# Pausing for the tube



## Melclin (Aug 1, 2010)

I've been thinking lately about the time spent pausing compressions for intubation during cardiac arrest causing a bit of a hullabaloo and I remembered FLEMTP saying mentioning not pausing at all. 

So.. I can't think of a way to break down a poll properly so if we could just post... How many of you do not pause compressions for intubation and if you do, how long and why exactly (other than, because mosby's EMT-P said so)?


(I know other threads have touched on this issue, but I couldn't find one that gave me the numbers to answer my questions)


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## sir.shocksalot (Aug 1, 2010)

I never pause compressions for a tube, the one time I did, it didn't make much of a difference for me. I have seen docs do it, but its for no more than 30 seconds or so. Studies have pretty well shown that time off the chest is bad for patient survival rates, and field arrests tend to have more time off the chest than there should be (in my experience).


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## MrBrown (Aug 1, 2010)

Most here just whip out an LMA, shove it down the patients gob and blow up the cuff.

I have only seen one cardiac arrest intubated and that was post ROSC when he was still unconscious with a GCS of 3.


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## emt/ff71185 (Aug 1, 2010)

I never pause for a tube.  I have also seen doctors pause in the ER setting but I do not feel it is worth the pause.  Take a quick look with compressions in progress and if you don't see anything than pull out and insert appropriate blind airway device.


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## bstone (Aug 1, 2010)

If you have veinous access established, then don't use the tube. LMA, King, etc. Less down time, better outcomes.


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## MasterIntubator (Aug 1, 2010)

If the airway is patent and compliant, we just do the meat of the stuff.  When its desert time, I tube without stopping compressions.  Once the equipment is ready... about 5 seconds is all that is needed to pass the tube.


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## Lifeguards For Life (Aug 1, 2010)

Don't pause.


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## task (Aug 1, 2010)

Just need to pause for a second to check for breath / epigastric sounds after the tube is placed. 

Cric pressure helps when tubing a pt with CPR in progress.


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## Veneficus (Aug 1, 2010)

Melclin said:


> I've been thinking lately about the time spent pausing compressions for intubation during cardiac arrest causing a bit of a hullabaloo and I remembered FLEMTP saying mentioning not pausing at all.
> 
> So.. I can't think of a way to break down a poll properly so if we could just post... How many of you do not pause compressions for intubation and if you do, how long and why exactly (other than, because mosby's EMT-P said so)?
> 
> ...



I do not pause for compressions to intubate. But I do hold my breath and when it is time for me to breath it is time for the patient to breathe.


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## alphatrauma (Aug 1, 2010)

task said:


> Just need to pause for a second to check for breath / epigastric sounds after the tube is placed.



capnography?


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## BLSBoy (Aug 1, 2010)

I don't pause. I also load my tubes with a gum bougie, so its MUCH easier to pull the tube up a bit, put the bougie in, and slide the tube down.


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## alphatrauma (Aug 1, 2010)

Veneficus said:


> I do not pause for compressions to intubate. But I do hold my breath and _when it is time for me to breath it is time for the patient to breathe_.



I like this!


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## CCNRMedic1982 (Aug 4, 2010)

Veneficus said:


> I do not pause for compressions to intubate. But I do hold my breath and when it is time for me to breath it is time for the patient to breathe.



I have heard of quite a few people doing this and it doesn't really make alot of sense to me......I can barely hold my breath for 30 seconds, my wife used to be a swimmer and she can hold her breath forever( or so it seems, really for a few minutes w/o feeling short of breath).  So how do you know how long goes by that your not ventilating your patient?  I don't stop CPR for Intubation if it appears that it is going to be a difficult airway then Intubation isn't even attempted and a BIAD is inserted.  Minimizing interruptions in CPR is very vital to pt. outcome, The same should be said for providing adequate ventilations and oxygenation to the pt. I think sometimes this is forgotten during an arrest so that someone can do a cool skill....


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## Veneficus (Aug 4, 2010)

CCNRMedic1982 said:


> I have heard of quite a few people doing this and it doesn't really make alot of sense to me......I can barely hold my breath for 30 seconds, my wife used to be a swimmer and she can hold her breath forever( or so it seems, really for a few minutes w/o feeling short of breath).  So how do you know how long goes by that your not ventilating your patient?  I don't stop CPR for Intubation if it appears that it is going to be a difficult airway then Intubation isn't even attempted and a BIAD is inserted.  Minimizing interruptions in CPR is very vital to pt. outcome, The same should be said for providing adequate ventilations and oxygenation to the pt. I think sometimes this is forgotten during an arrest so that someone can do a cool skill....



