2012)

As we all know, since the EMT-B's to EMT-P's, the interruption of chest compressions to ventilate the patient (according to the recommendation of 30:2), drastically decreases the coronary perfusion pressure, seriously decreasing the survival probability of the patient.
We also know that the only way to vent without interrupting cardiac compressions is to ensure an advanced airway (encontraqueal tube, laryngeal mask or Combitube). So why ILS or ALS teams, when identify cardiac arrest, the first approach is not to proceed with endotracheal intubation, or placement of the laryngeal mask?
In Portugal, we use the recommendations from the American Heart Association, and we have our protocols with specific actions, as I think which happens in the U.S..

I accepted suggestions, approaches, and everything you find relevant to this discussion.


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## Veneficus (Feb 3, 2012)

HMartinho said:


> As we all know, since the EMT-B's to EMT-P's, the interruption of chest compressions to ventilate the patient (according to the recommendation of 30:2), drastically decreases the coronary perfusion pressure, seriously decreasing the survival probability of the patient.
> We also know that the only way to vent without interrupting cardiac compressions is to ensure an advanced airway (encontraqueal tube, laryngeal mask or Combitube). So why ILS or ALS teams, when identify cardiac arrest, the first approach is not to proceed with endotracheal intubation, or placement of the laryngeal mask?
> In Portugal, we use the recommendations from the American Heart Association, and we have our protocols with specific actions, as I think which happens in the U.S..
> 
> I accepted suggestions, approaches, and everything you find relevant to this discussion.



A few reasons not too rooted in the delivery of 02 (do2) and o2 extraction.

intubation with excessive ventilaton is more harmful than compressions only. If you read the AHA position, it states intrathoracic pressure increases during ventilation

Another off hand point is there is a physiologic reserve of oxygen, so it is not the most important treatment.

back to Do2, if there is a clot blocking blood flow, or bleeding reducing flow, then excess o2 isn't getting anywhere.

There is also the issue of reperfusion injury and the secondary effects of free radical generation.

Furthermore, since CPR and defib are the only proven treatments, those take priority over o2 delivery.

Not a complete or indepth post by any means.

If I might respectfully suggest something?

Read up on physiology.

This topic is explained very well in this book:


http://www.amazon.com/Physiologic-B...1382/ref=sr_1_2?ie=UTF8&qid=1328282027&sr=8-2

or if you have a medical library at hand:

http://www.amazon.com/Millers-Anest...=sr_1_1?s=books&ie=UTF8&qid=1328282073&sr=1-1


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## Shishkabob (Feb 3, 2012)

My agency wants a King put in place.  The only time they want an ETT on a cardiac arrest is if you either can't get a King, or after you get ROSC as part of the stabilization procedures.  

Putting a King in won't interrupt compressions.  Though if you're good enough, ETI won't interrupt compressions either.


If you have to stop to put an airway in, you've chosen the wrong airway.


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## shfd739 (Feb 3, 2012)

We still intubate but not until the 8min mark of working. Up to that point we use passive oxygenation with an OPA and NRB.

Medic gets one attempt then has to move to a Combitube.


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## fast65 (Feb 3, 2012)

We have the option of going with a King, or attempting to intubate, either way, we can't stop compressions. However, like Vene said, the only two proven treatments in cardiac arrest are CPR and defibrillation, so ventilation takes a backseat to both of those.


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## MSDeltaFlt (Feb 3, 2012)

AHA does not require intubation in cardiac arrest.  It is not a requirement for ventilation in an apneic pt.  However, intubation, LMA's, Combitubes, and the like do make it easier.  The only requirement in the pulseless and apneic pt is an airway.  Advanced airways are only "considered" further down the algorithm. 

You only intubate or place a supraglottic airway if you can place them without interruption of chest compressions.  Once you start compressions, you don't stop unless you A) check rhythm/pulse or B) shock.


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## NYMedic828 (Feb 3, 2012)

Veneficus said:


> A few reasons not too rooted in the delivery of 02 (do2) and o2 extraction.
> 
> *intubation with excessive ventilaton is more harmful than compressions only. If you read the AHA position, it states intrathoracic pressure increases during ventilation
> 
> ...




The two bolded statements, are the main reason for AHA not wanting airway to be your primary concern. 

The cause of cardiac arrest in adults, is rarely due to respiratory arrest. This being the case, that means that the blood statically sitting in the body during arrest still has sufficient oxygen in it to initially perfuse vital organs.  Not until we start doing CPR does that oxygen reserve get utilized. 

