# How did you learn to intubate?



## newEMT (May 7, 2012)

So, I'm not a paramedic. I'm a 3rd year med student who just started my anesthesia rotation. Up to this point, I've been intubating plastic heads with no body. Today, they let me try to intubate a real patient. 

I started by opening their mouth with the scissor technique. I slid the largynoscope in, but I couldn't get past the tip of their tongue because the handle was hitting their chest. I didn't want to crank back and break all of their teeth. I stood there thinking for a second because this was the first time my "patient" actually had a torso. In hindsight, I should have just extended their head more. The resident didn't offer any pointers. Instead, she took over and did the intubation. She told me just to watch. Then, she spent 10 minutes telling me that it's not important for me to learn how to intubate. She told me just to watch for now on. So, there went my first and last chance to intubate. 

My question is how do paramedics learn to intubate and do you have any pointers for me? I probably won't get to intubate again until I'm an emergency medicine resident. But, I still want to know.


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## Aidey (May 7, 2012)

Don't pull back, push up away from you. If the handle was on their chest your positioning was WAY off. A good starting point is for the angle of the handle to be in line with their nose.

And we learn to intubate the same way. With a plastic head and then on real people. Once you get the technique down it isn't that difficult. 

If you have some adventurous friends you can always practice the technique on a real person. Just find someone who lacks a gag reflex or use some Lido throat spray. You obviously can't actually intubate them, but you can get familiar with visualizing the cords.


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## terrible one (May 7, 2012)

YouTube might help show you some pointers. The handle should never come close to touching the chest, not sure how you pulled that off?


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## newEMT (May 7, 2012)

I think their head was too flexed and I couldn't even get the blade past the tip of their tongue because the handle was on their chest. Similar to pic below. 

http://utenti.unife.it/giampaolo.garani/Trauma/Trauma-Ped/Fig-caso/intubate.jpg


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## Aidey (May 7, 2012)

Flexion may have been an issue, but once you slide the blade in using that position you have to push up and away if you want to see anything. Not pull back.


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## newEMT (May 7, 2012)

Aidey said:


> Flexion may have been an issue, but once you slide the blade in using that position you have to push up and away if you want to see anything. Not pull back.



Yeah, I never pulled back. I was very conscious of the teeth. I never got past the tip of the tongue. I just stopped because I didn't know what to do. And, they immediately took it out of my hands and did it for me. I didn't mind that, but being told to "watch" for the rest of the rotation because I couldn't do it on my first attempt sucks. It's not like I injured the patient :sad:


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## Aidey (May 7, 2012)

Anesthesiologists are a difficult group I've found. When I did my OR time to practice intubating only one of the 5 or 6 supervising us was truly helpful. One insisted we know all the doses for all the anesthesia drugs before we could intubate. Not just the drugs commonly used in by paramedics, all of them. 

Your best bet may be to watch YouTube videos, and see if you can do another shift and try again. The ED is not the best environment to learn in because everything tends to be rushed and hectic. 

Some of the ED docs here let us intubate if they know us (we need a minimum number of tubes a year for our certs). Excluding the patients that are dead, a lot of the time the pt is getting Intubated prior to going for a CT or MRI because they are a potential CVA or head injury. The docs want them tubed and gone ASAP. With the impending respiratory failure patients things aren't quite as rushed, but then you have to worry about RT taking over.


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## NYMedic828 (May 7, 2012)

When I went for my first incubation on a real patient I made the same mistake of being too gentle.

Extend their neck first. Be gentle, but make sure you actually extend it. You aren't going to break their neck it is meant to bend.

You really need to scissor their mouth open all the way. Your fingers will be spread pretty far apart if you extended the jaw far enough.

Insert the blade sort of riding on the tongue until you feel it is in the velecula. (this takes a couple times to get a feel for)

At that point, lift up. Don't change the angle of your blade.

The best thing about being in the hospital, is you can get your head at the level of the patient to get a great view. On a stretcher or a floor in a house you don't get this privilege and sometimes may not be able tell for sure if the tube went through the cords until you confirm it.


Side note, I found almost every anesthesiologist where I did my rotations to be stuck up :censored::censored::censored::censored::censored::censored::censored::censored:s. None of them were American either so I could barely understand them. The nicest person there was the CRNA who I did my best to cling to and ask questions.


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## MSDeltaFlt (May 7, 2012)

I learned as a staff respiratory therapist that took detailed in-service and got checked off by nurse anesthetist in surgery.  Very hands on and patient CRNA who had to deal with a nervous kid who was scared to death.