Intubation is not a cool skill. Surgical cric is a cool skill, but I don't look for reasons to do it. 

As for the breath thing. The simple answer for me is I think I am fairly average in the ability to willfully control my respiratory drive. It certainly isn't 2 minutes worth of ability. Usually I have to stop and vent before even the ETCO2 falls to 35mmhg. (in which case the machine starts alarming and that is always the cue to ventilate)

An anesthesia friend of mine likes to say (and I buy into 100%) people don't die from not having a plastic tube in their face. They die from tissues not properly being perfused.

As I am sure you are aware, an ET tube may be the gold standard of controlling an airway, it certainly doesn't solve all of the issues associated with ventilation or oxygenation.

Inserting a tube isn't automatically the focus of my attention in a code. (though sometimes circumstances call for it to be)


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## WolfmanHarris (Aug 4, 2010)

alphatrauma said:


> capnography?



Shouldn't rely on just capnography for verification. Protocol not withstanding (we're required to verify and document x2) when I insert a king I auscultate epigastric and lungs, watch rise and fall and misting of the tube and attach the ETCO2 filterline.


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## Melclin (Aug 4, 2010)

*Very Interesting*

Wow so..its very common. I wouldn't speak to the whole system here, but in my two arrests that got tubed, the Intensive Care paramedic paused both times, once for almost a minute (which is obviously unacceptable). Talking to a few paramedics around uni, the norm seems to be to pause. Disappointing, but maybe I've got the wrong end of the stick.

To the people who do not pause: is it common in your system not to pause, or are you leading the way?


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## medic farva (Aug 5, 2010)

I don't even attempt to tube my cardiac arrests any more. Insert the king and move on. Don't stop compressions for this. It's about VENTILATION, not intubation. While it may not take too long once your equipment is readied, it takes longer to ready your intubation equipment than it does to slam a king and inflate the cuff and start ventilating.


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## CCNRMedic1982 (Aug 5, 2010)

Veneficus said:


> Intubation is not a cool skill. Surgical cric is a cool skill, but I don't look for reasons to do it.



I like that response, thanks.  

Surg. Cric is a cool skill, I just did one on a trauma pt. maybe like two weeks ago. But besides the point.  Thanks for the reply and like I said just never made alot of sense to me but I do see where your coming from.


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## Aidey (Aug 5, 2010)

Veneficus said:


> Usually I have to stop and vent before even the ETCO2 falls to 35mmhg. (in which case the machine starts alarming and that is always the cue to ventilate)



Huh? Falls to 35mm/hg? That doesn't make any sense to me. I've been taught that in cardiac arrest you want your ETCO2 to be between 45-55mm/hg (with normal living person range being 35-45mm/hg). How low are you getting their CO2 for it to "fall" to 35? 

As for the OP, I do everything but actually put the tube in while compressions are going. I look, suction, position the blade, get the cords in view and then right before I put it in I will say stop, and have them resume immediately after it goes through the cords. Pause of 5-10 seconds tops because I don't have to look for the cords, I already can see them.


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## CCNRMedic1982 (Aug 5, 2010)

medic farva said:


> I don't even attempt to tube my cardiac arrests any more. Insert the king and move on. Don't stop compressions for this. It's about VENTILATION, not intubation. While it may not take too long once your equipment is readied, it takes longer to ready your intubation equipment than it does to slam a king and inflate the cuff and start ventilating.




Interesting do you notice an increase in survival rate when you have continuous compressions.  I agree with this train of thought and am trying to get my System director and my medical director to buy off on considering this for our cardiac arrest patients.  System director is not a fan and thinks that doing this will ultimately take the skill ETI away from the system all together.  We have a few medics that do it here just because but alot of the people don't have years on years of experience so when they see something "cool" everything just kind of stops i.e. compressions (which of course is defeating the purpose) but just curious on what kind of results you get from doing this.