Its like holding your breath underwater. Though you aren't breathing for an extended period of time, your body does still receive oxygen and hence you retain consciousness and a heartbeat. 

On the other hand, if you note that AHA recommends 15:2 for kids when more than one provider is present, this is based on the idea that when kids go into cardiac arrest, it is usually related to respiratory arrest. If respiratory arrest is the cause, then the body will not have this remaining cache of oxygen in the blood to utilize as soon as you begin compressions. The thing is that we don't know for sure if respiratory arrest is the cause, so to play it safe they kept compressions first, but split the time until ventilation started down the middle. Hence 15:2.

Also as stated above, intubating has its fair share of complications. First of all, not everyone is the most skilled in intubation. The AEMT (sort of like intermediate here) in my volunteer department, most of have never intubated a real person. The AEMT class here, does not require intubations on anything but a manikin. (paramedic does)

So, you now have someone who truly doesn't know what they are doing, but thinks they do and wastes all this time trying to intubate 10 times.

Next up is the fact that is is MUCH easier to cause an increase in thoracic pressure when a patient has an advanced airway in place vs mask to face. 9/10 the mask wont make a perfect seal with the face, but it will be adequate to ventilate. This allows for overpressure to have at least some route of escape vs. directly over-inflating the lungs. An ET tube gives you one way in and one way out. If the provider is still pressing in on that bag, the air inst coming out. Pop-off valves aren't set to each patient. A 21 year old kid won't have the same tolerance to over-inflation as an 80 year old. Through this, not only have you caused potential damage to the lungs, you may not be letting enough air to escape the lungs. This causes respiratory acidosis, and more importantly has the potential to cause obstruction to the inferior vena cava and Aorta, decreasing the return of blood to the heart and thereby decreasing cardiac output, the exact thing we are trying to repair. Patients should receive absolutely no more than enough volume of air to see the chest rise. (hard to tell when you are doing them in sync with compressions)

AHA has a very strong emphasis on HIGH QUALITY CPR. BLS before ALS every time. Always remember that no pressor drugs or anything but HIGH QUALITY CPR and early defibrillation has been proven by any studies to increase our chances of ROSC. CPR itself is the only proven method. As long as that patient is getting enough air to perfuse the alveoli and slightly expand the chest, your job is done. Gastric inflation is of course a concern, but there are bigger things in the picture to focus on than a potential secondary or tertiary problem.

(I am an BLS AHA instructor)


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## Fish (Feb 3, 2012)

Linuss said:


> My agency wants a King put in place.  The only time they want an ETT on a cardiac arrest is if you either can't get a King, or after you get ROSC as part of the stabilization procedures.
> 
> Putting a King in won't interrupt compressions.  Though if you're good enough, ETI won't interrupt compressions either.
> 
> ...



Seconded


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## Smash (Feb 3, 2012)

Linuss said:


> Putting a King in won't interrupt compressions.  Though if you're good enough, ETI won't interrupt compressions either.



Indeed.  We intubate all our arrests.  It is reasonably simple to get everything set up, get the blade in, pass the tube, or wait till a pulse check occurs and slip it in then.  No interruption to compressions beyond what would normally happen with a pulse/rhythm check taking a few seconds.

We have over 30% survival to discharge for VF/VT arrests, so I guess we do something right!

However, if your practitioners aren't experienced and comfortable with ETI and would take some time to get a tube in, go an EGD, or basic airway care; we all know what makes a difference in arrests, and it sure ain't the bit of plastic down the throat...


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## tssemt2010 (Feb 4, 2012)

my agency does king tube immediately, then after we get situated we intubate


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## Ramis46 (Feb 5, 2012)

Isn't it funny though that was are ingrained to think; Airway, Breathing, Circulation. All the way through school ABC... And then it comes to ALS and now CPR and difbrilation or the major players. hmmm


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## usalsfyre (Feb 5, 2012)

Talked with one of the docs heavily involved in the ROC trial the other day. Very interesting things to say about Kings and CombiTubes.


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## abckidsmom (Feb 5, 2012)

usalsfyre said:


> Talked with one of the docs heavily involved in the ROC trial the other day. Very interesting things to say about Kings and CombiTubes.



Details, you tease...


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## Veneficus (Feb 5, 2012)

Ramis46 said:


> Isn't it funny though that was are ingrained to think; Airway, Breathing, Circulation. All the way through school ABC... And then it comes to ALS and now CPR and difbrilation or the major players. hmmm



Welcome to medicine.