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## NomadicMedic (May 7, 2012)

I learned by doing HUNDREDS on a series of plastic heads. 

Then I went to the OR and did a bunch with a CRNA and an Anesthesiologist. I learned a LOT from both of them. They enjoyed teaching and let me have lots of time to learn, ask questions and practice. From what I understand, that's very rare in the OR and I feel truly lucky to have had such a positive experience.

I also take advanced airway labs whenever possible. The ShockTrauma cadaver lab is excellent. I visit the OR at least twice a year and spend a day with the CRNAs dropping tubes and LMAs. 

And I get more than a few in the field. <_< 

And I’m still only baseline competent. I feel that every tube is a learning experience and I know I'll never be nonchalant about intubation.


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## NYMedic828 (May 7, 2012)

On a side note, we have an anesthesiologist who just joined at my volly house to be an EMT. He is worthless.

He won't talk to patients on alarms and has no medical advice to share. He said he isn't comfortable talking to patients who are awake. He barely speaks English as well. 

I was excited to hear about his membership until I met him. Very disappointing.


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## EpiEMS (May 7, 2012)

NYMedic828 said:


> He said he isn't comfortable talking to patients who are awake.



h34r:


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## jjesusfreak01 (May 7, 2012)

EpiEMS said:


> h34r:



Hey, could be worse...they could have gotten a pathologist...you know where i'm going with that.


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## EpiEMS (May 7, 2012)

jjesusfreak01 said:


> Hey, could be worse...they could have gotten a pathologist...you know where i'm going with that.



Haha! Or a colorectal surgeon..."I can only talk to patients with my finger in their arse."


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## ah2388 (May 7, 2012)

It sounds as though you're kind of down about this experience.

The skill will come, dont sweat it.

I'd suggest giving it another shot, possibly with a CRNA or different resident.


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## triemal04 (May 7, 2012)

newEMT said:


> I started by opening their mouth with the scissor technique. I slid the largynoscope in, but *I couldn't get past the tip of their tongue because the handle was hitting their chest*. I didn't want to crank back and break all of their teeth. I stood there thinking for a second because this was the first time my "patient" actually had a torso. *In hindsight, I should have just extended their head more*. The resident didn't offer any pointers. Instead, she took over and did the intubation. She told me just to watch. Then, she spent 10 minutes telling me that it's not important for me to learn how to intubate. She told me just to watch for now on. So, there went my first and last chance to intubate.
> 
> My question is how do paramedics learn to intubate and do you have any pointers for me? I probably won't get to intubate again until I'm an emergency medicine resident. But, I still want to know.


That'll sometimes happen.  Usually due to poor positioning, but it can happen with obese patient's as well.  Since this was in the OR I'm guessing there was either a doughnut under the head or some other type of padding to extend the head, so you probably just needed to flex the neck more.  Not to much though, and remember it's head extension + neck flexion, not just one.  It may not have helped in this situation, but once you have the blade (macintosh) mostly inserted you can put your right hand under the occiput and help manipulate the head.  Does wonders for your view.

If you are shooting for a specialty where you will be expected to intubate patients, then you should try and get practise now.  Next time you're there talk to the resident about how they intubate, why they do it like that, what makes it harder/easier, common problems, how to overcome them, common mistakes that are made and how to avoid them and the like.  The vast majority of residents that I've met are willing to teach, if you show an interest, don't act like a ****, and approach them at the right time ie not in the middle of a :censored::censored::censored::censored:ty intubation or crashing patient.

To answer your last question, most paramedics don't learn how to intubate, not at anything approaching competancy anyway.  It's a lot of the reason why the success rate is so dismal.  (but not the only reason)


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## Aidey (May 7, 2012)

This conversation reminds me of a code that was worked in one of the local hospitals. Code blue is called for a room on the general med/surg floor and the code team goes running. The NEPHROLOGIST visiting a patient next door had the patient intubated by the time the code team doc got there. He said that he was used to sticking tubes into little holes and it wasn't all that different.:blink:


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## NYMedic828 (May 7, 2012)

triemal04 said:


> To answer your last question, most paramedics don't learn how to intubate, not at anything approaching competancy anyway.  It's a lot of the reason why the success rate is so dismal.  (but not the only reason)



:unsure:

My program was pretty in depth on intubation. Our pulmonology portion was taught by our medical director which was nice of him to come in for. (very well respected EM doc. Hardass though)

We did some other stuff like intubating patients "tomahawk" style in a car or upside down and whatnot but obviously haven't done that on too many live ones. -_-

Think I did 5 or 6 tubes in the OR? Our success rates on my unit seem to be around 90% if i had to guess a number. I can't vouch for the rest of NYC but we do a few arrests a month per shift.