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## Veneficus (Aug 5, 2010)

Aidey said:


> Huh? Falls to 35mm/hg? That doesn't make any sense to me. I've been taught that in cardiac arrest you want your ETCO2 to be between 45-55mm/hg (with normal living person range being 35-45mm/hg). How low are you getting their CO2 for it to "fall" to 35?



I think you are not understanding what I meant.

I am not suggesting maintaining at 35 or anywhere near there. When intubating, both the spo2 and etco2 decline when you pause ventilation to intubate. (which of course you have to)In both the theatre and the icu, where i do my clinical time, 35mm/hg is considered the lowest etco2 is permitted to get prior to suspending any procedure attempts (like intubating, because you may have started with a conscious sedation, an LMA or not on a vent for whatever the reason) to resumption of ventilation. If the alarm is sounded because of delays for whatever the reason, that is considered a fault. (unacceptable practice)

Prior to or after the intubation attempt, we like our ETCO2 between 40-45mmhg. Prior to hyper oxygenating for an ET attempt, we usually don't let etco2 reach 50 or above unless there are special circumstances calling for it.

I can see the argument for increasing ETCO2 beyond 50 in a code to attempt to compensate for potential acidosis, but there is also a valid argument that a nonperfusing person actually needs less ventilatory support than a live person. Considering that there is ample documentation of reperfusion injury (because most places I know actually vent with 100% o2 on a code) as well as long term potential toxic effects of 02, unless providers start ventilating with room air as is the trend with neonates, or reduced oxygen levels in adults, I do not see a compelling reason to increase etco2 past normal ranges in the absence of a prolonged downtime or specific pathologies that would benefit from it.  


Meclin,

I was taught not to pause for compressions. In all the places I have worked it seems to be the norm. Even in the hospital, on a difficult airway, there are many gadgets available to assist with a difficult intubation, and not shortage of expertise.

If it looks difficult in the field, my last service used combitubes, so we just stuck that in rather than try an ET attempt.


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## Aidey (Aug 5, 2010)

Ok, now I'm even more confused.

Poor oxygenation causes a rise in CO2. If someone is at 35 mm/hg and you stop ventilating them the number will go up, not down.


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## zmedic (Aug 5, 2010)

Wait, are you talking about an end tidal CO2 reading? Because  if you are bagging a patient you have a wave form with the peak corresponding to the CO2 in the alveloli. When you stop bagging the waveform drops to zero, because there is no C02 hitting the sensor (ie the mask is lying on the bed while you are tubing and doesn't tell you anything about the patient.) While you are tubing a patient (in a patient with a heart beat) CO2 is still being dropped off in the lungs and the alvolar CO2 will continue to climb, but you won't see this until you start ventillating again. Then you get a big peak CO2 that trends down as you blow off the CO2. 

The SpO2 on the other hand keeps reading if the patient still has a pulse. After a delay in not bagging it'll start to drop.


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## Veneficus (Aug 5, 2010)

zmedic said:


> Wait, are you talking about an end tidal CO2 reading? Because  if you are bagging a patient you have a wave form with the peak corresponding to the CO2 in the alveloli. When you stop bagging the waveform drops to zero, because there is no C02 hitting the sensor (ie the mask is lying on the bed while you are tubing and doesn't tell you anything about the patient.) While you are tubing a patient (in a patient with a heart beat) CO2 is still being dropped off in the lungs and the alvolar CO2 will continue to climb, but you won't see this until you start ventillating again. Then you get a big peak CO2 that trends down as you blow off the CO2.
> 
> The SpO2 on the other hand keeps reading if the patient still has a pulse. After a delay in not bagging it'll start to drop.



Sorry, my fault, 

I was trying to type out 2 thoughts and integrate them at the same time in as few words as possible, let me attempt to make it right.

On the machines our anesthesia dept uses, there is a series of numbers that are very large. The one that stands out the most is lableled ETCO2, on an already intubated patient. (it alarms at 35)

When ventilating the pt manually, the longer you delay ventilation, the lower the number drops. (this should be the waveform, I assume, but they are older machines, and there is just a set of various numbers.

The time it takes for me to hold my breath is and give up ventilating a non intubated patient is less than the time it takes to watch that number fall from 45 to 35 in the intubated patient.

The more you ventilate the intubated pt, the higher that number climbs.

I really messed up what I was trying to communicate with what I said and in my reply, sorry again. No excuse, just failed at what I was trying to explain.