If you went to school in the last 5 years you should probably demand some money back.

If you went to school in the last 10 and didn't hear CPR and defib were going to be the major players, your instructor was more concerned about memory aids than teaching science.

"What gives" is they didn't know. You'll see that a lot in EMS instruction.


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## usalsfyre (Feb 5, 2012)

abckidsmom said:


> Details, you tease...



Basically neurologically intact survival
was significantly worse with a King than an ETT, and both were WAY worse than BVM alone. 

No one seems to know why right now though. Data hasn't been fully analyzed and published yet though.


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## Veneficus (Feb 5, 2012)

usalsfyre said:


> Basically neurologically intact survival
> was significantly worse with a King than an ETT, and both were WAY worse than BVM alone.
> 
> No one seems to know why right now though. Data hasn't been fully analyzed and published yet though.



Not surprised, reading at this very moment the damage and complications caused by esophageal airway devices.


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## HMartinho (Feb 5, 2012)

Thank you all for your great answers and links.

In fact, we all know that the only really effective treatment in cardiac arrest is the cpr and defibrillation. However, in a cardiac arrest victim without an advanced airway inserted, we have to interrupt compressions to ventilate, impairing coronary perfusion. It was here that my question was based.

I'm glad for knowing that some of your states, allow you insert an advanced airway, like king or the Combitube, which allows ventilating the patient without interrupting compressions.

Here, doctors and nurses in pre-hospital, just insert an ETT, laryngeal mask / Combitube, when cardiac arrest is prolonged, and the patient does not respond after the 3rd or 4th shock.

Uunfortunately ,we EMT-B's can only use OPA and NPA airways, using the 30:2 ratio.


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## abckidsmom (Feb 5, 2012)

usalsfyre said:


> Basically neurologically intact survival
> was significantly worse with a King than an ETT, and both were WAY worse than BVM alone.
> 
> No one seems to know why right now though. Data hasn't been fully analyzed and published yet though.



Interesting.  Watching the pendulum swing is like being at a tennis match.


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## zmedic (Feb 5, 2012)

They tell us in school that 50% of what we learn will be proven wrong by the end of careers in medicine. The problem is that no one knows which 50%. Especially in EMS you have to expect a lot of changes. I'd say that about 75% of what is done in the field has little or no evidence behind it saving lives (backboard, KED, magnesium for asthma etc etc). So it shouldn't be such a shock when things change. 

Also the CAB v ABC thing is silly and confusing. I understand what the AHA is trying to do, trying to reduce the delay to compressions. But in a lot of things it still makes sense to do ABC. For example, you have a trauma patient. If they don't have a pulse they are pretty much dead, so checking a pulse before airway doesn't make sense since if they aren't breathing because of an obstructed airway correcting the airway is the priority. 

Also with resuscitation since things keep changing you have to keep going back and looking at the things that have stayed the same. So if you looked at the effect of intubation in patients with the 2005 guidelines, you may get different results with the 2010 guidelines.


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## DrParasite (Feb 6, 2012)

tssemt2010 said:


> my agency does king tube immediately, then after we get situated we intubate


Just so I am sure, you king tube immediately, do some CPR, then yank the king out and intubate with the ETT?  

I just want to make sure I am understanding you


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## Tigger (Feb 6, 2012)

DrParasite said:


> Just so I am sure, you king tube immediately, do some CPR, then yank the king out and intubate with the ETT?
> 
> I just want to make sure I am understanding you



It may be possible to insert an ETT through a King, or maybe I am thinking about an entirely different airway...


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## DPM (Feb 6, 2012)

Tigger said:


> It may be possible to insert an ETT through a King, or maybe I am thinking about an entirely different airway...



No, the King is a blind stick that ends up in the esophagus. The distal cuff inflates, closing this off, and the proximal cuff inflates in the pharynx to stop air escaping out of the mouth.


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## Tigger (Feb 6, 2012)

Good to know, I have very little experience with that device since I don't work anywhere it is carried. Is it possible to use a rescue airway to assist with an endotracheal intubation or is it always one or the other?


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## DPM (Feb 6, 2012)

Tigger said:


> Good to know, I have very little experience with that device since I don't work anywhere it is carried. Is it possible to use a rescue airway to assist with an endotracheal intubation or is it always one or the other?



You can pass a bougie (sp?) through a king tube that is correctly situated, removing the need to laryngoscopy, but this isn't something I've ever tried.

