New study: ETI versus Supraglottic Airway Insertion in OOH Cardiac Arrest
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I think the logic here is flawed. By doing an intubation every shift (mannequin or otherwise) you're simply keeping in practice. There's no magic here. Muscle memory? Really? How 'bout just practicing and reinforcing good technique?
Also - if there is one attempt total, I can understand that. One attempt and then someone else gets to try is not the greatest concept. On the occasions that I have difficulty with an intubation and don't get it on the first attempt, by seeing the anatomy that's there, I know what I have to do on my second attempt, whether it's better position, change blades, use a bougie, or use something else like an LMA to secure the airway. If you're experienced at airway management, then you should have a really good idea of what you need to do if you miss.
If your idea is that you get one shot only and you better make it good, then I think you've already put yourself at a disadvantage because you're likely to spend more time trying than you should.
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Shishkabob
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No, that one is a tad bit older than the one I'm speaking of, but shows the general relation as described. Especially since Combis aren't used anymore.
I mean, if that's the agency I'm working for
h34r:How is the logic flawed? Keeping in practice is essentially creating 'muscle memory'.
In what world is one slightly longer attempt worse than multiple attempts, as you proclaim? And if you're thinking that the bougie should only be used after your first attempt, you're already spending more time than you should. Use what you have to to minimize the amount of attempts required... which means the bougie should be your first thing going in. Just as continuous capnography should be required for all verification, bougies should be required for all initial attempts.
For my agency, an attempt is defined as an ETT passing the teeth. You can put the blade in and see if it gives you a good visual, if not, back out and switch blades.
I'm an outspoken critic of research in to success rates and attempts and what not. They don't matter nearly as much as the 'experts' proclaim. Who cares if I miss an IV, so long as I notice it and fix it before pushing necrotizing meds through it? Who cares if you miss an ETI so long as you recognize that you missed and correct it in a timely manner?
Don't take forever tubing, don't stop other interventions, and recognize when you're not in the trachea, and that solves many issues from opponents trying to get rid of pre-hospital ETI.
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So... After looking at the data presented in the powerpoint, it appears that your service actually had a 70% first pass success for the 4/1/06-8/31/07 time period. Slide 14 states that the overall ETI success was 74% But, of the patients that were successfully intubated, 95% were intubated on the first attempt. Prior to the one attempt policy, your overall ETI success was 84%, apparently.
Overall, I think it is a reasonable policy, but saying your 1st pass success is "near 100%" is misleading (though I assume that was not purposeful).
Also, it is worth mentioning the definition of an attempt - I suppose what counts as an attempt is somewhat controversial, but I think of it as inserting the blade in to the mouth, not inserting the tube in to the mouth. (The National Association of EMS Physicians uses the blade-based definition, as does most text books, anesthesiologists, and EM physicians.) The ETT-based definition is much more forgiving. In retrospect, if I used the ETT-based definition for determining first-pass, I'd have a 95% first pass rate. But, when I consider the laryngoscope based definition, my first pass rate drops to the high 70s/low 80s.
Anyhow, I look forward to seeing the updated data when it is published.
Overall, I think it is a reasonable policy, but saying your 1st pass success is "near 100%" is misleading (though I assume that was not purposeful).
Also, it is worth mentioning the definition of an attempt - I suppose what counts as an attempt is somewhat controversial, but I think of it as inserting the blade in to the mouth, not inserting the tube in to the mouth. (The National Association of EMS Physicians uses the blade-based definition, as does most text books, anesthesiologists, and EM physicians.) The ETT-based definition is much more forgiving. In retrospect, if I used the ETT-based definition for determining first-pass, I'd have a 95% first pass rate. But, when I consider the laryngoscope based definition, my first pass rate drops to the high 70s/low 80s.
Anyhow, I look forward to seeing the updated data when it is published.