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## EpiEMS (May 7, 2012)

NYMedic828 said:


> We did some other stuff like intubating patients "tomahawk" style in a car or upside down and whatnot but obviously haven't done that on too many live ones. -_-



Woah. That's pretty darn cool. The medic I was working with today lay prone to tube somebody –:censored:hadn't seen that before, and that was pretty boss, so I can't imagine how awesome upside down intubation would be!

Speaking as a BLS fellow, how do you want us BLS'ers to help when you're tubing a patient, beyond pre-oxygenation? Sellick's?


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## Aidey (May 7, 2012)

Really? If the person is on the floor or ground I usually lie prone to intubate them. It is much easier than kneeling. I once had to lie under a bed to tube a guy because the room was too small for me to lay anywhere else and there was no where else to move him.


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## NYMedic828 (May 7, 2012)

EpiEMS said:


> Woah. That's pretty darn cool. The medic I was working with today lay prone to tube somebody –:censored:hadn't seen that before, and that was pretty boss, so I can't imagine how awesome upside down intubation would be!
> 
> Speaking as a BLS fellow, how do you want us BLS'ers to help when you're tubing a patient, beyond pre-oxygenation? Sellick's?



Prone is a pretty common occurrence all over the place. As far as upside down goes we strapped a manikin to the bottom of a table its not as cool as it sounds on a dummy lol.

We usually put the patient on the floor immediately if it hasn't been done already before we get there. I usually get on my knees and hope to have a decent enough view before I attempt to kiss the floor of a project apartment.

As far as helping, continue CPR to the best of your abilities because that is all that really matters.


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## triemal04 (May 7, 2012)

NYMedic828 said:


> :unsure:
> 
> My program was pretty in depth on intubation. Our pulmonology portion was taught by our medical director which was nice of him to come in for. (very well respected EM doc. Hardass though)
> 
> ...


So you think that the average paramedic is truly proficient at intubating?  (notice, that like when I said "most" in my previous post I said "average" here)  I'm not pointing any fingers at anybody so don't get upset, but, like it or not, taken as a whole EMS sucks at intubation.  Even ignoring studies done in southern Cali or Florida where everybody and their brother is a paramedic, intubation is not something that most (that word again) paramedics can say they are truly proficient at.  Yes, there are notable exceptions to that.

You say your service does a few arrests a month.  How many times a month is your average paramedic intubating?  How often are they getting success on the first pass?  How often are they able to intubate with absolutely zero interruption in compression?  How often is there ANY trauma inflicted during the attempt? (that means even a small, small smear of blood on the blade)  There's more to ask than that, but you get the picture.  

You say you had an EM doc teach you pulmonology...great.  No sarcasm, I mean that.  How many schools do you think have a doctor taking active involvement in teaching?  How much went into specifically teaching you how to intubate?  How long did you spend in the OR to initially learn?  How often are you intubating each year?  How often are you having to use an adjunct of any kind to successfuly intubate?  And the other questions I asked above.  Like I said, there are plenty of exceptions to what I've said, but on average most paramedics don't intubate very often, and, given that many schools don't send students to the OR, never learned very well in the first place.  Hell, one prolific poster here recently said something along the lines of it being several monthes since their last tube...nationally, do you think that's uncommon?

I'm not saying any of this to get into a pissing match, just to be honest.  Really, it's a damn shame, especially since there is starting to be more info that indicates that intubation, _if done properly by a competant provider _is beneficial.

I'm also not saying any of this to mean that I'm the :censored::censored::censored::censored: when it comes to intubation.  I've got to a acceptable level of skill only, and hopefully will be able to maintain that throughout my career.


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## Handsome Robb (May 8, 2012)

Take my advice with a grain of salt. I've intubated one live patient and that was a 19 month old cardiac arrest and that was sitting in the airway chair in the box so I was able to really set myself up how I wanted to and had excellent lighting. 