That said, it should take too long to deflate the king, whip it out and then in pass an ET the old fashioned way.


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## medicsb (Feb 6, 2012)

usalsfyre said:


> Basically neurologically intact survival
> was significantly worse with a King than an ETT, and both were WAY worse than BVM alone.
> 
> No one seems to know why right now though. Data hasn't been fully analyzed and published yet though.



Interesting, but lets consider who is contributing a huge proportion of the data on intubation of cardiac arrests for ROC (or data in general)... Not exactly representative of EMS training or ongoing experience (sadly).


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## Medic Tim (Feb 6, 2012)

Tigger said:


> It may be possible to insert an ETT through a King, or maybe I am thinking about an entirely different airway...



Some have a port on the back where you can insert an OG tube.


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## STXmedic (Feb 6, 2012)

DPM said:


> You can pass a bougie (sp?) through a king tube that is correctly situated, removing the need to laryngoscopy, but this isn't something I've ever tried.
> 
> That said, it should take too long to deflate the king, whip it out and then in pass an ET the old fashioned way.



I've tried it a few times and it's never worked. The King gets a slight bend in it once it's inserted, which prevents the bougie from passing through.

Side note: If you have the King LTS-D (the King with the G-tube port), and you do not have a G-tube... PLUG THE HOLE!! Found out the hard way that the port has a tendency to provide a release for (read: spray) vomit when not plugged... h34r:


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## systemet (Feb 7, 2012)

Tigger said:


> Good to know, I have very little experience with that device since I don't work anywhere it is carried. Is it possible to use a rescue airway to assist with an endotracheal intubation or is it always one or the other?



There is an intubating-LMA out there, that has a port you can pass an ETT through.  For some reason, they're ungodly expensive.  Never used one.


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## systemet (Feb 7, 2012)

PoeticInjustice said:


> Side note: If you have the King LTS-D (the King with the G-tube port), and you do not have a G-tube... PLUG THE HOLE!! Found out the hard way that the port has a tendency to provide a release for (read: spray) vomit when not plugged... h34r:



This was also a great form of confirmation when pracing the combitube.  Vomit sprays explosively out of tube #2.

The thoughtful folks at Laerdal, Phillip Morris, or Mattel or whoever made that mass of plastic provided a nice vomit deflector you could put on top, so you could pick your victim.  Watch out EMS supervisor!  Watch out fire medical responder! 

[Just kidding of course, because intentionally spraying vomit over another human being is probably "wrong".]


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## ffemt8978 (Feb 7, 2012)

systemet said:


> This was also a great form of confirmation when pracing the combitube.  Vomit sprays explosively out of tube #2.
> 
> The thoughtful folks at Laerdal, Phillip Morris, or Mattel or whoever made that mass of plastic provided a nice vomit deflector you could put on top, so you could pick your victim.  Watch out EMS supervisor!  Watch out fire medical responder!
> 
> [Just kidding of course, because intentionally spraying vomit over another human being is probably "wrong".]



Works well on the bystanders that won't step back.  :whistle:

Sent from my Android Tablet using Tapatalk


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## NYMedic828 (Feb 7, 2012)

Just as a side note to this thread, the ALS coordinator of my area informed yesterday that if we have an arrest, and we get ROSC, but we cannot get a capnography value we have to extubate and BVM the patient....

This stemmed from an arrest I had an arrest 2 days back where the guy was an easy tube. It was so easy that even though I forgot to put a stylet into the tube, I still got it right in. (got lucky on that dumb mistake)

Problem was, for some reason the machine wouldn't give me a capnography value. I tried 2 additional cap lines, still no value, just 0s.

So now the problem is either 

A: Hes super dead and has no viable lung tissue
B: Monitor failure.

Turned out the monitor worked fine when I blew into a new line after the run to test it later on.

But the moral of this story is, NYC does not allow you to keep an ET tube in a patient if they regain ROSC but you cannot get a capnography value. Regardless of the fact that 3 paramedics, and the ER staff all agreed the tube was perfectly placed and I saw it go directly through the cords, on paper it is unacceptable.

If we had an alternative airway in NYC, this wouldn't be a problem. Granted we do carry combi-tubes, but you cannot combitube a living patient as per protocol, and I wouldn't want to anyway because of the potential trauma that beast of an airway can cause.


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## zmedic (Feb 11, 2012)

I guess you can look at it from the other side. If your three explanations are 

1: Patient's dead
2: Monitor failure
3: The tube is not in the trachea. 

