# Scope Expanded to Combitube



## AMF (Mar 7, 2011)

To the Paramedics who browse the BLS forum,
    EMTs in my area (Dallas) recently became able to use combitubes and ET Intubation (and maybe King's?).  Do you recommend learning these (I'm a student) or will paramedics mostly take care of this?  Also, do people in your profession have some sort of problem with EMTs performing advanced airway interventions?  Do you think it's something requires the basic-science background/high clinical exposure you must have?


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## usalsfyre (Mar 7, 2011)

AMF said:


> To the Paramedics who browse the BLS forum,
> EMTs in my area (Dallas) recently became able to use combitubes and ET Intubation (and maybe King's?).  Do you recommend learning these (I'm a student) or will paramedics mostly take care of this?  Also, do people in your profession have some sort of problem with EMTs performing advanced airway interventions?  Do you think it's something requires the basic-science background/high clinical exposure you must have?



opcorn:

Considering there's probably close to 100 ambulance services in the Metroplex, I highly doubt it's the whole area, unless theres a move afoot in the Texas EMS culture I don't know about.

To answer you original question, supraglotic airways are fine (think super OPA) but considering how poor paramedics are at ET intubation, no, I don't think basics need to be anywhere near the business end of a laryngoscope. 

I really think though, based on the MASSIVE number of threads covering this...:nosoupfortroll:


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## AMF (Mar 7, 2011)

usalsfyre said:


> opcorn:
> 
> Considering there's probably close to 100 ambulance services in the Metroplex, I highly doubt it's the whole area, unless theres a move afoot in the Texas EMS culture I don't know about.
> 
> ...



I was not aware that his was a trolling topic.  And no, this is just Parkland IFT as far as I am aware.


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## Veneficus (Mar 7, 2011)

In a handful of places, I know basics can place supraglotic airways in arrest patients.

When I got my original EMT cert, the EOA was the standard arrest airway for EMT-Bs to use in an arrest.

Given the ease of use for combitubes, how bad could it really be to let somebody insert one in a dead person?

If you are working in IFT I suspect many of those patients are DNR or DNI, so they won't be used much anyway.


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## Firemanfred55 (Mar 7, 2011)

Combitubes are a great tool, don’t be in a rush to get sued.


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## TransportJockey (Mar 7, 2011)

I've been using combitubes as a basic since I was certified (in Jan 08 in NM). I know my service ot here in W. Tx our EMT-Bs are allowed to use MLAs.


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## Veneficus (Mar 7, 2011)

Firemanfred55 said:


> Combitubes are a great tool, don’t be in a rush to get sued.



get sued by who and for what?


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## STXmedic (Mar 7, 2011)

We don't have combitubes, but all the basics in our system are authorized to place Kings (which are currently on my **** list, along with some of the providers placing them)


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## usafmedic45 (Mar 7, 2011)

> Do you recommend learning these (I'm a student) or will paramedics mostly take care of this? Also, do people in your profession have some sort of problem with EMTs performing advanced airway interventions? Do you think it's something requires the basic-science background/high clinical exposure you must have?



Non-visualized airways (Combitube and King) aren't rocket science.  Any professional EMS provider should have it as an option (I was taught the Combitube as a first responder).

As for ETI....honestly I have reservations with letting paramedics intubate, let alone EMT-Bs.

You show me an EMS provider of any level with "the basic-science background/high clinical exposure you must have" and I'll show you someone who either came into the field with a lot of prior education or has gone beyond their EMS training.


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## usalsfyre (Mar 7, 2011)

PoeticInjustice said:


> We don't have combitubes, but all the basics in our system are authorized to place Kings (which are currently on my **** list, along with some of the providers placing them)



Care to elaborate? I'd rather a half-@ssed provider place a supraglotic device than muck up an intubation.


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## usafmedic45 (Mar 7, 2011)

> (which are currently on my **** list, along with some of the providers placing them)



Yeah, please elaborate.  



> I'd rather a half-@ssed provider place a supraglotic device than muck up an intubation.



....or trying to maintain an airway with an OPA or NPA and a BVM.


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## usalsfyre (Mar 7, 2011)

To clarify my earlier post, I think basics placing Kings, Combis and LMAs is fine. It kind of read like I thought they should be limited to OPAs, but what I meant are these devices are kinda like OPAs on steroids.

