Study on Survival vs Intubation during IHCR

[Summit]

Key Points
Question: Is tracheal intubation during adult in-hospital cardiac arrest associated with survival?

Findings: In a study of 86 628 adults with in-hospital cardiac arrest using a propensity-matched cohort, tracheal intubation within the first 15 minutes was associated with a significantly lower likelihood of survival to hospital discharge compared with not being intubated (16.3% vs 19.4%, respectively).

Meaning: These findings do not support early tracheal intubation for adult in-hospital cardiac arrest.

http://jamanetwork.com/journals/jama/fullarticle/2598717#150045279

 

[CWATT]

From the article:

"Multiple mechanisms could explain a potential causal relationship between tracheal intubation and poor outcomes.
First, tracheal intubation might lead to a prolonged interruption in chest compressions.
Second, tracheal intubation might lead to hyperventilation and hyperoxia, which are associated with poor outcomes.
Third, tracheal intubation could delay other interventions such as defibrillation or epinephrine administration.
Fourth, delays in the time to success of intubation could result in inadequate ventilation or oxygenation by other means.
Fifth, unrecognized esophageal intubation or dislodgement of the tube during the cardiac arrest could lead to fatal outcomes."


My thoughts:

I do wonder about delaying chest compressions to insert an ET tube. Has anyone intubated someone while chest compressions are continued (either manually or with a Lucas)? What was your experience like?

Secondly, hyperventilation and hyperoxia can occur with a King or OPA/BVM, so I think this is a separate issue and not specific to ET.

Third, you should never delay defibrillation. I'm wondering if the article states this because practitioners were doing that. Epi on the other hand - well, an ED doc recently told me we give Epi for ourselves and not the patient (because it makes us feel better / like we're doing something)

 

[FLdoc2011]

Have been involved in a lot of in-hospital arrests and I try not to interrupt compressions. Can be tricky but certainly possible to intubate during compressions or during a brief pulse check.

 

[reaper]

We do not stop compressions for intubations. We started about 2 years ago and it helped reduce time off chest. It is not difficult. Just have to get providers used to doing it.

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[EpiEMS]

This is begging for a large-scale RCT...

 

[NomadicMedic]

It should be CPR=SGA. If you get ROSC, then you can eff around with ETI.

 

[Uclabruin103]

Most of the time you don't need to stop compressions for a tube. If anything I'll do a brief pause while I actually pass the tube, but otherwise keep compressing.

 

[reaper]

ETI takes no more time then a SGA. Just do not stop compressions.

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[Midazzled]

Placing a SGA seems reasonable. I certainly wouldn't advocate multiple intubation attempts on a pulseless patient.

 

[MackTheKnife]

From the article:

"Multiple mechanisms could explain a potential causal relationship between tracheal intubation and poor outcomes.
First, tracheal intubation might lead to a prolonged interruption in chest compressions.
Second, tracheal intubation might lead to hyperventilation and hyperoxia, which are associated with poor outcomes.
Third, tracheal intubation could delay other interventions such as defibrillation or epinephrine administration.
Fourth, delays in the time to success of intubation could result in inadequate ventilation or oxygenation by other means.
Fifth, unrecognized esophageal intubation or dislodgement of the tube during the cardiac arrest could lead to fatal outcomes."


My thoughts:

I do wonder about delaying chest compressions to insert an ET tube. Has anyone intubated someone while chest compressions are continued (either manually or with a Lucas)? What was your experience like?

Secondly, hyperventilation and hyperoxia can occur with a King or OPA/BVM, so I think this is a separate issue and not specific to ET.

Third, you should never delay defibrillation. I'm wondering if the article states this because practitioners were doing that. Epi on the other hand - well, an ED doc recently told me we give Epi for ourselves and not the patient (because it makes us feel better / like we're doing something)

During CPR in the prehospital setting, I timed my intubation with compressions. Didn't need to stop CPR or delay. During compression, the cords would open allowing passage of the ETT. Easy peasy. As for in hospital, now that I'm an RN, can't say. But ETI is the GOLD STANDARD.

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[MackTheKnife]

It should be CPR=SGA. If you get ROSC, then you can eff around with ETI.

Disagree.

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[Carlos Danger]

But ETI is the GOLD STANDARD.

Full spinal immobilization is THE GOLD STANDARD, too.

Oh, wait.....

 

[LaAranda]

ETI takes no more time then a SGA. Just do not stop compressions.

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I've not found this to be true.

 

[reaper]

Practice! Better you get, easier it will become.

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[Carlos Danger]

ETI takes no more time then a SGA. Just do not stop compressions.

I intubate and place SGA's every single day and there is no way I could consistently intubate during CPR with as little interruption to compressions as SGA placement would require.

 

[reaper]

If you did it without stopping each time, you get the hang of it. [emoji6]

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[Carlos Danger]

If you did it without stopping each time, you get the hang of it. [emoji6]

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Or maybe I'd just overestimate my own abilities.

 

[reaper]

Long time and I never overestimate my abilities.

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[Carlos Danger]

Why do people in EMS have such a hard time with the idea that intubation shouldn't always be the first thing that we do for patients?

Here we have people essentially rejecting a study with a sample size of almost 90,000 patients across 14 years worth of data - supporting the findings of other smaller studies that found the same thing - just because it says that maybe we should think twice about intubating early in cardiac arrest. You see it with the dozens of studies on intubation in the prehospital setting, too.

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.

 

[reaper]

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.

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