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It may be possible to insert an ETT through a King, or maybe I am thinking about an entirely different airway...
ET entubation in cardiac arrest victims
- Thread starter HMartinho
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It may be possible to insert an ETT through a King, or maybe I am thinking about an entirely different airway...
No, the King is a blind stick that ends up in the esophagus. The distal cuff inflates, closing this off, and the proximal cuff inflates in the pharynx to stop air escaping out of the mouth.
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Good to know, I have very little experience with that device since I don't work anywhere it is carried. Is it possible to use a rescue airway to assist with an endotracheal intubation or is it always one or the other?
You can pass a bougie (sp?) through a king tube that is correctly situated, removing the need to laryngoscopy, but this isn't something I've ever tried.
That said, it should take too long to deflate the king, whip it out and then in pass an ET the old fashioned way.
Interesting, but lets consider who is contributing a huge proportion of the data on intubation of cardiac arrests for ROC (or data in general)... Not exactly representative of EMS training or ongoing experience (sadly).
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Some have a port on the back where you can insert an OG tube.
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I've tried it a few times and it's never worked. The King gets a slight bend in it once it's inserted, which prevents the bougie from passing through.
Side note: If you have the King LTS-D (the King with the G-tube port), and you do not have a G-tube... PLUG THE HOLE!! Found out the hard way that the port has a tendency to provide a release for (read: spray) vomit when not plugged...
h34r:There is an intubating-LMA out there, that has a port you can pass an ETT through. For some reason, they're ungodly expensive. Never used one.
Side note: If you have the King LTS-D (the King with the G-tube port), and you do not have a G-tube... PLUG THE HOLE!! Found out the hard way that the port has a tendency to provide a release for (read: spray) vomit when not plugged...
This was also a great form of confirmation when pracing the combitube. Vomit sprays explosively out of tube #2.
The thoughtful folks at Laerdal, Phillip Morris, or Mattel or whoever made that mass of plastic provided a nice vomit deflector you could put on top, so you could pick your victim. Watch out EMS supervisor! Watch out fire medical responder!
[Just kidding of course, because intentionally spraying vomit over another human being is probably "wrong".]
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This was also a great form of confirmation when pracing the combitube. Vomit sprays explosively out of tube #2.
The thoughtful folks at Laerdal, Phillip Morris, or Mattel or whoever made that mass of plastic provided a nice vomit deflector you could put on top, so you could pick your victim. Watch out EMS supervisor! Watch out fire medical responder!
[Just kidding of course, because intentionally spraying vomit over another human being is probably "wrong".]
Works well on the bystanders that won't step back. :whistle:
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NYMedic828
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Just as a side note to this thread, the ALS coordinator of my area informed yesterday that if we have an arrest, and we get ROSC, but we cannot get a capnography value we have to extubate and BVM the patient....
This stemmed from an arrest I had an arrest 2 days back where the guy was an easy tube. It was so easy that even though I forgot to put a stylet into the tube, I still got it right in. (got lucky on that dumb mistake)
Problem was, for some reason the machine wouldn't give me a capnography value. I tried 2 additional cap lines, still no value, just 0s.
So now the problem is either
A: Hes super dead and has no viable lung tissue
B: Monitor failure.
Turned out the monitor worked fine when I blew into a new line after the run to test it later on.
But the moral of this story is, NYC does not allow you to keep an ET tube in a patient if they regain ROSC but you cannot get a capnography value. Regardless of the fact that 3 paramedics, and the ER staff all agreed the tube was perfectly placed and I saw it go directly through the cords, on paper it is unacceptable.
If we had an alternative airway in NYC, this wouldn't be a problem. Granted we do carry combi-tubes, but you cannot combitube a living patient as per protocol, and I wouldn't want to anyway because of the potential trauma that beast of an airway can cause.
This stemmed from an arrest I had an arrest 2 days back where the guy was an easy tube. It was so easy that even though I forgot to put a stylet into the tube, I still got it right in. (got lucky on that dumb mistake)
Problem was, for some reason the machine wouldn't give me a capnography value. I tried 2 additional cap lines, still no value, just 0s.
So now the problem is either
A: Hes super dead and has no viable lung tissue
B: Monitor failure.
Turned out the monitor worked fine when I blew into a new line after the run to test it later on.
But the moral of this story is, NYC does not allow you to keep an ET tube in a patient if they regain ROSC but you cannot get a capnography value. Regardless of the fact that 3 paramedics, and the ER staff all agreed the tube was perfectly placed and I saw it go directly through the cords, on paper it is unacceptable.
If we had an alternative airway in NYC, this wouldn't be a problem. Granted we do carry combi-tubes, but you cannot combitube a living patient as per protocol, and I wouldn't want to anyway because of the potential trauma that beast of an airway can cause.
zmedic
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I guess you can look at it from the other side. If your three explanations are
1: Patient's dead
2: Monitor failure
3: The tube is not in the trachea.
If it's #1, it doesn't matter to me if that patient is bagged or has an ET tube in, they aren't coming back. If I remember right no one get successfully revived if their ETC02 is bellow a certain number (7? 5?, something like that. Either way 0 is less that that threshold). So that tube doesn't really matter in that case.
If the truth is number 3, clearly the tube should get pulled.
If it's number 2, ideally there should be another monitor available (ie the condition boss's) that can be tried.
Given the reduction of importance of intubation in ACLS, it worries me a little if a lot of time and effort on the code are being spent trouble shooting this tube. In the ER if there is bad CO2 we pull the tube, even if their are good breath sounds.
If I were a medical director, thinking on a system level, it would make me a little nervous keeping a tube in with a C02 of 0. I'm sure you and your partner are very good medics, but there are a lot of guys out there who are just over the competency line and who I could see arguing that they are sure a tube is in, when it in fact isn't. I think I'd rather have 10 or even 20 tubes taken out that were really in, rather than have 1 patient transported with an esophegeal tube.