If it's #1, it doesn't matter to me if that patient is bagged or has an ET tube in, they aren't coming back. If I remember right no one get successfully revived if their ETC02 is bellow a certain number (7? 5?, something like that. Either way 0 is less that that threshold). So that tube doesn't really matter in that case. 

If the truth is number 3, clearly the tube should get pulled. 

If it's number 2, ideally there should be another monitor available (ie the condition boss's) that can be tried. 

Given the reduction of importance of intubation in ACLS, it worries me a little if a lot of time and effort on the code are being spent trouble shooting this tube. In the ER if there is bad CO2 we pull the tube, even if their are good breath sounds. 

If I were a medical director, thinking on a system level, it would make me a little nervous keeping a tube in with a C02 of 0. I'm sure you and your partner are very good medics, but there are a lot of guys out there who are just over the competency line and who I could see arguing that they are sure a tube is in, when it in fact isn't. I think I'd rather have 10 or even 20 tubes taken out that were really in, rather than have 1 patient transported with an esophegeal tube. 

Final thought is if you have a 3rd C02 line, blowing into the monitor during the code to confirm that it isn't a monitor problem, and documenting that on your run form so if someone looks at the strip they don't think there was ROSC. If you did that during the call you know it's not the line and it's not the monitor, so you are left with options 1 and 3. Either way leaving the tube in doesn't help the patient, and if 3 it will hurt them.

How did the patient do?


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## NYMedic828 (Feb 11, 2012)

zmedic said:


> I guess you can look at it from the other side. If your three explanations are
> 
> 1: Patient's dead
> 2: Monitor failure
> ...



Pretty cool to now there is an NYC ER Doc on the board.

The patient had Gastric cancer, and the circumstances by which he was given to us, were very sketchy and brought up many questions. 

That aside, the ER did manage ROSC, but it was short lived if even half an hour.

I took the monitor back and tested it after the call to ensure it could stay in service. I honestly think the ETC02 was in fact 0 it is the only thing that makes sense.

The patient was extremely malnourished and had next to no body fat, even without visualizing/auscultation, you could tell by seeing all of his intercostals evenly rising.

It was honestly a terrible day for intubations. We had a second arrest following the first, who aspirated his entire breakfast into his trachea. His throat was filled up with fluid above the level of the glottis. After suctioning the heck out of him during CPR, I get the tube in only to find a fireman has moved the tape I needed to secure it. I make the mistake of letting go of the tube and no sooner does the BLS crew rip it out by mistake in an attempt to ventilate. (got it back in with some more suctioning, had to suction the tube almost immediately after as well it was so full of vomitus)

Like you said, the ET tube seems to hurt us a significant amount of the time depending on the competency of the provider. I volunteer as well here and in my county we have mostly "Critical-Care Techs" which are able to do everything a paramedic can, but have to contact medical control for approval for just about anything but D50, routine IV and cardiac arrest procedures. Most "CCs" have never and will never intubate a real human being.

I wasn't there but was informed of an arrest we had, in which 4 people on the crew attempted to obtain an ET tube, and failed rather than realize the need to just use a combitube and focus on quality CPR. (they rolled into the ER with no airway maintenance device to my understanding)


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## systemet (Feb 11, 2012)

NYMedic828 said:


> The patient had Gastric cancer, and the circumstances by which he was given to us, were very sketchy and brought up many questions.



Is it possible that he exsanguinated into the abdomen? This might explain no PETCO2.


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## NYMedic828 (Feb 11, 2012)

systemet said:


> Is it possible that he exsanguinated into the abdomen? This might explain no PETCO2.



There was no distension or anything that would suggest it, but the patient as I stated was extremely malnourished so his fluid volume was probably not too fantastic to begin with. (The poor guy was basically a walking ribcage)

I never followed up on the patient past if the ER agreed the tube was viable or not. I tried finding the doc later but they changed shifts.


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## Veneficus (Feb 11, 2012)

NYMedic828 said:


> The patient had Gastric cancer, and the circumstances by which he was given to us, were very sketchy and brought up many questions.
> 
> That aside, the ER did manage ROSC, but it was short lived if even half an hour.
> 
> ...



A cancer pt in a catabolic state who arrests?

This guy was dead before you got there.

I am amazed he wasn't a DNR and even more so the ED chose to work him.


