# intubation during CPR



## goidf (Oct 1, 2009)

I have quite a basic question, that I have surprisingly not found in the literature. in order to intubate one must first hyperventilate the pt. now in an arrest hyperventilating comes at the price of compressions, and according to the latest research compressions are more important then ventilation.


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## sgoemt (Oct 1, 2009)

I'll start off by saying that I am only a medic student, but when I've done this a couple times during clinicals, I tube during the 10-12 seconds that we stop to analyze rhythm/check pulse. Granted, it usually extends to about 15 seconds, but so far I haven't had any complaints from preceptors.

But I'm just a medic student, so I'm learning as well.


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## MasterIntubator (Oct 1, 2009)

I suppose some standard of how you do things may be dictated by what technology you have.
In my area, we no longer "hyperventilate" prophylactically, meaning.... we don't blindly do it.  We use Waveform EtCO2 in-line with the BVM to help judge our ventilation speed, then go from there.
Typically, we will do non-stop compressions with BVM ventilations every 6-10 seconds.  If we have good ventilation compliance, I may choose not to place an ETT in unless I have done all my big guns. ( one exception being a asthmatic type code... where I can give epi or such down the tube for fast action ) 
If there is an airway problem, then that becomes one of my big guns, intubating during compressions. 
If you have good compliance, hyperventilation is un-needed anyway, as the desaturation curve won't happen until well after 3 minutes of no ventilation... 3 minutes is a looooooooooooooooooooooooooong time to do stuff and intubate.  6 people can gang intubate that person before lack of O2 becomes a problem. 
Big key is... don't stop your compressions for anything ( common sense applies ) other than to do a 3-5 second check.  That means have your defib charged and ready to go during that 3-5 seconds.
Once intubated, you will get an EtCO2 number and waveform pretty daggone quick... typically we find it 70 or higher.  Then I hand the BVM over to someone, advising to breathe faster if its over 45.... slower if it drops below 20... and keep the numbers somewhere between 25-40 ( I like a wide range.. eases the uh ohh factor ).  The BVM specialist can take it from there now that they have some feedback.

We no longer do ventilations based on compression ratio....  its almost like CPR/Ventilation in complete heart block.... each one does their own thing.
And we have had mad success... documented.  Over and over.


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## sgoemt (Oct 1, 2009)

MasterIntubator said:


> I suppose some standard of how you do things may be dictated by what technology you have.
> In my area, we no longer "hyperventilate" prophylactically, meaning.... we don't blindly do it.  We use Waveform EtCO2 in-line with the BVM to help judge our ventilation speed, then go from there.
> Typically, we will do non-stop compressions with BVM ventilations every 6-10 seconds.  If we have good ventilation compliance, I may choose not to place an ETT in unless I have done all my big guns.
> If there is an airway problem, then that becomes one of my big guns, intubating during compressions.
> ...



You're quite correct. I'd failed to mention that there have been times when both my preceptor and I opted to NOT intubate since we had adequate ventilations. Problem here is, in the sticks of WV most of the services don't have Wave-Form Capnography, except for the CCT rigs. And we aren't allowed to do ride time on those.


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## MasterIntubator (Oct 1, 2009)

Gotcha... a good rule of thumb is to ventilate for them for lets say... a couple minutes once every 3-5 seconds, then back your vents off to 6-10 or so.  During a code this stuff is tough to remember when its new.... but practicing will get your hands and your internal clock adjusted to what 'feels' right.

All you are trying to do is blow off that CO2, but just enough to get their chemistry back in check.  Too low CO2 and too high CO2  won't let the cells play right.  Which is what we have been doing in the past... breathing too fast, blowing off all the CO2.... and thats not good.  

Also keep in mind... some codes will not have any gas exchange ( meaning no readings on EtCO2... and if you intubated, you should KNOW you are in with no kinks in any system.... and a EtCO2 value near a 0 is not good, and very poor resuscitation stats.


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## MasterIntubator (Oct 1, 2009)

Don't forget about colormetric capnography... although its not the greatest, it works in a pinch when you don't have that extra $$$$ lying around. 

Just like those old colormetric glucometer strips ( not sure if you remember those )  You match the tested color pad on the bottle and get a glucose range. ( like urine test strips )


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## sgoemt (Oct 1, 2009)

MasterIntubator said:


> Gotcha... a good rule of thumb is to ventilate for them for lets say... a couple minutes once every 3-5 seconds, then back your vents off to 6-10 or so.  During a code this stuff is tough to remember when its new.... but practicing will get your hands and your internal clock adjusted to what 'feels' right.
> 
> All you are trying to do is blow off that CO2, but just enough to get their chemistry back in check.  Too low CO2 and too high CO2  won't let the cells play right.  Which is what we have been doing in the past... breathing too fast, blowing off all the CO2.... and thats not good.
> 
> Also keep in mind... some codes will not have any gas exchange ( meaning no readings on EtCO2... and if you intubated, you should KNOW you are in with no kinks in any system.... and a EtCO2 value near a 0 is not good, and very poor resuscitation stats.