Maybe I do need some adderall?


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## socalmedic (Aug 6, 2010)

ven, i think you may still have the values mixed, or i am way confused. what i do know is that as you ventilate the etco2 will go down. Hyperventilating will drop the etco2 (not elevate it) further. hypoventilating will raise the Etco2 reading. there is also no way to measure Etco2 while intubating. maby that reading is SPco2 which can be measured with a finger probe. either way they measure exactly the same thing (the partial pressure of CO2 in the blood stream, which normaly will be 35-45mmhg).

hope that cleared some things up. now i am interested as to what value the monitor you use is measuring.


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## the_negro_puppy (Aug 7, 2010)

At my paramedic level we dont tube, but our Intensive Care paramedics do tube. On 2 arrests ive been asked to stop compressions for a short period while they tube...though both times LMA were ineffective, LMA stays if its working


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## jjesusfreak01 (Aug 7, 2010)

the_negro_puppy said:


> At my paramedic level we dont tube, but our Intensive Care paramedics do tube. On 2 arrests ive been asked to stop compressions for a short period while they tube...though both times LMA were ineffective, LMA stays if its working



I've never seen an LMA in use, but they just look like they would want to pop back out and they don't prevent aspiration. I suppose the best use of LMA is an unstable (likes to close off) epiglottis but you don't really have time/skill to intubate? I'd stick with the King or ET.


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## Aidey (Aug 7, 2010)

Naw, the best use of the LMA is a surgical patient who is in the OR.


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## Melclin (Aug 8, 2010)

the_negro_puppy said:


> At my paramedic level we dont tube, but our Intensive Care paramedics do tube. On 2 arrests ive been asked to stop compressions for a short period while they tube...though both times LMA were ineffective, LMA stays if its working



This is the same experience as I've had. Makes me wonder if we're getting a bit behind the times when it comes to pausing. 

I've only seen one LMA attempt and it failed too. Although I should say that the pt had his face run over by a tractor so....probably not the LMA's fault in this instance. 



jjesusfreak01 said:


> I've never seen an LMA in use, but they just look like they would want to pop back out and they *don't prevent aspiration*. I suppose the best use of LMA is an unstable (likes to close off) epiglottis but you don't really have time/skill to intubate? I'd stick with the King or ET.



Its not a matter of do or don't. ETT doesn't _stop_ aspiration either. LMA significantly reduces the likelihood of aspiration compared to BVM/OPA, but not as much as ETT.


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## Durchii (Aug 23, 2010)

The King is one of the better things to happen to Airway Management for quite some time, especially for those who don't have the skill set to place ET's. You can drop one in a tenth of the time that it would take you to intubate someone and you can begin ventilating your patient (which, ultimately, is the desired outcome when all is said and done).

Just the opinion of someone who has placed his fair share of them.


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## wiggy762 (Oct 24, 2010)

Durchii said:


> The King is one of the better things to happen to Airway Management for quite some time, especially for those who don't have the skill set to place ET's. You can drop one in a tenth of the time that it would take you to intubate someone and you can begin ventilating your patient (which, ultimately, is the desired outcome when all is said and done).
> 
> Just the opinion of someone who has placed his fair share of them.



 ***The following is based on the premise that the quoted poster has no ETT experience***
I understand that this is an opinion...BUT how can it be valid if you do not have first hand experience with intubation? It seems that a comparison as you have presented, would be most valid if the presenter could speak to both procedures.

I have placed both and I 'feel' / 'think' / 'postulate' / 'opine', that the ETT placement was both faster and more comforting to me, re: definitive airway control. YMMV


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## TomB (Oct 25, 2010)

Just out of curiosity, wiggy762, at what point do you 'feel'/'think'/'postulate'/'opine' that a paramedic becomes 'experienced' at laryngoscopy and tracheal intubation? Is there a specific number of clinical encounters? What variety of airway anatomies? How many difficult airways? How many to achieve a success rate of at least 90% on the first pass? Enlighten us with your worldly view of the subject.


