ET entubation in cardiac arrest victims

[HMartinho]

As we all know, since the EMT-B's to EMT-P's, the interruption of chest compressions to ventilate the patient (according to the recommendation of 30:2), drastically decreases the coronary perfusion pressure, seriously decreasing the survival probability of the patient.
We also know that the only way to vent without interrupting cardiac compressions is to ensure an advanced airway (encontraqueal tube, laryngeal mask or Combitube). So why ILS or ALS teams, when identify cardiac arrest, the first approach is not to proceed with endotracheal intubation, or placement of the laryngeal mask?
In Portugal, we use the recommendations from the American Heart Association, and we have our protocols with specific actions, as I think which happens in the U.S..

I accepted suggestions, approaches, and everything you find relevant to this discussion.

 

[Veneficus]

As we all know, since the EMT-B's to EMT-P's, the interruption of chest compressions to ventilate the patient (according to the recommendation of 30:2), drastically decreases the coronary perfusion pressure, seriously decreasing the survival probability of the patient.
We also know that the only way to vent without interrupting cardiac compressions is to ensure an advanced airway (encontraqueal tube, laryngeal mask or Combitube). So why ILS or ALS teams, when identify cardiac arrest, the first approach is not to proceed with endotracheal intubation, or placement of the laryngeal mask?
In Portugal, we use the recommendations from the American Heart Association, and we have our protocols with specific actions, as I think which happens in the U.S..

I accepted suggestions, approaches, and everything you find relevant to this discussion.

A few reasons not too rooted in the delivery of 02 (do2) and o2 extraction.

intubation with excessive ventilaton is more harmful than compressions only. If you read the AHA position, it states intrathoracic pressure increases during ventilation

Another off hand point is there is a physiologic reserve of oxygen, so it is not the most important treatment.

back to Do2, if there is a clot blocking blood flow, or bleeding reducing flow, then excess o2 isn't getting anywhere.

There is also the issue of reperfusion injury and the secondary effects of free radical generation.

Furthermore, since CPR and defib are the only proven treatments, those take priority over o2 delivery.

Not a complete or indepth post by any means.

If I might respectfully suggest something?

Read up on physiology.

This topic is explained very well in this book:


http://www.amazon.com/Physiologic-B...1382/ref=sr_1_2?ie=UTF8&qid=1328282027&sr=8-2

or if you have a medical library at hand:

http://www.amazon.com/Millers-Anest...=sr_1_1?s=books&ie=UTF8&qid=1328282073&sr=1-1

 

[Shishkabob]

My agency wants a King put in place. The only time they want an ETT on a cardiac arrest is if you either can't get a King, or after you get ROSC as part of the stabilization procedures.

Putting a King in won't interrupt compressions. Though if you're good enough, ETI won't interrupt compressions either.


If you have to stop to put an airway in, you've chosen the wrong airway.

 

[shfd739]

We still intubate but not until the 8min mark of working. Up to that point we use passive oxygenation with an OPA and NRB.

Medic gets one attempt then has to move to a Combitube.

 

[fast65]

We have the option of going with a King, or attempting to intubate, either way, we can't stop compressions. However, like Vene said, the only two proven treatments in cardiac arrest are CPR and defibrillation, so ventilation takes a backseat to both of those.

 

[MSDeltaFlt]

AHA does not require intubation in cardiac arrest. It is not a requirement for ventilation in an apneic pt. However, intubation, LMA's, Combitubes, and the like do make it easier. The only requirement in the pulseless and apneic pt is an airway. Advanced airways are only "considered" further down the algorithm.

You only intubate or place a supraglottic airway if you can place them without interruption of chest compressions. Once you start compressions, you don't stop unless you A) check rhythm/pulse or B) shock.

 

[NYMedic828]

A few reasons not too rooted in the delivery of 02 (do2) and o2 extraction.

intubation with excessive ventilaton is more harmful than compressions only. If you read the AHA position, it states intrathoracic pressure increases during ventilation

Another off hand point is there is a physiologic reserve of oxygen, so it is not the most important treatment.

back to Do2, if there is a clot blocking blood flow, or bleeding reducing flow, then excess o2 isn't getting anywhere.