Final thought is if you have a 3rd C02 line, blowing into the monitor during the code to confirm that it isn't a monitor problem, and documenting that on your run form so if someone looks at the strip they don't think there was ROSC. If you did that during the call you know it's not the line and it's not the monitor, so you are left with options 1 and 3. Either way leaving the tube in doesn't help the patient, and if 3 it will hurt them.
How did the patient do?
1: Patient's dead
2: Monitor failure
3: The tube is not in the trachea.
If it's #1, it doesn't matter to me if that patient is bagged or has an ET tube in, they aren't coming back. If I remember right no one get successfully revived if their ETC02 is bellow a certain number (7? 5?, something like that. Either way 0 is less that that threshold). So that tube doesn't really matter in that case.
If the truth is number 3, clearly the tube should get pulled.
If it's number 2, ideally there should be another monitor available (ie the condition boss's) that can be tried.
Given the reduction of importance of intubation in ACLS, it worries me a little if a lot of time and effort on the code are being spent trouble shooting this tube. In the ER if there is bad CO2 we pull the tube, even if their are good breath sounds.
If I were a medical director, thinking on a system level, it would make me a little nervous keeping a tube in with a C02 of 0. I'm sure you and your partner are very good medics, but there are a lot of guys out there who are just over the competency line and who I could see arguing that they are sure a tube is in, when it in fact isn't. I think I'd rather have 10 or even 20 tubes taken out that were really in, rather than have 1 patient transported with an esophegeal tube.
Final thought is if you have a 3rd C02 line, blowing into the monitor during the code to confirm that it isn't a monitor problem, and documenting that on your run form so if someone looks at the strip they don't think there was ROSC. If you did that during the call you know it's not the line and it's not the monitor, so you are left with options 1 and 3. Either way leaving the tube in doesn't help the patient, and if 3 it will hurt them.
How did the patient do?
NYMedic828
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Pretty cool to now there is an NYC ER Doc on the board.
The patient had Gastric cancer, and the circumstances by which he was given to us, were very sketchy and brought up many questions.
That aside, the ER did manage ROSC, but it was short lived if even half an hour.
I took the monitor back and tested it after the call to ensure it could stay in service. I honestly think the ETC02 was in fact 0 it is the only thing that makes sense.
The patient was extremely malnourished and had next to no body fat, even without visualizing/auscultation, you could tell by seeing all of his intercostals evenly rising.
It was honestly a terrible day for intubations. We had a second arrest following the first, who aspirated his entire breakfast into his trachea. His throat was filled up with fluid above the level of the glottis. After suctioning the heck out of him during CPR, I get the tube in only to find a fireman has moved the tape I needed to secure it. I make the mistake of letting go of the tube and no sooner does the BLS crew rip it out by mistake in an attempt to ventilate. (got it back in with some more suctioning, had to suction the tube almost immediately after as well it was so full of vomitus)
Like you said, the ET tube seems to hurt us a significant amount of the time depending on the competency of the provider. I volunteer as well here and in my county we have mostly "Critical-Care Techs" which are able to do everything a paramedic can, but have to contact medical control for approval for just about anything but D50, routine IV and cardiac arrest procedures. Most "CCs" have never and will never intubate a real human being.
I wasn't there but was informed of an arrest we had, in which 4 people on the crew attempted to obtain an ET tube, and failed rather than realize the need to just use a combitube and focus on quality CPR. (they rolled into the ER with no airway maintenance device to my understanding)
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Is it possible that he exsanguinated into the abdomen? This might explain no PETCO2.
NYMedic828
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There was no distension or anything that would suggest it, but the patient as I stated was extremely malnourished so his fluid volume was probably not too fantastic to begin with. (The poor guy was basically a walking ribcage)
I never followed up on the patient past if the ER agreed the tube was viable or not. I tried finding the doc later but they changed shifts.
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A cancer pt in a catabolic state who arrests?
This guy was dead before you got there.
I am amazed he wasn't a DNR and even more so the ED chose to work him.
NYMedic828
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Thats where the sketchyness came in.
We pulled up to the PD BLS unit doing CPR in front of the entrance to the airport. (the cop was actually a medic working BLS)
The story was, this guy is with his relative (some guy, barely spoke english) and went "unconscious" so he pulls into the airport and calls for help and PD gets there, calls the arrest.
So we pull up, move him out of the crowd of people into our ambulance and in NYC, once resuscitation has been initiated it must be continued regardless of findings unless discontinued by a physician.
He was cold to the touch, but he was outside in winter for who knows how long before help arrived. We also have no idea whether or not this guy was a fresh arrest, which we highly doubted or if he was down in this guys car for who knows how long.
So long story somewhat short, we ran the arrest because we knew the medical director would not tell us to call it on the basis of it potentially being fresh and we were already at the ambulance, why leave a body in the public eye.
As far as a DNR goes, we assumed he had to have one in his state, but it wasn't present on-scene so that was out the window.
The second arrest was actually an end-stage cancer patient as well. (Pancreatic) He had the same malnourished body but he ate breakfast, went to bed, 30 min later was in arrest. He was acidoditic at 58 if i recall for initial ETC02, we got rosc on him after 3 shocks and some meds but he was short lived as well. No DNR because of his selfish wife who would rather him suffer than to lose him peacefully.
cruiseforever
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Then he/she is not a doctor, just somebody with a medical degree.
(there is a world of difference)
That is unfortunate.
I have no doubt you were doing the best you could in the care of this patient.
A medical director who won't terminate efforts or give permission for such on an end stage cancer patient in arrest isn't really doing what is best for the patient. Probably just generating a bill or practicing resuscitation skills.