Study on Survival vs Intubation during IHCR

[E tank]

.... regardless of how good we are or aren't at it, it just isn't the best thing for these patients.

Well this is it exactly. Tracheal intubation, as an element by itself, is an objective good for patients that have arrested. "We" are just not so objective in how good we are in intubating the trachea.

 

[Carlos Danger]

Because this study is flawed. It studied an area that stops compressions to gain intubation. A lot of areas have gone to not stopping compressions during CPR and are seeing the results from it. If you stop compressions in your area, then yes, drop a SGA. But not all areas practice the same way. This is how we find the new ideas that work.

Where in the study does it say that these patients all had compressions stopped to perform the intubation?

And what data is there that indicates that it even makes a difference? Reference, please.

 

[VentMonkey]

Before this turns into the super heated airway debate it probably will, I'd like to chime in.

Honestly I haven't even read the study yet. Why? Well, it's nothing really new or surprising in regards to ETI regardless if it's in the field, or a "controlled" environment. It hardly seems like something new; still worth inciting good discussion though, @Summit.

I still firmly believe that prehospital ETI should be reserved for a select few with advanced airway training, not the standard paramedic curriculum alone. Yes, this would include how, and why they should be placed directly on the ventilator.

FWIW, at least at my service, nowadays more often than not we're looking for ways to not have to intubate someone. Unless of course it poses an absolute risk to the patient, and/ or flight itself.

Clearly, SGA's these days aren't what they were 20 plus years ago, neither is the ACLS algorithm.

Another point I think worth mentioning is even though I haven't been doing this incredibly long, I've done it long enough to see a positive shift in this particular paradigm with respect to the newer generation of paramedics and properly prioritizing their airway management in a SCA's treatment tree.

 

[EpiEMS]

It's like people are so emotionally attached to this intervention, that for some reason they just can't admit that maybe we aren't as good at it as we think we are, OR that maybe regardless of how good we are or aren't at it, it just isn't the best thing for these patients.

This is so true. We cannot define a profession by a single skill alone - but so often "I have a laryngoscope and a drug box, therefore I am a paramedic" is the rallying cry.

On the study itself, they specifically stated:

Potential confounders such as the skills and experience of health care professionals, the underlying cause of the cardiac arrest, the quality of chest compressions, and the indication for intubation were not available in the registry.

Obviously, these are important - recognized - confounders. What would get rid of this is a good ol' RCT. However, to throw out this study *solely* on the basis of this one confounder is overly reductionist.

 

[MackTheKnife]

Remi, seriously? There is a lazyness towards intubation and you know it.

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[reaper]

This is so true. We cannot define a profession by a single skill alone - but so often "I have a laryngoscope and a drug box, therefore I am a paramedic" is the rallying cry.

On the study itself, they specifically stated:



Obviously, these are important - recognized - confounders. What would get rid of this is a good ol' RCT. However, to throw out this study *solely* on the basis of this one confounder is overly reductionist.

Where has anyone stated that? The decision to control an airway comes on a as needed basis. We are learning from mistakes of The past and finding out what works and what to change. There is a reason the AHA makes changes and updates. They look at New ways of doing things. What is bringing very good success in resuscitation today, would have never been thought of 10-20 years ago. This is why we evolve and expand.

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[EpiEMS]

@reaper, FWIW, the AHA is very often behind the state of the science. I'm not sure what you mean with respect to the "as-needed" use of ETI?

 

[reaper]

Have you attended an AHA resuscitation conference? The Drs on this board are some of the best in the industry. They may be behind some areas, because they study the results before publishing changes.

As needed means just that. Each provider must assess the pt in front of them and decide the best course of treatment for that pt. Airway control could be ETI, an SGA or basic adjuncts and maintenance.

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[Carlos Danger]

Where has anyone stated that? The decision to control an airway comes on a as needed basis. We are learning from mistakes of The past and finding out what works and what to change. There is a reason the AHA makes changes and updates. They look at New ways of doing things. What is bringing very good success in resuscitation today, would have never been thought of 10-20 years ago. This is why we evolve and expand.

It is very much the prevailing attitude among paramedics. Any study that doesn't support intubation is quickly dismissed as "flawed". I've been doing this going on 20 years, and it's always been like that.