There is also the issue of reperfusion injury and the secondary effects of free radical generation.

Furthermore, since CPR and defib are the only proven treatments, those take priority over o2 delivery.

Not a complete or indepth post by any means.

If I might respectfully suggest something?

Read up on physiology.

This topic is explained very well in this book:


http://www.amazon.com/Physiologic-B...1382/ref=sr_1_2?ie=UTF8&qid=1328282027&sr=8-2

or if you have a medical library at hand:

http://www.amazon.com/Millers-Anest...=sr_1_1?s=books&ie=UTF8&qid=1328282073&sr=1-1

The two bolded statements, are the main reason for AHA not wanting airway to be your primary concern.

The cause of cardiac arrest in adults, is rarely due to respiratory arrest. This being the case, that means that the blood statically sitting in the body during arrest still has sufficient oxygen in it to initially perfuse vital organs. Not until we start doing CPR does that oxygen reserve get utilized.

Its like holding your breath underwater. Though you aren't breathing for an extended period of time, your body does still receive oxygen and hence you retain consciousness and a heartbeat.

On the other hand, if you note that AHA recommends 15:2 for kids when more than one provider is present, this is based on the idea that when kids go into cardiac arrest, it is usually related to respiratory arrest. If respiratory arrest is the cause, then the body will not have this remaining cache of oxygen in the blood to utilize as soon as you begin compressions. The thing is that we don't know for sure if respiratory arrest is the cause, so to play it safe they kept compressions first, but split the time until ventilation started down the middle. Hence 15:2.

Also as stated above, intubating has its fair share of complications. First of all, not everyone is the most skilled in intubation. The AEMT (sort of like intermediate here) in my volunteer department, most of have never intubated a real person. The AEMT class here, does not require intubations on anything but a manikin. (paramedic does)

So, you now have someone who truly doesn't know what they are doing, but thinks they do and wastes all this time trying to intubate 10 times.

Next up is the fact that is is MUCH easier to cause an increase in thoracic pressure when a patient has an advanced airway in place vs mask to face. 9/10 the mask wont make a perfect seal with the face, but it will be adequate to ventilate. This allows for overpressure to have at least some route of escape vs. directly over-inflating the lungs. An ET tube gives you one way in and one way out. If the provider is still pressing in on that bag, the air inst coming out. Pop-off valves aren't set to each patient. A 21 year old kid won't have the same tolerance to over-inflation as an 80 year old. Through this, not only have you caused potential damage to the lungs, you may not be letting enough air to escape the lungs. This causes respiratory acidosis, and more importantly has the potential to cause obstruction to the inferior vena cava and Aorta, decreasing the return of blood to the heart and thereby decreasing cardiac output, the exact thing we are trying to repair. Patients should receive absolutely no more than enough volume of air to see the chest rise. (hard to tell when you are doing them in sync with compressions)

AHA has a very strong emphasis on HIGH QUALITY CPR. BLS before ALS every time. Always remember that no pressor drugs or anything but HIGH QUALITY CPR and early defibrillation has been proven by any studies to increase our chances of ROSC. CPR itself is the only proven method. As long as that patient is getting enough air to perfuse the alveoli and slightly expand the chest, your job is done. Gastric inflation is of course a concern, but there are bigger things in the picture to focus on than a potential secondary or tertiary problem.

(I am an BLS AHA instructor)

 

[Fish]

My agency wants a King put in place. The only time they want an ETT on a cardiac arrest is if you either can't get a King, or after you get ROSC as part of the stabilization procedures.

Putting a King in won't interrupt compressions. Though if you're good enough, ETI won't interrupt compressions either.


If you have to stop to put an airway in, you've chosen the wrong airway.

Seconded

 

[Smash]

Putting a King in won't interrupt compressions. Though if you're good enough, ETI won't interrupt compressions either.

Indeed. We intubate all our arrests. It is reasonably simple to get everything set up, get the blade in, pass the tube, or wait till a pulse check occurs and slip it in then. No interruption to compressions beyond what would normally happen with a pulse/rhythm check taking a few seconds.