Now ET intubation...a good percentage of my paramedic coworkers don't need to be doing ETTs, I'll leave it at that.


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## Firemanfred55 (Mar 7, 2011)

Veneficus said:


> get sued by who and for what?


WOW! Joke made on the fact that the more you know and attempt the higher the liability.


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## Shishkabob (Mar 7, 2011)

AMF said:


> I was not aware that his was a trolling topic.  And no, this is just Parkland IFT as far as I am aware.



By "Parkland IFT", do you mean Parkland hospital?  They don't have their own IFT, and AMR holds the contract with Parkland.... and unless something changed recently, AMR wouldn't allow EMTs to do ETT, especially since the Medics don't get enough attempts at it themselves.


I'm fine with EMTs doing supraglottic airways... and while it's technically legal for EMTs to do ETT if their med control allows... I know of no place that allows it in the Metroplex.


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## Martyn (Mar 7, 2011)

We are taught OPA & NPA along with the combitube here I'm Florida


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## Handsome Robb (Mar 7, 2011)

I learned the Combitube as a B in Colorado. Then KING and ETT as an I in Nevada. But Washoe county doesn't allow I's to intubate, since the medics don't get enough tubes just like everyone else said.


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## fast65 (Mar 7, 2011)

Basics in Oregon are taught to use supraglottic airways, however, ETT is reserved for paramedics.

I am a bit unsure though, did the OP say that basics were actually being given the privilege to intubate?


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## AMF (Mar 7, 2011)

Yeah, it's actually part of the NREMT-B curriculum, I believe.


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## usafmedic45 (Mar 7, 2011)

AMF said:


> Yeah, it's actually part of the NREMT-B curriculum, I believe.



For all intents and purposes once you get past testing, the "national standards" and "curriculum" mean next to nothing.


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## fast65 (Mar 7, 2011)

AMF said:


> Yeah, it's actually part of the NREMT-B curriculum, I believe.



I think you're confusing ET intubation with the placement of supraglottic airways (i.e. Combitube or King)


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## Handsome Robb (Mar 7, 2011)

ETT is definitely not a BLS skill.


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## Shishkabob (Mar 7, 2011)

AMF said:


> Yeah, it's actually part of the NREMT-B curriculum, I believe.



Trust me, ETT is not an official skill / teaching point for ANY EMT-Basic program.

Your school may teach you so you know a bit more with what Paramedics do, but that's it.


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## bigbaldguy (Mar 8, 2011)

I was shown how to use a king tube at the outfit I volunteer with but I can't imagine a situation I would be called on to use it as all our trucks have a medic. The airline I work for has king tubes in the EMKs we have onboard for inflight Medicals so I guess there is a million to one chance it might come up on an aircraft but I just don't see it being very likely that I would ever do it while on the truck.


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## tao (Mar 8, 2011)

Non-visualized airways are okay for Basics, but something as complex as ETT should be left to medics.

However, if I recall correctly, ETT is technically part of the NREMT-B curriculum.  Heaven only knows why.


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## STXmedic (Mar 8, 2011)

usalsfyre said:


> Care to elaborate? I'd rather a half-@ssed provider place a supraglotic device than muck up an intubation.



In the last two months, one first responder attempted placing a King in a semi-conscious pt with an intact gag reflex 2/2 low O2 Sats; a second first responder on a separate call managed to attempt a size 5 King in a 5'2"ish patient and couldn't figure out why it was difficult to bag. "They have sizes?" As Ron White so elegantly put it, "You can't fix stupid."

As far as the King tube itself goes, the King LTS-D's wonderful feature of being able to suction the stomach to relieve pressure and limit emesis is great... assuming that you have a means to suction it. A portable hand-suction device is somewhat lacking in this area. What happens when you take fluid under mild pressure, then funnel it into a smaller opening from whence it came? All my firefighters should know this one! Hint: try placing your finger over a water hose... :glare:

By no means am I advocating that "half-@ssed providers" of any level attempt an ETT. I'd much rather show up on scene to find a patient with an OPA/NPA and being bagged, than some mediocre attempt at an advanced airway with a nice wavy or flat line on the EtCO2.


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## Shishkabob (Mar 8, 2011)

PoeticInjustice said:


> As far as the King tube itself goes, the King LTS-D's wonderful feature of being able to suction the stomach to relieve pressure and limit emesis is great... assuming that you have a means to suction it. A portable hand-suction device is somewhat lacking in this area.