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## NYMedic828 (Feb 11, 2012)

Veneficus said:


> A cancer pt in a catabolic state who arrests?
> 
> This guy was dead before you got there.
> 
> I am amazed he wasn't a DNR and even more so the ED chose to work him.



Thats where the sketchyness came in.

We pulled up to the PD BLS unit doing CPR in front of the entrance to the airport. (the cop was actually a medic working BLS) 

The story was, this guy is with his relative (some guy, barely spoke english) and went "unconscious" so he pulls into the airport and calls for help and PD gets there, calls the arrest.

So we pull up, move him out of the crowd of people into our ambulance and in NYC, once resuscitation has been initiated it must be continued regardless of findings unless discontinued by a physician.

He was cold to the touch, but he was outside in winter for who knows how long before help arrived. We also have no idea whether or not this guy was a fresh arrest, which we highly doubted or if he was down in this guys car for who knows how long. 

So long story somewhat short, we ran the arrest because we knew the medical director would not tell us to call it on the basis of it potentially being fresh and we were already at the ambulance, why leave a body in the public eye.

As far as a DNR goes, we assumed he had to have one in his state, but it wasn't present on-scene so that was out the window.




The second arrest was actually an end-stage cancer patient as well. (Pancreatic) He had the same malnourished body but he ate breakfast, went to bed, 30 min later was in arrest. He was acidoditic at 58 if i recall for initial ETC02, we got rosc on him after 3 shocks and some meds but he was short lived as well. No DNR because of his selfish wife who would rather him suffer than to lose him peacefully.


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## cruiseforever (Feb 11, 2012)

Veneficus said:


> A cancer pt in a catabolic state who arrests?
> 
> This guy was dead before you got there.
> 
> I am amazed he wasn't a DNR and even more so the ED chose to work him.




His Dr. was too scared to bring up the subject.


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## Veneficus (Feb 12, 2012)

cruiseforever said:


> His Dr. was too scared to bring up the subject.



Then he/she is not a doctor, just somebody with a medical degree.
(there is a world of difference)


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## Veneficus (Feb 12, 2012)

NYMedic828 said:


> in NYC, once resuscitation has been initiated it must be continued regardless of findings unless discontinued by a physician..



That is unfortunate.



NYMedic828 said:


> we ran the arrest because we knew the medical director would not tell us to call it on the basis of it potentially being fresh..



I have no doubt you were doing the best you could in the care of this patient. 

A medical director who won't terminate efforts or give permission for such on an end stage cancer patient in arrest isn't really doing what is best for the patient. Probably just generating a bill or practicing resuscitation skills.


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## zmedic (Feb 12, 2012)

Veneficus; said:
			
		

> A medical director who won't terminate efforts or give permission for such on an end stage cancer patient in arrest isn't really doing what is best for the patient. Probably just generating a bill or practicing resuscitation skills.



People are throwing a lot of blanket statements out there, throwing the doc under the bus. Here is my 2 cents. 

1: Pronouncing people over the phone is difficult. There are patients who I might stop working in the ER who I would feel less comfortable doing so over the phone. If someone called me and said they had an "end stage cancer patient who does not have a DNR" I immediately have some questions. Why don't they have a DNR? Is that because the family or the patient wanted aggressive treatment up until the end? Why was 911 called? If this was the expected demise of a cancer patient, clearly someone wasn't ready for that or they wouldn't have called 911. How do you know it's end stage? Do you know where in their treatment they were? How they were responding? 

Don't be so quick to judge an ER doc for not wanting to terminate the resus of a patient with viable rhythm based on third hand information (the medic telling me what the patient's family member is telling them their doctor said)

Now clearly if someone called in and said that patient was in asystole after 2 rounds of dugs fine, stop. Or if the family was saying stop. But if there is confusion about what is going on with a witnessed arrest I'd rather have them transported and sort it out in person. 

The other thing is the DNR. Yeah, people with end stage cancer should have one. But the truth is people tend to have agressive treatment till very very near the end. A lot of patients aren't ready for the discussion while they are still getting treatment that is aimed at cure. It's also a very hard discussion to have. One which we often start by feeling out where the patient is in their thinking. If they make clear they aren't receptive to having a DNR we don't push it. 

I'd recommend that those who think the doctor is just a wuss because their patient doesn't have a DNR should try having one of those discussions with a patient undergoing cancer treatment.


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## Veneficus (Feb 12, 2012)

zmedic said:


> People are throwing a lot of blanket statements out there, throwing the doc under the bus. Here is my 2 cents. .



I don't see it as throwing anyone under a bus. 