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## usalsfyre (Oct 25, 2010)

wiggy762 said:


> ***The following is based on the premise that the quoted poster has no ETT experience***
> I understand that this is an opinion...BUT how can it be valid if you do not have first hand experience with intubation? It seems that a comparison as you have presented, would be most valid if the presenter could speak to both procedures.
> 
> I have placed both and I 'feel' / 'think' / 'postulate' / 'opine', that the ETT placement was both faster and more comforting to me, re: definitive airway control. YMMV



My guess is that you have limited experience with both procedures. I have done far more ETT placements under direct laryengoscopy than King airway placements, but I have a fair amount of both. There's no way I can place an ETT faster than a King airway. Not gonna happen, no way no how. 

In addition "definitive airway control" is anything that allows the patient to be properly ventilated and provides a reasonable degree of airway protection. That may be an ETT, it may be a King, it may be an NPA. Protecting against aspiration is a different concern, that an ETT may assist with but in no way prevent.


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## wiggy762 (Oct 25, 2010)

*For me (and me only)...I figure...*

...that somewhere around 100+ successful intubations allows some sort of experience-based authority. At this number, the Medic has a good amount of experience with the other than normal airways.

Like I said..."YMMV" (Your Mileage May Vary)

I apologize if I ruffled some feathers.






TomB said:


> Just out of curiosity, wiggy762, at what point do you 'feel'/'think'/'postulate'/'opine' that a paramedic becomes 'experienced' at laryngoscopy and tracheal intubation? Is there a specific number of clinical encounters? What variety of airway anatomies? How many difficult airways? How many to achieve a success rate of at least 90% on the first pass? Enlighten us with your worldly view of the subject.


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## wiggy762 (Oct 25, 2010)

*I was with you...*

...until the part, "...a reasonable degree of airway protection. That may be an ETT..."

An ETT is the definitive airway specifically because of the unparalleled airway protection it affords int he case of aspiration. In addition, the ETT provides the only definitive protection against gastric distention, which may lead to vagal stimulation or distention induced emesis. 

I admit that I have limited experience with the King, and that this less than comfortable-ness is part of my leaning towards y tried and true friend.

YMMV (Your Mileage May Vary)





usalsfyre said:


> My guess is that you have limited experience with both procedures. I have done far more ETT placements under direct laryengoscopy than King airway placements, but I have a fair amount of both. There's no way I can place an ETT faster than a King airway. Not gonna happen, no way no how.
> 
> In addition "definitive airway control" is anything that allows the patient to be properly ventilated and provides a reasonable degree of airway protection. That may be an ETT, it may be a King, it may be an NPA. Protecting against aspiration is a different concern, that an ETT may assist with but in no way prevent.


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## usalsfyre (Oct 25, 2010)

wiggy762 said:


> ...until the part, "...a reasonable degree of airway protection. That may be an ETT..."
> 
> An ETT is the definitive airway specifically because of the unparalleled airway protection it affords int he case of aspiration. In addition, the ETT provides the only definitive protection against gastric distention, which may lead to vagal stimulation or distention induced emesis.



Not to be rude, but...

The way to protect against aspiration is to prevent aspiration. The tools to do that are a gastric tube, either NG or OG, placed as soon as conviently possible, and good oral care in the form of suction. They can both be performed with a ETT or King in place (granted oral care is tough). Thousands of cases of VAP will disagree with you on the aspiration protection offered by ETT, and an ETT placement does nothing to deal with gastric distension that may have occured PTA. Although it's entirely conjecture, I'll bet a King/OG tube combo will do as much (or more) to protect against aspiration as a ETT alone. Remember that airway protection and intubation are not one and the same.    



> I admit that I have limited experience with the King, and that this less than comfortable-ness is part of my leaning towards y tried and true friend.
> 
> YMMV (Your Mileage May Vary)



I've done around 100 intubations (stopped counting a while ago) and about 30 King placements. I'm not anti ETT, but unless services are willing to provide the oversite and training needed, and individual medics are willing to devote the time master airway control (not just intubation) then LMAs or Kings/Combis are the only thing that should be allowed.


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## TransportJockey (Oct 25, 2010)

I'd rather toss in a King and then deflate the stomach through the port on it, or an MLA and deflate through the tube you're not using. No stopping and way under 30 seconds for an advanced airway. I dont have a lot of experience with the King, so I'll always fall back to the Combi if I can. 
Even though I can tube now in my service, I still will be hard pressed to not go for the MLA.


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## Handsome Robb (Oct 26, 2010)

Protocols at the company that I am going to I school call for a King. They dont even consider a tube unless ROSC is present and the current airway isn't patent, but kings tend to do the trick pretty well according to the medics I have rode with and talked to.


