# Straight to advanced airway on code?



## lsmft (Oct 12, 2012)

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 (Oct 12, 2012)

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 (Oct 12, 2012)

lsmft said:


> 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 (Oct 12, 2012)

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 (Oct 12, 2012)

lsmft said:


> 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 (Oct 12, 2012)

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 (Oct 12, 2012)

emt.dan said:


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



And post-ROSC hypothermia!


----------



## lightsandsirens5 (Oct 12, 2012)

lsmft said:


> *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 (Oct 12, 2012)

Brandon Oto said:


> 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 (Oct 12, 2012)

lsmft said:


> 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 (Oct 12, 2012)

Brandon Oto said:


> 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 (Oct 12, 2012)

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 (Oct 12, 2012)

Brandon Oto said:


> 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 (Oct 12, 2012)

emt.dan said:


> 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 (Oct 12, 2012)

Brandon Oto said:


> 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 (Oct 12, 2012)

lsmft said:


> 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. )



lsmft said:


> 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 (Oct 12, 2012)

emt.dan said:


> 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 (Oct 12, 2012)

usalsfyre said:


> 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 (Oct 12, 2012)

emt.dan said:


> 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.



emt.dan said:


> 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.



emt.dan said:


> 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 (Oct 12, 2012)

lsmft said:


> 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.


----------



## usalsfyre (Oct 12, 2012)

lsmft said:


> 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.



Gas laws and diffusion young padawan, gas laws and diffusion...

This is why the people that told you "street smarts" were more important than "book smarts" were dead nuts wrong.


----------



## WestMetroMedic (Oct 15, 2012)

Here is my initial disclaimer.  
-i work for one of the centers pushing out research mentioned earlier.  One of the principles is my medical director.
-we have the Lucas2 fully deployed in all of our trucks.
-we run with two paramedics and work with primarily full time first response agencies (police and fire)

We have our first responders place a king airway after they start compressions.  After we arrive, we deal with the initial salvo of tasks to get an arrest rolling.  After that has subsided, and about ten minutes have elapsed, we remove the king and intricate the patient.  The Lucas2 never stops.  I have run 6 or 7 codes since we changed our practice early this year, and have had excellent results.  Intubating with consistent Lucas CPR is rather easy for this mediocre paramedic.  

It's all about compressions, but if you can manager the airway subordinate to the compressions, why not provide the best care you can.


----------



## mycrofft (Oct 15, 2012)

lsmft said:


> 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.



1. In a witnessed field code, immediately start compressions and defib, and get thee to a hospital. 
2. If that is being taken care of, Contestant #2 (no offense) will get an IV in and airway if possible.

All these studies...I'm not seeing satisfactory statistical control for three variables: transport time/distance; control of gastric distention/regurgitation; and etiology/presenting severity/length of time down before contact.


----------



## Frozennoodle (Oct 25, 2012)

emt.dan said:


> 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.




I'd argue that's due to the fact that providers are messing around trying to intubate and pausing compressions to do so.  The longer you wait the more time the heart has to reestablish some perfusion.  The flip side to that coin is that 30:2 is worse than continuous compressions so getting advanced airway placement also becomes a coronary profusion issue.  You also have a much harder time deploying a resQpod with straight BVM ventilations further reducing cardiac efficiency.  Anyways, yes prioritize and treat the etiology.  Also remember one of the reasons we insert an OPA/NPA is to confirm loss of a gag reflex before performing advanced airway interventions.


----------



## Frozennoodle (Oct 25, 2012)

WestMetroMedic said:


> Here is my initial disclaimer.
> -i work for one of the centers pushing out research mentioned earlier.  One of the principles is my medical director.
> -we have the Lucas2 fully deployed in all of our trucks.
> -we run with two paramedics and work with primarily full time first response agencies (police and fire)
> ...



I love this.


----------



## Brandon O (Oct 25, 2012)

Frozennoodle said:


> Also remember one of the reasons we insert an OPA/NPA is to confirm loss of a gag reflex before performing advanced airway interventions.



I am not sure if I am on board with this approach. An OPA can induce vomiting just as much as an ET tube; I would not advise sticking it places unless you're already pretty darn sure about a gag.


----------



## Frozennoodle (Oct 25, 2012)

Brandon Oto said:


> I am not sure if I am on board with this approach. An OPA can induce vomiting just as much as an ET tube; I would not advise sticking it places unless you're already pretty darn sure about a gag.



I don't mean for it to come across like I'm saying its like a CBG or ETCO2 as far as diagnostic equipment goes.  But if you think a pt lost a gag reflex and is otherwise unresponsive its easier to take an OPA out than a combi or king if you're wrong.


----------



## Brandon O (Oct 25, 2012)

Frozennoodle said:


> I don't mean for it to come across like I'm saying its like a CBG or ETCO2 as far as diagnostic equipment goes.  But if you think a pt lost a gag reflex and is otherwise unresponsive its easier to take an OPA out than a combi or king if you're wrong.



Fair enough. And we've probably all stuck one in there and had to do a "whoop, never mind" when we were wrong.


----------



## Akulahawk (Oct 25, 2012)

I'm of the opinion that I'd get going on compressions and electrical therapy in this scenario. It's a witnessed field arrest and I want to get some / keep some blood circulating before I start kicking the heart with some electricity. After a round or two, I'm going then consider getting airway equipment handy & hooked up ASAP. As to airway adjuncts, I'm going to likely use an OPA at first, then switch over to ETI as time and opportunity permits. If I have other options, I may consider using those instead of the ETI, but again, time/opportunity is a factor. I may have my partner stop the vehicle and come in the back to take over compressions while I do other things if necessary, and then resume transport.


----------



## RackCityEMT (Oct 27, 2012)

In our system if they code en route we will pull over to have that extra set of hands and if need be we will drop a king if we have time. Normally its just an OPA or NPA and a bag.


----------