From the description given, it sounds like nobody even called the ED.

I have seen many times patients who should not have been worked in the ED get worked. For a variety of reasons over the years. Many of which came down to not understanding pathology or emotion.





zmedic said:


> 1: Pronouncing people over the phone is difficult. There are patients who I might stop working in the ER who I would feel less comfortable doing so over the phone. If someone called me and said they had an "end stage cancer patient who does not have a DNR" I immediately have some questions. Why don't they have a DNR? Is that because the family or the patient wanted aggressive treatment up until the end? Why was 911 called? If this was the expected demise of a cancer patient, clearly someone wasn't ready for that or they wouldn't have called 911 .



All very reasonable questions I think any doc would ask if called, but as I said, in this case, I do not see anywhere where a doc was called.




zmedic said:


> . How do you know it's end stage? Do you know where in their treatment they were? How they were responding?.



I focused in on the extremely emaciated state mentioned twice. In cancer, once a catabolic state is reached, it is terminal. Treatment is usually discontinued at that point for palliative measures. I think most oncologists will tell you though, once that statge is reached, any therapy is palliative.  



zmedic said:


> Don't be so quick to judge an ER doc for not wanting to terminate the resus of a patient with viable rhythm based on third hand information (the medic telling me what the patient's family member is telling them their doctor said)



I am judging a decision on a call that doesn't seem made. I think you are right, if a field provider did call, a plethora of questions need to be answered to a satisfactory level. 

But having said that, once the doc laid eyes on the pt. a rhthym is not the only deciding factor in a resuscitative effort. I have seen my fair share of pts in a unit who were basically Frankenstein's monster on a vent with multiple pressors, an IABP, paraenteral nutrition, and hemofiltration who were never going home. (including end stage cancer patients)



zmedic said:


> Now clearly if someone called in and said that patient was in asystole after 2 rounds of dugs fine, stop. Or if the family was saying stop. But if there is confusion about what is going on with a witnessed arrest I'd rather have them transported and sort it out in person.



Seems very reasonable.



zmedic said:


> The other thing is the DNR. Yeah, people with end stage cancer should have one. But the truth is people tend to have agressive treatment till very very near the end. A lot of patients aren't ready for the discussion while they are still getting treatment that is aimed at cure..



Just because a patient is getting treatment does not excuse the discussion of prognosis. Some patients refuse to have that conversation, I understand, but intentially not talking about likely outcome or even offering, seems a bit like avoidance to me. 

If a patient wants to avoid that's one thing, but a doctor? C'mon. 



zmedic said:


> It's also a very hard discussion to have. One which we often start by feeling out where the patient is in their thinking. If they make clear they aren't receptive to having a DNR we don't push it.



I have no sympathy for doctors who are too emotional for the medicine they practice. If discussions or decisions are too difficult, find another job.

As for pushing DNRs, I am not suggesting pushing them, but I have found how you approach the subject plays a large role in how receptive patients are. I would wager that many patients aren't ready to talk about thier end. But initiating an attempt at that discussion is still the responsibility of the doctor.



zmedic said:


> I'd recommend that those who think the doctor is just a wuss because their patient doesn't have a DNR should try having one of those discussions with a patient undergoing cancer treatment.



I never suggested the doctor was a wuss because the pt doesn't have a DNR. The patient may have refused one.

Based on the comment about the doctor not discussing one, I question whether or not it was because of how the patient felt or if the doctor was shielding himself.



zmedic said:


> try having one of those discussions with a patient undergoing cancer treatment.



I have. On a handful of occasions. Including one patient who is a physician. Perhaps I am just a cold hearted :censored::censored::censored::censored::censored::censored::censored:, but I do not find it any more or less difficult than many other aspects of patient care.

(I suspect though it is a combination of my desensitization and way too much pathophysiology.)


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## zmedic (Feb 12, 2012)

The wuss comment was in response to: "his Dr. was too scared to bring up the subject." I don't know what the situation was in that case. But I think everyone here should realize that they shouldn't be judging someone else as incompetent without having all the information. Sure there are cases when DNR should have been discussed but it wasn't. But lack of DNR + patient with cancer does not =incompetence. 

As to it being "too emotional for doctors," I agree, that isn't a reason not to have the conversation. But rather that there are situations where bringing up a DNR comes across as we are giving up on the person. I have seen the opposite approach which is that DNR is discussed with ever single patient. Makes it easier not have to decide who to talk to about it, but I think it creates uneeded problems with those healthy 50 year olds who are like, "I'm here because I have pneumonia, what are you talking about?" 

