Pausing for the tube

[Veneficus]

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.

 

[Aidey]

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.

 

[zmedic]

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.

 

[Veneficus]

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?

 

[socalmedic]

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.

 

[the_negro_puppy]

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

 

[jjesusfreak01]

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.

 

[Aidey]

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

 

[Melclin]

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.

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.

 

[Durchii]

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.

 

[wiggy762]

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

 

[TomB]

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.

 

[usalsfyre]

***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.

 

[wiggy762]

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.

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.

 

[wiggy762]

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)

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.

 

[usalsfyre]

...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.

 

[TransportJockey]

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.

 

[Handsome Robb]

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.

 

[MrBrown]

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

 

[TransportJockey]

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

I've had my suspicions...