****Set yourself up for success.****

Get everything you will or might need all set up organized. Position the patient, pad behind their shoulders and extend their neck. Once you've got that done get your scope and do it just like you've been taught. Once you visualize the cords *don't* take your eyes off them, ask the person next to you to hand you the tube you want while you keep your eyes on the cords. Watch the tube pass, listen to confirm, get the capnography going, secure the tube, re-check your placement, pass bagging off, *do the funky chicken dance*.

The last step is the key step.


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## DrParasite (May 8, 2012)

Aidey said:


> If you have some adventurous friends you can always practice the technique on a real person. Just find someone who lacks a gag reflex


I knew a couple of girls in college like this....


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## Sasha (May 8, 2012)

NVRob said:


> Take my advice with a grain of salt. I've intubated one live patient and that was a 19 month old cardiac arrest and that was sitting in the airway chair in the box so I was able to really set myself up how I wanted to and had excellent lighting.
> 
> ****Set yourself up for success.****
> 
> ...



I prefer to walk it out after. The funky chicken dance is old AHA standards. 

Although i have read some of the more advanced system do the Cupid shuffle afterwards.


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## NomadicMedic (May 8, 2012)

I knew I needed to get the Cupid Shuffle  added to our protocols! 

Ours still say, "...consider the Macarena"


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## Sasha (May 8, 2012)

n7lxi said:


> I knew I needed to get the Cupid Shuffle  added to our protocols!
> 
> Ours still say, "...consider the Macarena"



Holy ancient protocols Batman!


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## Veneficus (May 8, 2012)

NYMedic828 said:


> Prone is a pretty common occurrence all over the place. As far as upside down goes we strapped a manikin to the bottom of a table its not as cool as it sounds on a dummy lol.
> 
> We usually put the patient on the floor immediately if it hasn't been done already before we get there. I usually get on my knees and hope to have a decent enough view before I attempt to kiss the floor of a project apartment.
> 
> As far as helping, continue CPR to the best of your abilities because that is all that really matters.



I used to play all those games of contorted positions, etc. Then a much experienced paramedic gave me the secret...

Just bag them until you put them on the stretcher, then either raise the head 30 degrees or the stretcher to the level you like.

If you end up not transporting, just put them back on the floor.

Work smarter not harder.


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## EpiEMS (May 8, 2012)

Aidey said:


> Really? If the person is on the floor or ground I usually lie prone to intubate them. It is much easier than kneeling. I once had to lie under a bed to tube a guy because the room was too small for me to lay anywhere else and there was no where else to move him.



First live tube I've seen outside of an OR, so anything qualified as cool 




NYMedic828 said:


> As far as helping, continue CPR to the best of your abilities because that is all that really matters.



Yeah, that makes sense. I just want to be sure I'm being as useful to ALS providers as I can possibly be.


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## NYMedic828 (May 8, 2012)

Veneficus said:


> I used to play all those games of contorted positions, etc. Then a much experienced paramedic gave me the secret...
> 
> Just bag them until you put them on the stretcher, then either raise the head 30 degrees or the stretcher to the level you like.
> 
> ...



Never thought about that, but we usually don't have stretcher access to the room and most times we don't end up transporting unless we get a pulse back.

We usually need to use the bedsheets or a scoop to carry the patient to the hallway and on the stretcher.


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## Aidey (May 8, 2012)

^^^ Exactly. The call where I was under the bed was on the third floor of a house. No way in heck we were going to carry him down unless we got a pulse back.


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## BLS Systems Limited (May 8, 2012)

As a Respiratory Therapist, I found success by placing a towel under the head, raising it slightly.  Of course you wouldn't do this for head/neck trauma, but it works far, far better than tilting the head.  For the older ones in the crowd, it was called the "morning sniff" position, or one that would resemble a Thurston Howell III jaw jut.  Slide the scope in until the tip hits the valecula and have the handle pointing towards the join between the wall and the ceiling.  Lift in the direction of the handle and definitely don't tilt backwards.  When done properly, physics wins as I have seen very petite anaesthesiologists tube very large heads.


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## NomadicMedic (May 8, 2012)

It's a simple matter of aligning the three airway axes. Between padding and manual manipulation you can almost always see something.


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## Christopher (May 8, 2012)

BLS Systems Limited said:


> Slide the scope in until the tip hits the valecula...



I think this is the step that both novice and seasoned intubators struggle with, mostly because while they know what it is and where it is, they aren't proficient at getting there consistently.

The only way to do this consistently is to have a methodical approach, based on identification of the epiglottis and arytenoids (posterior cartilage).