I'm still waiting on a citation to support your claim a few posts back.

 

[VentMonkey]

 

[EpiEMS]

Have you attended an AHA resuscitation conference? The Drs on this board are some of the best in the industry. They may be behind some areas, because they study the results before publishing changes.

As needed means just that. Each provider must assess the pt in front of them and decide the best course of treatment for that pt. Airway control could be ETI, an SGA or basic adjuncts and maintenance.

While I haven't attended such a conference, I certainly acknowledge that the AHA is regarded as the organization that promulgates what might be considered the standard of care for resuscitation.
As far as airway control and "as needed" choices, I don't buy that - there is evidence for use of certain methods in certain circumstances, and it is incumbent on providers to lean on evidence where possible. In the absolute worst case, biologically/anatomically plausible expert opinions are pertinent. But RCT evidence comes first!

 

[reaper]

10 years ago, I would agree. Times have changed and most systems and Paramedics are advancing the thinking and evidence based medicine. I have been in this 27 years and have seen the changes and evolution of the industry.

The study posted states that a main cause is interuption of compressions and other interventions.

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[reaper]

While I haven't attended such a conference, I certainly acknowledge that the AHA is regarded as the organization that promulgates what might be considered the standard of care for resuscitation.
As far as airway control and "as needed" choices, I don't buy that - there is evidence for use of certain methods in certain circumstances, and it is incumbent on providers to lean on evidence where possible. In the absolute worst case, biologically/anatomically plausible expert opinions are pertinent. But RCT evidence comes first!

Is this not what I said? Each pt is assessed at that time. The treatment decision is made on what is evidence based best for that pt. That comes on a case by case basis by the findings of your assessment of the pt.

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[E tank]

Where has anyone stated that? The decision to control an airway comes on a as needed basis. We are learning from mistakes of The past and finding out what works and what to change. There is a reason the AHA makes changes and updates. They look at New ways of doing things. What is bringing very good success in resuscitation today, would have never been thought of 10-20 years ago. This is why we evolve and expand.

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Nah...AHA guidelines don't change in order to evolve and expand, ie, "improve". They change to dumb down and simplify for the masses of differently abled providers. Vasopressin is a great drug, but it was taken off in the interests of simplicity, not because it is less useful than epinephrine. The AHA guidelines are just that and there are levels of providers both prehospital and hospital that are not obligated to adhere to them, simply because they are not by any stretch of the imagination "enough" for what is called for in many settings.

 

[StCEMT]

Remi, seriously? There is a lazyness towards intubation and you know it.

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Well 99% of the people I see don't need it. Not as much laziness as lack of necessity. And considering the last 2/3 arrests I know of to go out were heroic OD's, I am gonna guess they weren't in the most ideal locations (one was a bp bathroom I believe). I'm not about to get down on that nasty floor when I can drop an igel, be done in seconds and let the vent do the work from there.

 

[MackTheKnife]

Understand that in some cases other means are more appropo. I just continue to see in a general way intubation being viewed negatively.

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[Carlos Danger]

Understand that in some cases other means are more appropo. I just continue to see in a general way intubation being viewed negatively.

Endotracheal intubation is simply a clinical intervention. In and of itself, it is neither good or bad. It all depends on the scenario.

The problem is that for a long, long time, paramedics had drilled into their heads that any sick patient who had any type of respiratory or airway compromise needed to be intubated ASAP, and that any other manner of airway management was inferior and would only be used by a paramedic of inferior skill. Which of course is false in so many ways, but the idea still became a big part of EMS culture. That's why the ability to intubate is one of the first things that many paramedics bring up in the paramedic vs. RN debates.

It seems that this hard line has been softened quite a bit, but underlying everything is still the idea that ETI is "the gold standard" in every case, and that the more "clinically aggressive" you are (i.e. the more interventions you do) the better paramedic you are. To this day that attitude still very often trumps any research based or well-reasoned recommendation for a more conservative approach.

This study is just the latest in a LONG series of research that fails to support routine early intubation in most scenarios that paramedics do airway management in. Yet still, just look through the responses here. Instead of much discussion even taking place about the study, we get knee-jerk reactions against it. I bet most of the commenters didn't even read it, but are still quick to make nonsensical claims about how quickly they can do an RSI, and how anyone can consistently intubate faster than they can place an SGA, etc. I don't thing many anesthesiologists and CRNA's are as confident in their airway skills as many paramedics are.