A few thoughts:
For the cardiac arrest setting, I think it's difficult to say whether one longer attempt is worse than several shorter attempts. I think this really depends on whether CPR is ongoing during the intubation, and what the cause of the arrest is.
I do see how focusing on first-pass success, or limiting the number of intubation attempts could cause a mentality where providers push the envelope on how long an intubation attempt should be.
I think you could make an intelligent argument that for closed head injuries, multiple shorter attempts might be preferable to a single longer attempt, if we can avoid hypoxia / hypercapnia during the shorter intubation attempts. But we have a different set of priorities during cardiac arrest, where CPR is the priority in most situations.
At the very least we can probably accept that a longer intubation attempt + ongoing compressions is much better than a longer intubation attempt without compressions.
I don't claim to be any sort of airway expert, nor at my best, was I ever a particularly great intubator. But it seems that the numbers only reveal part of the story, and the success or failure of an intubation as a binary outcome fails to describe how traumatic, prolonged, hypoxic, hypercapnic the event was. There's a danger to win a battle, but lose the war if we focus too heavily on success rates.
I think the blade past the teeth rule works well for cardiac arrests. I think it's less ideal when you're intubating without paralytics, and there's an element of uncertainly as to whether you have intubating conditions -- you pass the blade, there's too much muscle tone, or some reflex remaining, and then you've used up one attempt. You give more drugs, try again, and if there's any problem, you might be committed to a difficult airway algorithm.
What are other people's opinions on this?
As an aside: a lot of the cardiac arrest data has also discussed the effects of overaggressive PPV on intrathoracic pressure and venous return, has anyone made/used/trialed a cheap airway pressure monitor that might give some idea as to whether we've PEEP'd the crap out of the patient? Would this even be useful?
For the cardiac arrest setting, I think it's difficult to say whether one longer attempt is worse than several shorter attempts. I think this really depends on whether CPR is ongoing during the intubation, and what the cause of the arrest is.
I do see how focusing on first-pass success, or limiting the number of intubation attempts could cause a mentality where providers push the envelope on how long an intubation attempt should be.
I think you could make an intelligent argument that for closed head injuries, multiple shorter attempts might be preferable to a single longer attempt, if we can avoid hypoxia / hypercapnia during the shorter intubation attempts. But we have a different set of priorities during cardiac arrest, where CPR is the priority in most situations.
At the very least we can probably accept that a longer intubation attempt + ongoing compressions is much better than a longer intubation attempt without compressions.
I don't claim to be any sort of airway expert, nor at my best, was I ever a particularly great intubator. But it seems that the numbers only reveal part of the story, and the success or failure of an intubation as a binary outcome fails to describe how traumatic, prolonged, hypoxic, hypercapnic the event was. There's a danger to win a battle, but lose the war if we focus too heavily on success rates.
I think the blade past the teeth rule works well for cardiac arrests. I think it's less ideal when you're intubating without paralytics, and there's an element of uncertainly as to whether you have intubating conditions -- you pass the blade, there's too much muscle tone, or some reflex remaining, and then you've used up one attempt. You give more drugs, try again, and if there's any problem, you might be committed to a difficult airway algorithm.
What are other people's opinions on this?
As an aside: a lot of the cardiac arrest data has also discussed the effects of overaggressive PPV on intrathoracic pressure and venous return, has anyone made/used/trialed a cheap airway pressure monitor that might give some idea as to whether we've PEEP'd the crap out of the patient? Would this even be useful?
I don't think it is appropriate to use 2 different definitions of an intubation attempt based on patient characteristics. Whether you insert a tube or not during the attempt doesn't change the fact that you were intending to intubate. Additionally, whether one attempts to place the tube or not, you are still having to cease manual ventiation, you will still provoke some sort physiological response to laryngoscopy, you still run the risk of causing physical injury to the pharyngeal structures, and then there is always the risk of hypoxic injury. Basically, the potential for harm is pretty much the same whether you attempt to place the tube or not.