Another Study Negative Toward EMS Intubation

[docB]

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This study just came out in Annals of EM. It says that prehospital intubation causes long stoppages in CPR which is a big no no under the new guidelines.

 

[MexicanDr]

This study just came out in Annals of EM. It says that prehospital intubation causes long stoppages in CPR which is a big no no under the new guidelines.

So would it be best to Combitube the pt, since this will decrease time spent intubating?

 

[Dwindlin]

Does anyone foresee ETT actually being removed from the curricula? Even with the data coming out I just can't see it going by the wayside.

 

[leviathan]

That sounds more like a call to stop intubation in an arrest situation, and not necessarily a mark on EMS members. Where I worked the paramedics usually intubated without having people stop compressions.

 

[Paseo Del Norte]

So would it be best to Combitube the pt, since this will decrease time spent intubating?

Devices such as the ETT, LMA, & Combitube are considered advanced airways by the AHA. Neither method of airway management appears to be better according to AHA. However, it is well within AHA recommendations to simply place an ETC, and continue with the code. Clearly, having a properly placed, functional, and well secured device can make the providers job much easier, as good mask technique really takes three people.

However, airway management does not appear to be the money shot of cardiac arrest management. Good CPR and and timely defibrillation if indicated appear to be very important concepts however.

AHA should be updating guidelines in the next year or so. This typically happens every five years and the last update was in 2005.

 

[deleted6669]

I took the difficult airway course( www.theairwaysite.com) a few yrs ago. they are in favor of the king lt airway
http://www.kingsystems.com/EDUCATION/FrequentlyAskedQuestions/KINGLTAirways/tabid/132/Default.aspx
> combitube as a back up field device...

 

[Paseo Del Norte]

Everybody has a favorite device; however, I am not sure that one device excels over another in the big picture. Anecdotally, I have had good experiences with the Combitube and the King LTSD. I have personally used a Combitube to salvage a failed airway and I have also transported patients with ETC's in place. However, earlier in my career, I saw an anesthesiologist work a miracle using a LMA on a botched flight crew RSI.

Therefore, all the alternative devices have merit and likely excel and fail in a variety of situations. Bottom line being, choose a device and know how to use it well IMHO. Clearly, knowing how to bag somebody is critical, but that is a soap box for another thread perhaps.

 

[docB]

It seems as though the prevailing wisdom at this point is not going toward replacing endotracheal intubation with King or Combitube but to abandon advanced airway altogether in favor of BLS airway with uninterrupted CPR.

 

[csmmedic]

It seems as though the prevailing wisdom at this point is not going toward replacing endotracheal intubation with King or Combitube but to abandon advanced airway altogether in favor of BLS airway with uninterrupted CPR.

ETT is already far down the algorithm in ACLS 2005. I did not visit the link you provided yet, but at least where I am from we are using BLS airways in arrest situations for the first 6-8 minutes or so as long as the BLS airway is allowing effective ventilation. The King airway is also encouraged.

We will see the new guidelines soon, I am curious as to what they will say.

 

[pseudoknot]

It may be that we end up with no ventilation at all. It's already been shown that compression only CPR is superior in the first several minutes after a witnessed v-fib arrest (i.e., the only kind where there is any realistic chance of meaningful recovery). Here is a new paper adding to this data:

http://www.annemergmed.com/article/PIIS0196064409006428/abstract?rss=yes

 

[pianoman511]

Throw that in with the existing data regarding decrease coronary artery perfusion pressure with even a brief interruption in chest compressions and it makes the case even more for compression only. Just throw on a NRB and OPA and maybe a C-collar to maintain good head position and start pumping away !

 

[Paseo Del Norte]

Throw that in with the existing data regarding decrease coronary artery perfusion pressure with even a brief interruption in chest compressions and it makes the case even more for compression only. Just throw on a NRB and OPA and maybe a C-collar to maintain good head position and start pumping away !

I think it would be easier to simply insert your supraglottic airway of choice. OPA's are rather prone to dislodgment. Plus, you can insert a King while doing compressions.

 

[leviathan]

You can attempt to intubate during compressions, too...

 

[Paseo Del Norte]

You can attempt to intubate during compressions, too...