I agree  that there should be goals of care discussions. But if the goal is to cure that patient DNR isn't really appropriate. You shouldn't be doing agressive chemo or surgery on someone and discussing DNR. Actually DNRs are automatically invalidated if the person is having surgery. Found that out the other day on anesthesia. If the case being done and the code they are worked. No DNR in the OR. I guess the thinking is if they are comfort care only you wouldn't be doing surgery. Maybe so they don't add to the perioperative mortality stats. Don't know if I agree with that policy but it's interesting.


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## Veneficus (Feb 13, 2012)

zmedic said:


> But lack of DNR + patient with cancer does not =incompetence.



For certain. Like I said, pt could have refused. 



zmedic said:


> As to it being "too emotional for doctors," I agree, that isn't a reason not to have the conversation. But rather that there are situations where bringing up a DNR comes across as we are giving up on the person. I have seen the opposite approach which is that DNR is discussed with ever single patient. Makes it easier not have to decide who to talk to about it, but I think it creates uneeded problems with those healthy 50 year olds who are like, "I'm here because I have pneumonia, what are you talking about?"



I think that this is probably an over reaction from doctors not discussing DNRs when appropriate. Just like everything else, there are probably 1 or 2 incidents in question and a blanket policy is made to try to correct it after the fact.

Personally, I like more targeted intervention than blanket policy.  



zmedic said:


> I agree  that there should be goals of care discussions. But if the goal is to cure that patient DNR isn't really appropriate. You shouldn't be doing agressive chemo or surgery on someone and discussing DNR.



I respectfully disagree with this statement. 

In some cases, particularly in stage iv malignancies, the cancer was likely discovered too late for a high probability of curative interventon. It is my opinion that the full course of the disease and prognosis with and without treatment be discussed. 

It was 4 years ago almost, but I saw a palliative care study that showed people who fight and people who deny serious illness as psychological protection usually have about the same length of survival. With depressed patients less. So I can see your point. 

However, having said that, if you are not looking at a case where the stars are lining up so, I think the DNR discussion needs to come early. Perhaps with the aid of social, family, and relious support if viable.



zmedic said:


> Actually DNRs are automatically invalidated if the person is having surgery. Found that out the other day on anesthesia. If the case being done and the code they are worked. No DNR in the OR. I guess the thinking is if they are comfort care only you wouldn't be doing surgery. Maybe so they don't add to the perioperative mortality stats. Don't know if I agree with that policy but it's interesting.



I think there is a bit more to this than what is explained here.

If a person is compensating for any disease and is taken to surgery, with the exceptions of massive injury or catastrophic illness (like a ruptured aneurysm, which I argue is an injury but that is a topic for another time) then unless something went wrong, should be perfectly capable of being resuscitated to their pre-surgical state. An arrest in surgery, whether induced or as a complication is likely reversible.

But if I could point out, there are palliative surgeries for cancer. Examples include reduction of a painful mass, or helping to relieve an airway obstructing tumor.(like bronchogenic carcinoma) These patients are told prior to surgery that the surgery will not cure their disease.

I have not yet met a surgeon who would provide paliative surgery when a tumor had infiltrated a great vessle though.


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## Basermedic159 (Feb 20, 2012)

HMartinho said:


> As we all know, since the EMT-B's to EMT-P's, the interruption of chest compressions to ventilate the patient (according to the recommendation of 30:2), drastically decreases the coronary perfusion pressure, seriously decreasing the survival probability of the patient.
> We also know that the only way to vent without interrupting cardiac compressions is to ensure an advanced airway (encontraqueal tube, laryngeal mask or Combitube). So why ILS or ALS teams, when identify cardiac arrest, the first approach is not to proceed with endotracheal intubation, or placement of the laryngeal mask?
> In Portugal, we use the recommendations from the American Heart Association, and we have our protocols with specific actions, as I think which happens in the U.S..
> 
> I accepted suggestions, approaches, and everything you find relevant to this discussion.



For a BIAD I like the King Airway. Do you have kings or just combitubes?


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## Medic Tim (Feb 20, 2012)

I am a fan of the king airway.


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## HMartinho (Feb 22, 2012)

Basermedic159 said:


> For a BIAD I like the King Airway. Do you have kings or just combitubes?



In our ILS units, where I work with my nurse partner, we have ET tubes, LMA's and combitubes.

Kings are not usual here.


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