We have NG/OG tubes


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## STXmedic (Mar 8, 2011)

Linuss said:


> We have NG/OG tubes



One of my services does, the other does not. Needless to say, it can be quite frustrating at times when working at the (much) more limited of the two.


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## Shishkabob (Mar 8, 2011)

If an agency has Paramedics, they should also have OG tubes... no reason not to.


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## STXmedic (Mar 8, 2011)

Preaching to the choir, brother.


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## AMF (Mar 8, 2011)

https://www.nremt.org/nremt/about/exam_coord_man.asp#BSkillSheets

Not saying it makes sense.


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## fast65 (Mar 8, 2011)

AMF said:


> https://www.nremt.org/nremt/about/exam_coord_man.asp#BSkillSheets
> 
> Not saying it makes sense.




Damn straight, that makes absolutely no sense


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## Shishkabob (Mar 8, 2011)

It's the NR... since when did they EVER make sense?


Trust me, ETT is not now, nor has it been recently, nor will it ever be, an EMT-Basic skill at the national level.


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## fast65 (Mar 8, 2011)

Linuss said:


> It's the NR... since when did they EVER make sense?
> 
> 
> Trust me, ETT is not now, nor has it been recently, nor will it ever be, an EMT-Basic skill at the national level.




hmmmm, how do I know I can trust you? h34r:


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## CAOX3 (Mar 10, 2011)

I was trained on multiple advanced airways including ETI, leave the intubations to the medics, I can manage the majority of airways with a bvm an a adjunct.


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## AtlantaEMT (Mar 10, 2011)

Has anyone ever had a medic use a combitube?  I had a medic once who used it on a full code.  I went for the intubatin kit but he told me to get the combitube.


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## usalsfyre (Mar 10, 2011)

AtlantaEMT said:


> Has anyone ever had a medic use a combitube?  I had a medic once who used it on a full code.  I went for the intubatin kit but he told me to get the combitube.



I use them (King LTS-D anyway)first line in all of my cardiac arrest, and used one first line on a patient who needed airway control but was not a good candidate for endotracheal intubation the other day.


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## Handsome Robb (Mar 10, 2011)

The local service just changed their protocols to the KING as well as a first shot airway in arrests. Only problem I have heard about with the KING is if the pt vomits they have a tendency to dislodge, so you have to drop an OG tube through the port on the KING and suck it all out before it can happen.


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## calebsheltonmed23 (Mar 11, 2011)

AMF said:


> To the Paramedics who browse the BLS forum,
> EMTs in my area (Dallas) recently became able to use combitubes and ET Intubation (and maybe King's?).  Do you recommend learning these (I'm a student) or will paramedics mostly take care of this?  Also, do people in your profession have some sort of problem with EMTs performing advanced airway interventions?  Do you think it's something requires the basic-science background/high clinical exposure you must have?



I would recommend learning it.  I've been told numerous times to drop a combitube during a code, while the medic was getting an IV/IO established.  And as an EMT-P student, I'd rather have an EMT drop a tube while I'm pushing drugs because that's precious time being wasted if you have an EMT just sitting around and your not pushing drugs, in my opinion.


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## jjesusfreak01 (Mar 11, 2011)

calebsheltonmed23 said:


> I would recommend learning it.  I've been told numerous times to drop a combitube during a code, while the medic was getting an IV/IO established.  And as an EMT-P student, I'd rather have an EMT drop a tube while I'm pushing drugs because that's precious time being wasted if you have an EMT just sitting around and your not pushing drugs, in my opinion.



This is exactly why we use King airways. With a King airway available to them, an EMT has the complete ability to manage an airway during a cardiac arrest, leaving the medic free to start drugs or electrical therapies.


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## Veneficus (Mar 11, 2011)

calebsheltonmed23 said:


> I would recommend learning it.  I've been told numerous times to drop a combitube during a code, while the medic was getting an IV/IO established.  And as an EMT-P student, I'd rather have an EMT drop a tube while I'm pushing drugs because that's precious time being wasted if you have an EMT just sitting around and your not pushing drugs, in my opinion.



Did anyone in school tell you just how much those code drugs actually help?