On the whole, EMS only respects research that supports them doing what they want to do anyway. Anything that questions a sacred cow is quickly dismissed as flawed

 

[EpiEMS]

On the whole, EMS only respects research that supports them doing what they want to do anyway. Anything that questions a sacred cow is quickly dismissed as flawed.

You are - sadly - too right!

 

[reaper]

Endotracheal intubation is simply a clinical intervention. In and of itself, it is neither good or bad. It all depends on the scenario.

[I believe this was already addressed. That it is a case by case basis of what airway control is needed for the pt in front of you.]

The problem is that for a long, long time, paramedics had drilled into their heads that any sick patient who had any type of respiratory or airway compromise needed to be intubated ASAP, and that any other manner of airway management was inferior and would only be used by a paramedic of inferior skill. Which of course is false in so many ways, but the idea still became a big part of EMS culture. That's why the ability to intubate is one of the first things that many paramedics bring up in the paramedic vs. RN debates.

[ This may still be the case in some areas. I for one have seen a major change in the way medics are educated and trained. That mindset is in the past.]

It seems that this hard line has been softened quite a bit, but underlying everything is still the idea that ETI is "the gold standard" in every case, and that the more "clinically aggressive" you are (i.e. the more interventions you do) the better paramedic you are. To this day that attitude still very often trumps any research based or well-reasoned recommendation for a more conservative approach.

[ I practice and teach to be as least invasive as possible in all treatments. You do what the pt needs. Some only need minor treatments, some need invasive treatment right from the start. Whether you are in or out of hospital, ETI is still " The Gold Standard" as some like to put it. It is the most secure airway we can achieve on the pt. It is not needed in most pts, but those that need it, need it.]

This study is just the latest in a LONG series of research that fails to support routine early intubation in most scenarios that paramedics do airway management in. Yet still, just look through the responses here. Instead of much discussion even taking place about the study, we get knee-jerk reactions against it. I bet most of the commenters didn't even read it, but are still quick to make nonsensical claims about how quickly they can do an RSI, and how anyone can consistently intubate faster than they can place an SGA, etc. I don't thing many anesthesiologists and CRNA's are as confident in their airway skills as many paramedics are.

[ There are many studies that look at statistics only. There are too many varibles for them to provide evidence based medicine. Most studies like this will state the same, just as this one did. When you look at controlled research studies, they provide the best evidence for any practice. Am I perfect on airways? No, no one is. That is why we practice to stay proficient. Through Sin labs, cadaver labs, and OR time. That is how you stay confident in your abilities. I believe someone stated That they intubate daily. I find this hard to believe, but if that is what they stated, maybe somehow they do. I do not know many medics that value their practice off how many tubes they can get. Those medics never make it too far.]

On the whole, EMS only respects research that supports them doing what they want to do anyway. Anything that questions a sacred cow is quickly dismissed as flawed

[ Seriously? EMS lives off evidence based research now a days. Most just know not to take many studies with much salt. A lot of studies published today do not support what they claim to. That is why we research the studies and the evidence before making major changes to anything.

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[EpiEMS]

There are many studies that look at statistics only. There are too many varibles for them to provide evidence based medicine. Most studies like this will state the same, just as this one did. When you look at controlled research studies, they provide the best evidence for any practice. Am I perfect on airways? No, no one is. That is why we practice to stay proficient. Through Sin labs, cadaver labs, and OR time. That is how you stay confident in your abilities. I believe someone stated That they intubate daily. I find this hard to believe, but if that is what they stated, maybe somehow they do. I do not know many medics that value their practice off how many tubes they can get. Those medics never make it too far.

Statistics only? I'm not sure what you mean by that. Do you mean retrospective reviews (case control) as opposed to RCTs? The caveats are clear with a case control or other data review.

(There aren't many large scale high quality RCTs that address prehospital ETI versus SGAs versus BVM that I am aware of.)

Regarding the number of intubations, there is actually very good evidence that practice/quantity matters and ongoing performance matters.