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## MrBrown (Oct 26, 2010)

Whats the fuss, Brown proclaims nobody ever died of cardiac arrest.


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## TransportJockey (Oct 26, 2010)

MrBrown said:


> Whats the fuss, Brown proclaims nobody ever died of cardiac arrest.



 I've had my suspicions...


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## MrBrown (Oct 26, 2010)

jtpaintball70 said:


> I've had my suspicions...



Lets Brown rephrase, nobody died of cardiac arrest by not having an inthierendotracheal tube shoved down thier gob


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## TomB (Oct 26, 2010)

wiggy762 said:


> ...that somewhere around 100+ successful intubations allows some sort of experience-based authority. At this number, the Medic has a good amount of experience with the other than normal airways.
> 
> Like I said..."YMMV" (Your Mileage May Vary)
> 
> I apologize if I ruffled some feathers.



The average paramedic in the United States will have fewer than 100 intubations under their belt at the end of their career, so clearly it is your mileage that varies.


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## reaper (Oct 27, 2010)

usalsfyre said:


> Not to be rude, but...
> 
> The way to protect against aspiration is to prevent aspiration. The tools to do that are a gastric tube, either NG or OG, placed as soon as conviently possible, and good oral care in the form of suction. They can both be performed with a ETT or King in place (granted oral care is tough). Thousands of cases of VAP will disagree with you on the aspiration protection offered by ETT, and an ETT placement does nothing to deal with gastric distension that may have occured PTA. Although it's entirely conjecture, I'll bet a King/OG tube combo will do as much (or more) to protect against aspiration as a ETT alone. Remember that airway protection and intubation are not one and the same.
> 
> ...



I agree with everything you wrote, right up until the last sentence. There are times when an ETT is needed and nothing else will do. For a system to totally do away with ETT is asking for trouble. I agree that on an arrest, a King would be my first choice. They are excellent designed airways and provide ventilation without problems. But, there are still times when an ETT is needed or you will end up losing that airway.


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## usalsfyre (Oct 27, 2010)

reaper said:


> I agree with everything you wrote, right up until the last sentence. There are times when an ETT is needed and nothing else will do. For a system to totally do away with ETT is asking for trouble. I agree that on an arrest, a King would be my first choice. They are excellent designed airways and provide ventilation without problems. But, there are still times when an ETT is needed or you will end up losing that airway.



Completely agree. There are times when an ETT is the only intervention that will work, just like there's times when only a surgical airway will work. I don't wish to see these interventions taken away at all...

...*BUUUTTT*....

..at some point writing protocols becomes a numbers game about doing the most good for the most patients. Unless a particular system is vigilant about proficiency and QA/QI of ETTs (especially if RSI is used), my bet is a far larger number of patients will be helped by taking layrengoscopes out of "Mongo the Cavemedic's" hands than the few cases where an ETT is the level of airway needed.


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## swissmedic (Oct 29, 2010)

In our protocolls we are not allowed to stop cpr. First advanced airway tools is the larynxtube (kingtube) if this not work we use the glide scooe for ETT (don't forget the NG and OG tools. I often use them in the operationsrooms).
If you can't intubate and have a bad ventilation you can stop CPR for your airway management NOT LONGER FOR 30sec., but there not many patients with mallampati grade 3-4. In opinion in most of the cases the kingtube works good during cpr :unsure:
Matt


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## MrBrown (Oct 29, 2010)

Wasn't Wiggy off Laverne and Shirley? And wasn't that on in the SEVENTIES?


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## wiggy762 (Oct 29, 2010)

*That was Squiggy....*

...but I am from the way back.

Was practicing EMS in the 80's.


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## TransportJockey (Oct 29, 2010)

70s.? You mean they had wheels and ambulances back then?!


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## emtchick171 (Oct 29, 2010)

Never paused for placing an ET tube in during a cardiac arrest, I get someone to hold Cric pressure & make sure everything is in order before I begin & then it takes less than 10 secs to get the tube in place. The only time I pause compressions is to check for breath sounds after the tube is in place...then compressions start back immediately...and my ETCO2 detector is placed.


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## wiggy762 (Oct 29, 2010)

*Lp 5...*

was the cutting edge...B)


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