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## Shishkabob (Mar 11, 2011)

calebsheltonmed23 said:


> I would recommend learning it.  I've been told numerous times to drop a combitube during a code, while the medic was getting an IV/IO established.  And as an EMT-P student, I'd rather have an EMT drop a tube while I'm pushing drugs because that's precious time being wasted if you have an EMT just sitting around and your not pushing drugs, in my opinion.



I'd rather the EMT be doing compressions than toying with the airway.


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## AtlantaEMT (Mar 11, 2011)

Linuss said:


> I'd rather the EMT be doing compressions than toying with the airway.



I Agree if it is just an EMT and a Medic (or even a medic and medic).  If you have other people available (wether a cop, FF, student. or joe schmoe) to do chest compressions, it seems reasonable for a medic to work on the drugs and eletrical therapy, while the EMT secures an airway. Any bystander can maintain ABCs once an OPA and BVM is set up.


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## Madmedic780 (Mar 11, 2011)

Yeah I call shenanigans as well on this BS about ETT and BLS. No flippin way that basics can do that.

Here in Oregon they are giving the Advanced EMT's (AEMT) Intubation but all the county protocols are saying Paramedic only. 

Oregon Intermediates however (higher cert that AEMT's) can't intubate but can do kings/Combi and OG tubes.


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## calebsheltonmed23 (Mar 11, 2011)

Linuss said:


> I'd rather the EMT be doing compressions than toying with the airway.



If an EMT was intubating, I would completely agree.  But it's a combitube.  It's pretty much plug n' play.  If the first hole does'nt work, put it on the other.  Combitube is a BLS skill (atleast in Missouri), and IV's are an ALS skill.  If the EMT can do the same thing I could, just with a different device, why would you not have them do it.  Have a FF do compressions and you start a line (FF are automatically dispatched for an unconscious/unresponsive in my county).  Now if the patient was under 5' or was a ped, of course I would be intubating.  It just depends on the patients presentation and who you have with you.


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## calebsheltonmed23 (Mar 12, 2011)

Veneficus said:


> Did anyone in school tell you just how much those code drugs actually help?



No.  I assume they help a good amount otherwise we would'nt be pushing them.  It all depends on the patient, and all the factors (how long they've been down, traumatic or medical, what kind of medical, etc.) right?


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## usalsfyre (Mar 12, 2011)

calebsheltonmed23 said:


> No.  I assume they help a good amount otherwise we would'nt be pushing them.  It all depends on the patient, and all the factors (how long they've been down, traumatic or medical, what kind of medical, etc.) right?



:lol::lol::lol::lol::lol:

So new and naive...

Two things have been proven to change cardiac arrest outcomes in primary arrest. Chest compressions (notice I didn't say CPR) and defibrillation. Which bystanders can do. Drugs may help in other specific causes of arrest, but most paramedics aren't educated enough or don't care enough to identity those specific causes and the appropriate agent. Drugs have never been proven helpful in out of hospital arrest. Simply following an ACLS algorithm is not medical treatment, it's throwing $hit against a wall and hoping something sticks.


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## MrBrown (Mar 12, 2011)

Let Brown think .... 

During early 1993 it was loudly proclaimed to a group of Advanced Care Officer students that drugs in cardiac arrest have never been proven to be beneficial.

... and now it's 2011 and some still seem to have not gotten the message, although "Advanced Care Officer" is now called "Intensive Care Paramedic"


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## calebsheltonmed23 (Mar 13, 2011)

usalsfyre said:


> :lol::lol::lol::lol::lol:
> 
> So new and naive...
> 
> Two things have been proven to change cardiac arrest outcomes in primary arrest. Chest compressions (notice I didn't say CPR) and defibrillation. Which bystanders can do. Drugs may help in other specific causes of arrest, but most paramedics aren't educated enough or don't care enough to identity those specific causes and the appropriate agent. Drugs have never been proven helpful in out of hospital arrest. Simply following an ACLS algorithm is not medical treatment, it's throwing $hit against a wall and hoping something sticks.



I know that compressions and defibs are what mainly make up the resucitation and I thought drugs had a place in resucitation also but I will do research on that and be better informed.


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## usalsfyre (Mar 13, 2011)

calebsheltonmed23 said:


> I know that compressions and defibs are what mainly make up the resucitation and I thought drugs had a place in resucitation also but I will do research on that and be better informed.