See, I've told some of the other students in my class to come to this site and just.....read. I've gained a wealth of knowledge by just watching you guys. And my grades and preceptor comments prove it. One of the better agencies in a nearby area told me to come and see them when I get my card, as I seemed very promising. 

I flat stated that I got a lot of "secondary" education from this site. 


We shall see how much I've retained come the 1st week of January.


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## sgoemt (Oct 1, 2009)

Yep, I've used the colormetrics a few times. And I always have the same issue. By the time I get to the ED, the condensation in the tube has moistened the paper, and since there is no color change, the Docs :censored::censored::censored::censored::censored: and moan about the tube not being in place. I've had more tubes pulled that way!! ARGHHH!!!


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## MasterIntubator (Oct 1, 2009)

You only want to use the colormetric long enough to give you what you need... then get it out of the circuit.  If you 
A: Watched the tube pass thru the cords  
B: Listened well to lung sounds
C: Secured your tube right
D: Feel the beautiful feel of lung compliance ( uuUUUuu... that always gets me excited )
E: Recheck all the time

The rest of the confirmation tools are there to make you feel better about what you already know... unless it gives you numbers and progress feedback
Unless you have a portable x-ray unit... but really... who has those?  I'd just rather do a thoracotomy and look for myself.. more fun.   ( _don't really do that... really... .seriously_


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## MasterIntubator (Oct 1, 2009)

heh..... if the docs pulled your tubes just because of no color change... they should be :censored::censored::censored: and :censored::censored::censored::censored::censored: while you :censored::censored: their :censored:


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## cm4short (Oct 2, 2009)

goidf said:


> I have quite a basic question, that I have surprisingly not found in the literature. in order to intubate one must first hyperventilate the pt. now in an arrest hyperventilating comes at the price of compressions, and according to the latest research compressions are more important then ventilation.



The literature in our protocols changed "hyperventilate" to "Ventilate." Without the reminder; some medic's would intubate during the ventilation cycle; excluding it from the sequence of rotation; thus prolonging the patients hypoxic state.


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## MSDeltaFlt (Oct 2, 2009)

goidf said:


> I have quite a basic question, that I have surprisingly not found in the literature. *in* *order to intubate one must first hyperventilate the pt. now in an arrest hyperventilating comes at the price of compressions*, and according to the latest research compressions are more important then ventilation.


 
Negative, ghostrider.  You can intubate during CPR.  You just don't hold CPR.  The goal for intubation is to intubate during compressions.  The AHA's trend is focusing more on airway and not just the skill of intubation.  Intubation itself is further on down the algorhythm.


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## Dwindlin (Oct 2, 2009)

MSDeltaFlt said:


> Negative, ghostrider.  You can intubate during CPR.  You just don't hold CPR.  The goal for intubation is to intubate during compressions.  The AHA's trend is focusing more on airway and not just the skill of intubation.  Intubation itself is further on down the algorhythm.



Yeah you can actually place the tube during compressions, but until you have that ETT in trying to ventilate witha BVM is pointless during compressions, which is what I think the post you quoted was talking about. Pre-intubation ventilating, not post.

But in the end I agree with you, in that I think we'll be seeing many changes at the next AHA ACLS update.  Personally I think you'll see any kind of pre-intubation ventilation nixed, as there is research showing there is more available O2 in someone who's been in arrest than previously believed.


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## Smash (Oct 2, 2009)

Colormetric EtCO2 should really only be a last gasp fallback when your capnography has failed.  Waveform and numbers are vital, and, as mentioned capnography can also give you an idea of the likelihood of a successful outcome from the resus.  

I would also never, ever countenance RSI without waveform capnography.


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## TransportJockey (Oct 2, 2009)

If you're doing CPR, what harm would NOT hyperventilation do to the pt? Probably none in all likelyhood. I've tubed during CPR during clinicals, which was kinda funny cause the doc wanted everyone to stop doing everything so that the tube could go in... his attending told him not a chance


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## Crepitus (Oct 2, 2009)

Smash said:


> Colormetric EtCO2 should really only be a last gasp fallback when your capnography has failed.  Waveform and numbers are vital, and, as mentioned capnography can also give you an idea of the likelihood of a successful outcome from the resus.
> 
> I would also never, ever countenance RSI without waveform capnography.



Having newly returned to the field, capnography is foreign to me so I have a few questions.  I don't think it's enough of a highjack to start a new thread so here goes:

Doesn't placement of a colormetric device and the use of an electronic device, that generates a waveform, really serve different purposes?  They both would indicated successful tube placement yes, but don't the waveform devices give a whole different range of information?