Insert the blade midline and walk down the tongue, identifying structures, until the epiglottis comes into view
Slide the blade (Mac) to the right of midline to place the tongue on the left hand side of the flange (a Miller blade requires a different technique)
Once the epiglottis is visible, advance the tip of the blade forward until the epiglottis lifts itself from the posterior pharyngeal wall
At this point, if the epiglottis is not mobile you may need to provide external laryngeal manipulation in order to seat the tip in the valecula
Once the epiglottis is mobile--with respect to the tip of the blade--you lift the handle outward until you can identify the arytenoids

*Identification of the epiglottis and arytenoids are key, as these provide the inferior and superior boundaries of the glottic opening.*


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## Veneficus (May 8, 2012)

Aidey said:


> ^^^ Exactly. The call where I was under the bed was on the third floor of a house. No way in heck we were going to carry him down unless we got a pulse back.



Not being smart, but to the best of my memory, not once has intubation made a difference on whether or not a pulse was regained.

Just figured I would pass on the wisdom given to me by somebody who saved me one or two uniforms, strained muscles, and the station from more than a few roach infestations.


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## Aidey (May 8, 2012)

Unfortunately some of the docs around here are hesitant to let you call it unless the pt has been intubated. Don't ask me why. It is a pain in the arse when you have to transport just because the pt isn't tubed.


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## Veneficus (May 8, 2012)

Aidey said:


> Unfortunately some of the docs around here are hesitant to let you call it unless the pt has been intubated. Don't ask me why. It is a pain in the arse when you have to transport just because the pt isn't tubed.



Yea, that is rather common everywhere.

I think somebody at some time thought it was the only way to prove that the patient didn't have an airway obstruction and/or nonreversible hypoxia. 

Unfortunately it probably came out about the time as many other EMS practices and is forever enshrined in undisputable practice.

I wonder how anyone was pronounced dead prior to the invention of the battery powered laryngoscope?

"The patient is not dead until digitally intubated or surgically criced."


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## DrParasite (May 8, 2012)

so tube them.  why not?  unless they are obviously dead on onset, what is the downside to intubating a person in cardiac arrest?

people always say paramedics don't get enough intubations in order to maintain proficiency.  it's a clinical skill, one that has legitimate use in cardiac arrest patients.   and if the doc wants him pronounced, than just leave him on scene.

on an unrelated note, I once removed a patient (who was an intubated cardiac arrest) using the bedsheet, and carried him out about 6 feet to the stretcher waiting outside.  About 2 hours later, after the call was completed, I was called into the boss's office (paramedic who jumped the call because, well, he could), who said to never do that, since it can dislodge the tube, and to always use a reeves, backboard or scoop to maintain a neutral position.


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## Aidey (May 9, 2012)

We are almost required to put a c-collar on all intubated patients to prevent excessive neck movement. It isn't actually required, but it is so strongly recommended that if you have a pattern of not doing it you will get talked to.


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## medicsb (May 9, 2012)

DrParasite said:


> so tube them.  why not?  unless they are obviously dead on onset, what is the downside to intubating a person in cardiac arrest?
> 
> people always say paramedics don't get enough intubations in order to maintain proficiency.  it's a clinical skill, one that has legitimate use in cardiac arrest patients.   and if the doc wants him pronounced, than just leave him on scene.
> QUOTE]
> ...


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## EpiEMS (May 9, 2012)

I've gradually begun to think that medics shouldn't have more than 1 tube attempt for an arrest –if it's no good on the first try, throw in a BiAD, and let compressions continue. Compressions > ventilations, after all.

Interesting link: http://www.jems.com/article/patient-care/study-analyzes-use-eti-vs-king-lt-ds-car

I couldn't get access to the original study, but the basics are at that link. I'd like to see how survival rates compared, accounting for differences in rhythms.


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## Veneficus (May 9, 2012)

In my opinion chest compressions should never be interrupted for ETI. 

Either you can do it with chest compressions or it is time to ventilate by other means. (alternative airway, etc.)


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## EMSpursuit (May 9, 2012)

I think most times CPR should not be interrupted but some difficult intubation's stopping for 5-10 seconds is needed....


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## EpiEMS (May 9, 2012)

EMSpursuit said:


> I think most times CPR should not be interrupted but some difficult intubation's stopping for 5-10 seconds is needed....



But you can get ventilations in without having to stop for an ETT...so why bother? Yes, the ETT is the gold standard airway, but Kings and Combitubes do nearly as well, and are much easier to successfully place.