Sorry for my abrasiveness last night, I was pretty well fried by the time I posted that.

Drugs may have a situationally dependent place in cardiac arrest, for instance calcium in hyperkalemia. But the indiscriminate way we push them right now is pointless and probably harmful.


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## johnmedic (Mar 13, 2011)

usalsfyre said:


> Drugs may help in other specific causes of arrest, but most paramedics aren't educated enough or don't care enough to identity those specific causes and the appropriate agent. Drugs have never been proven helpful in out of hospital arrest.



Yep.

"There is no evidence to date that routine use of any vasopressor at any stage during management of pulseless VT, VF, or asystole increases rates of survival to hospital discharge. But there is evidence that the use of vasopressors favors initial resuscitation with ROSC."
P. 48 - ACLS Provider Manual - 2006

"Although there is no evidence that giving any antiarrhythmic routinely during cardiac arrest increases rates of survival to hospital discharge, amiodarone has been shown to increase rates of survival to hospital admission.."
P. 49 - ACLS Provider Manual - 2006


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## johnmedic (Mar 13, 2011)

& to address ET Intubation & expanding the skill to EMT-B's: From a recent study published in February from N.C., the numbers seem to speak for themselves.

"The authors found that... individuals with no ETI attempt were 5.46 times more likely to be discharged from the hospital alive compared with one successful ETI attempt. The authors concluded that ETI attempts are associated with negative outcomes in OOHCA."

Source: http://www.jems.com/article/patient-care/prehospital-intubation-cardiac


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## Shishkabob (Mar 13, 2011)

"amiodarone has been shown to increase rates of survival to hospital admission."

"But there is evidence that the use of vasopressors favors initial resuscitation with ROSC."



And honestly, those two right there are enough for me to continue research into the stuff as you can't have more survivals without more ROSC... we just need to find the missing piece, or concede that the ones that don't get ROSC will never get ROSC.


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## johnmedic (Mar 13, 2011)

Linuss said:


> And honestly, those two right there are enough for me to continue research into the stuff as you can't have more survivals without more ROSC... we just need to find the missing piece, or concede that the ones that don't get ROSC will never get ROSC.



Absolutely, I agree keep pushing them so we can keep up the research. Definitely not trying to say that it's futile.. But I feel like the survival rates to hospital discharge aren't widely known. Medics can have a blind overestimation of ACLS Drugs similar to the high expectations non-healthcare providers have of CPR.

& yeah, I'm sure I could've worded that better.


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## medic417 (Mar 13, 2011)

johnmedic said:


> & to address ET Intubation & expanding the skill to EMT-B's: From a recent study published in February from N.C., the numbers seem to speak for themselves.
> 
> "The authors found that... individuals with no ETI attempt were 5.46 times more likely to be discharged from the hospital alive compared with one successful ETI attempt. The authors concluded that ETI attempts are associated with negative outcomes in OOHCA."
> 
> Source: http://www.jems.com/article/patient-care/prehospital-intubation-cardiac



Well duhhhhhhhh.  If they don't need intubated they are probably not as near death as those that do need intubated.  :wacko:


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## calebsheltonmed23 (Mar 13, 2011)

usalsfyre said:


> Sorry for my abrasiveness last night, I was pretty well fried by the time I posted that.
> 
> Drugs may have a situationally dependent place in cardiac arrest, for instance calcium in hyperkalemia. But the indiscriminate way we push them right now is pointless and probably harmful.



No worries.  The calcium and sodium bicarb are the main ones I've heard/read about for cardiac arrest, so long as hyperkalemia and/or overdose of the certain meds that sodium bicarb can help with is the reason of it.  And I thought that epi would help during cardiac arrest because it helps contractility and increases HR, but we really have'nt went over any of the other drugs, so I'm still pretty uninformed about that subject.  Thanks for telling about it!


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## calebsheltonmed23 (Mar 13, 2011)

johnmedic said:


> Yep.
> 
> "There is no evidence to date that routine use of any vasopressor at any stage during management of pulseless VT, VF, or asystole increases rates of survival to hospital discharge. But there is evidence that the use of vasopressors favors initial resuscitation with ROSC."
> P. 48 - ACLS Provider Manual - 2006
> ...



Okay.  I will get out my ACLS book and start reading about it.  Thanks!


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