Second - to settle an arguement with the missus, isn't a colormetric a capnographic device by the strictest interpretation of the definition of capnography?  The books and the definitions that I check indicate that it is, but the missus insists that capnography only applies to the electronic devices that generate a waveform.  I think that is what the word has come to mean in common day practice.

Finally, specifically to directed to Smash, why would you withold RSI if you didn't have capnography available to you?  If the patient needs intubated they need intubated.  Right?  

I've personally not been able to place a tube in the field (multiple times to be sure), but I have never placed a tube in the esophagus, ventilated through it and remained unaware that I had misplaced it.  The colormetrics were just coming into common use when I went on hiatus, they are indeed an excellent tool, but I would never have not attempted a tube placement because they weren't available, thus I carry the thought forward - I wouldn't withhold an intubation attempt because electronic capnography wasn't available.

Is there a different view on the issue that would be valuable?


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## usalsfyre (Oct 2, 2009)

CapnoGRAPHy is related to an electronic device displaying a waveform. CapnoMETERy can be the colormetric device or an electronic device displaying a number. Capnography will do everything capnometery will do and more.


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## Crepitus (Oct 2, 2009)

"Capnography is the monitoring of the concentration or partial pressure of carbon dioxide (CO2) in the respiratory gases."

Above is wiki definition from google.   Is that definition any good?  IF so would it not also include capnometry?

I think I understand how the terms are being used every day language - capnography includes the waveform display, both measure and display ETCO2 in some way.  

(I know I'm parsing terms here, but I hate losing arguments with the missusB))


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## Smash (Oct 3, 2009)

Crepitus said:


> Having newly returned to the field, capnography is foreign to me so I have a few questions.  I don't think it's enough of a highjack to start a new thread so here goes:
> 
> Doesn't placement of a colormetric device and the use of an electronic device, that generates a waveform, really serve different purposes?  They both would indicated successful tube placement yes, but don't the waveform devices give a whole different range of information?
> 
> ...



It is a lot easier to get a false positive from a colormetric device than from a waveform.  Waveform is really the best (and arguably only) objective indicator of tracheal tube placement: nothing else is as reliable.  For example a colormetric device will indicate the presence of CO2 from a carbonated beverage in the stomach (a false positive) whereas capnography will give a very distinctive non-respiratory waveform that will allow you to immediately identify esophageal placement and hopefully correct it.

The reason I would withhold RSI in the absence of waveform capnography (although we carry 2, so it shouldn't be an issue  ), is that A ) RSI is a high risk procedure.  Failure to successfully intubate after you have eliminated the patient's respiratory function is catastrophic, and as noted above, waveform is the only real objective measure of successful intubation.

and B )  RSI (in the setting of a TBI), is not just about getting a tube down, it is about maintaining oxygentation and ventilation within a very narrow window to manage and reduce secondary brain injury appropriately.  Without accurate EtCO2 I am unable to do this and thus may be causing more harm than good - colormetric is simply not accurate enough to carry out the procedure safely.
It is simply not acceptable to just be ramming a tube home (or nasally intubating or trying to force an EGD or cric-ing) in a head injured patient.  RSI should be carried out in a very methodical and safe manner to ensure the best outcome.


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## Crepitus (Oct 3, 2009)

Great reply Smash.  And I'm sold on capnography as a tool.  Additionally, I see it's particular value in a RSI.  I am looking forward to learning this technology more thoroughly.

I learned (and performed RSI) prior to the introduction of field capnography.  The thought was if a person needed an airway profoundly enough then you would proceed.  It was not a common occurrence and was not highly thought of by the medical director.  But the few times that I performed an RSI it truly was a critical intervention for the patient.  I can't imagine witholding RSI from those pts.  I believe their outcomes would have suffered without it.

So I guess I would still RSI a pt in the right set of cirumstances, with or without the capnography.  The presumed circumstances being that the pt was going to expire without the airway intervention so what do you have to lose.  I'm presuming that RSI is more common today and thus you are at times paralyzing pt's that do indeed suffer harm if you fail to place a tube and provide subsequent airway care.

Thanks for the reply.


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## cm4short (Oct 3, 2009)

Crepitus said:


> Having newly returned to the field, capnography is foreign to me so I have a few questions. * I don't think it's enough of a highjack to start a new thread so here goes:*
> 
> Doesn't placement of a colormetric device and the use of an electronic device, that generates a waveform, really serve different purposes?  They both would indicated successful tube placement yes, but don't the waveform devices give a whole different range of information?
> 
> ...



I suggest a new thread... Capnography has so many uses above ETCO2 detectors, it's ridiculous. 

But with intubation and CPR: every pause in CPR decreases perfusion pressure which also affects the Oxygen Dissociation Curve along with other things. 

Second, the hyperventilation and ventilationhave two different effects. Both deliver oxygen to the lungs; but the difference lies in the gas exchange factors. CO2 concentrations are what should be considered when choosing hyperventilation verses the latter.


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