We have over 30% survival to discharge for VF/VT arrests, so I guess we do something right!

However, if your practitioners aren't experienced and comfortable with ETI and would take some time to get a tube in, go an EGD, or basic airway care; we all know what makes a difference in arrests, and it sure ain't the bit of plastic down the throat...

 

[tssemt2010]

my agency does king tube immediately, then after we get situated we intubate

 

[Ramis46]

Isn't it funny though that was are ingrained to think; Airway, Breathing, Circulation. All the way through school ABC... And then it comes to ALS and now CPR and difbrilation or the major players. hmmm

 

[usalsfyre]

Talked with one of the docs heavily involved in the ROC trial the other day. Very interesting things to say about Kings and CombiTubes.

 

[abckidsmom]

Talked with one of the docs heavily involved in the ROC trial the other day. Very interesting things to say about Kings and CombiTubes.

Details, you tease...

 

[Veneficus]

Isn't it funny though that was are ingrained to think; Airway, Breathing, Circulation. All the way through school ABC... And then it comes to ALS and now CPR and difbrilation or the major players. hmmm

Welcome to medicine.

If you went to school in the last 5 years you should probably demand some money back.

If you went to school in the last 10 and didn't hear CPR and defib were going to be the major players, your instructor was more concerned about memory aids than teaching science.

"What gives" is they didn't know. You'll see that a lot in EMS instruction.

 

[usalsfyre]

Details, you tease...

Basically neurologically intact survival
was significantly worse with a King than an ETT, and both were WAY worse than BVM alone.

No one seems to know why right now though. Data hasn't been fully analyzed and published yet though.

 

[Veneficus]

Basically neurologically intact survival
was significantly worse with a King than an ETT, and both were WAY worse than BVM alone.

No one seems to know why right now though. Data hasn't been fully analyzed and published yet though.

Not surprised, reading at this very moment the damage and complications caused by esophageal airway devices.

 

[HMartinho]

Thank you all for your great answers and links.

In fact, we all know that the only really effective treatment in cardiac arrest is the cpr and defibrillation. However, in a cardiac arrest victim without an advanced airway inserted, we have to interrupt compressions to ventilate, impairing coronary perfusion. It was here that my question was based.

I'm glad for knowing that some of your states, allow you insert an advanced airway, like king or the Combitube, which allows ventilating the patient without interrupting compressions.

Here, doctors and nurses in pre-hospital, just insert an ETT, laryngeal mask / Combitube, when cardiac arrest is prolonged, and the patient does not respond after the 3rd or 4th shock.

Uunfortunately ,we EMT-B's can only use OPA and NPA airways, using the 30:2 ratio.

 

[abckidsmom]

Basically neurologically intact survival
was significantly worse with a King than an ETT, and both were WAY worse than BVM alone.

No one seems to know why right now though. Data hasn't been fully analyzed and published yet though.

Interesting. Watching the pendulum swing is like being at a tennis match.

 

[zmedic]

They tell us in school that 50% of what we learn will be proven wrong by the end of careers in medicine. The problem is that no one knows which 50%. Especially in EMS you have to expect a lot of changes. I'd say that about 75% of what is done in the field has little or no evidence behind it saving lives (backboard, KED, magnesium for asthma etc etc). So it shouldn't be such a shock when things change.

Also the CAB v ABC thing is silly and confusing. I understand what the AHA is trying to do, trying to reduce the delay to compressions. But in a lot of things it still makes sense to do ABC. For example, you have a trauma patient. If they don't have a pulse they are pretty much dead, so checking a pulse before airway doesn't make sense since if they aren't breathing because of an obstructed airway correcting the airway is the priority.

Also with resuscitation since things keep changing you have to keep going back and looking at the things that have stayed the same. So if you looked at the effect of intubation in patients with the 2005 guidelines, you may get different results with the 2010 guidelines.

 

[DrParasite]

my agency does king tube immediately, then after we get situated we intubate

Just so I am sure, you king tube immediately, do some CPR, then yank the king out and intubate with the ETT?

I just want to make sure I am understanding you