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## Smash (May 9, 2012)

EpiEMS said:


> But you can get ventilations in without having to stop for an ETT...so why bother? Yes, the ETT is the gold standard airway, but Kings and Combitubes do nearly as well, and are much easier to successfully place.



They may not do nearly as well.  There is some interesting data coming out that extra-glottic airways may result in worse outcomes.

It really isn't difficult to intubate during an arrest without stopping CPR.  Get everything set up and pass the tube if you can whilst CPR is ongoing.  If you can't, wait for the brief pause that comes every 2 minutes and pass the tube then.  If you still can't, then just carry on with an alternative (or nothing at all)


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## EpiEMS (May 9, 2012)

Smash said:


> They may not do nearly as well.  There is some interesting data coming out that extra-glottic airways may result in worse outcomes.



Interesting! I'll keep an eye out for that, thanks!


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## Handsome Robb (May 9, 2012)

For what it's worth we don't intubate arrests unless its a pediatric and we have the option to stay with a bvm and opa for them. Adults get a KING LTD first line and intubation second line if the KING fails but I've never actually seen it fail. 

I'm waiting to see if we move away from the KING with the new research out about them.


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## EpiEMS (May 9, 2012)

NVRob said:


> I'm waiting to see if we move away from the KING with the new research out about them.



Found a couple studies that might be worthwhile to consider

"A Comparison of the King-LT to Endotracheal Intubation and Combitube in a Simulated Difficult Airway," Prehospital Emergency Care (2009)

  King LTs go in faster than the ETT and are successfully placed at a higher rate than ETTs.

(http://informahealthcare.com/doi/abs/10.1080/10903120701710488)

"The laryngeal tube device: a simple and timely adjunct to airway management," American Journal of Emergency Medicine (2007)

 Again, King LTs go in faster than the ETT (P < 0.0001). Also, among the paramedics, Kings are placed successfully significantly (P < 0.05) in higher percentage of trials than ETTs.

(http://ems.pgpic.com/pdf/kingairway_airway_management_independent.pdf)

"A pilot study of the King LT supralaryngeal airway use in a rural Iowa EMS system," International Journal of Emergency Medicine (2008)

 ETT insertion fails a lot. Kings are easy to use and insertion doesn't fail. Boom goes the dynamite.

(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657251/)


Additional thought: if the King LT was provided to Basics, we could be more useful to medics in an arrest situation – medics can handle meds and EKGs while BLS providers do A, B, and C.


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## DrParasite (May 9, 2012)

So why is the ETT the gold standard for airway maintenance, when the King is just as well as easier to us?


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## EpiEMS (May 9, 2012)

DrParasite said:


> So why is the ETT the gold standard for airway maintenance, when the King is just as well as easier to us?



I'm gonna ask an anesthesiologist next chance I get (no joke). 

Just a guess, maybe it provides better protection from the airway from stomach contents than the King does? Is that plausible?


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## Aidey (May 9, 2012)

In cardaic arrest I think it extends past pre-hospital and into the hospital where the pt will be put on the vent in the cath lab. Most RSI patients usually need some sort of immediate intervention also (surgery for trauma and CVA for example). I know at our hospitals the goals are to minimize time between initial pt contact by EMS and definitive care (cath lab/surgery). In some cases if we have the necessary interventions done we will bypass the ED and take the pt straight to the cath lab or to CT.


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## Pavehawk (May 10, 2012)

The gold standard of ETI has more to do with protecting the airway from aspiration. Look at some of the "uber airway" books and courses and you see the authors (Like Ron Walls.. et al) repeat that King, LMA, Combitube etc. do not secure the airway in the traditional sense and do not prevent aspiration.

I think the best thing that any prehospital provider can do is to evaluate the patient and choose the best intervention for the patient and the situation. The other tools in our airway bag should be mastered as well as the knowledge of when to use them or not use them. 

Judgement is the best skill set a field provider can have.


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## Veneficus (May 10, 2012)

EpiEMS said:


> I'm gonna ask an anesthesiologist next chance I get (no joke).
> 
> Just a guess, maybe it provides better protection from the airway from stomach contents than the King does? Is that plausible?



Just my speculation, but I think that intubation being the most optimal airway for mechanical ventilation in the hospital, it was just assumed to be optimal outside the hospital. 

Which is more and more proving not to be the case.

Not least of which is because of the inability to remain proficent at a skill.


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