Yeah, but I am lazy. It's easier to place a King and keep going with the code. That and I am not exactly intubating multiple patients a day, therefore I am not to proud to say I am probably more effective at utilising a supraglottic airway.

 

[jwk]

as good mask technique really takes three people.

GOOD mask technique only takes one person. If it takes three people, you're doing it wrong.

 

[MedicFL]

Yeah, but I am lazy. It's easier to place a King and keep going with the code. That and I am not exactly intubating multiple patients a day, therefore I am not to proud to say I am probably more effective at utilising a supraglottic airway.

No offence but if you have let your skills slip to the point you are too lazy to even try you need to turn in your medic patch and go back to being an EMT. This attitude is why EMS is seeing a back lash in recent times. People too lazy to keep up there own skills and other too lazy to try the hard but yet more effective road. I will admit flying in the chopper with RSI has made it easier to get more tubes but when I was on the ground every chance I got I would at least attempt and ET before just dropping in a king tube. If the FD already had a king tube in place and I was feeling good I could get the tube I would pull it and drop an ET. You can tube while compressions are going on and it should take you no longer than 30 secs to do. Sounds like you should seek out some Retraining...

 

[Dwindlin]

No offence but if you have let your skills slip to the point you are too lazy to even try you need to turn in your medic patch and go back to being an EMT. This attitude is why EMS is seeing a back lash in recent times. People too lazy to keep up there own skills and other too lazy to try the hard but yet more effective road. I will admit flying in the chopper with RSI has made it easier to get more tubes but when I was on the ground every chance I got I would at least attempt and ET before just dropping in a king tube. If the FD already had a king tube in place and I was feeling good I could get the tube I would pull it and drop an ET. You can tube while compressions are going on and it should take you no longer than 30 secs to do. Sounds like you should seek out some Retraining...

My major issue with this is does this really help your patient?

 

[MedicFL]

My major issue with this is does this really help your patient?

Yes it is good for the patient, I have seen King Tubes with vomit coming out of it, and they can dislodge, an ET tube that I place is something I know is placed correct and working. It was even worse with the LMA's they are complete junk for the EMS world.. Besides all the ED's pull king tubes and places ET tubes anyways so since it is the gold standard why not just do it right the first time..

 

[Paseo Del Norte]

I have seen ET tubes come into the ER placed in the esophagus. If it anecdotal hour at SDN, I am sure we have all sorts of stories relating to these devices. However, the bottom line being, we have allot of evidence based literature stating that intubation does not make a difference in cardiac arrest. In some cases, such as the study this thread is based upon, intubation may be harmful. Therefore, it is acceptable to consider alternatives to intubation.

Additionally, I do not consider transitioning to a supraglottic device or simply sticking with mask ventilation lazy. (In spite of my comments made in jest.) I simply do not see the benefit of intubating these patients. In addition, one of the most objective measure I have available for placement verification (capnography and capnometry) is not always accurate in low perfusion states. I am simply not willing to take such a risk when evidence supports a more conservative methodology as being just as effective.

The ER replacing a supraglottic airway with an ET tube is a price of tea in China argument IMHO. I am also not keen on replacing functional supraglottic airways in the field. The old saying the enemy of good is better applies in some cases, and I am willing to be much more conservative if the conservative modalities are working. Additionally, I am not a paramedic and have no patch to turn in.

 

[Dwindlin]

I have seen ET tubes come into the ER placed in the esophagus. If it anecdotal hour at SDN, I am sure we have all sorts of stories relating to these devices. However, the bottom line being, we have allot of evidence based literature stating that intubation does not make a difference in cardiac arrest. In some cases, such as the study this thread is based upon, intubation may be harmful. Therefore, it is acceptable to consider alternatives to intubation.

Additionally, I do not consider transitioning to a supraglottic device or simply sticking with mask ventilation lazy. (In spite of my comments made in jest.) I simply do not see the benefit of intubating these patients. In addition, one of the most objective measure I have available for placement verification (capnography and capnometry) is not always accurate in low perfusion states. I am simply not willing to take such a risk when evidence supports a more conservative methodology as being just as effective.

The ER replacing a supraglottic airway with an ET tube is a price of tea in China argument IMHO. I am also not keen on replacing functional supraglottic airways in the field. The old saying the enemy of good is better applies in some cases, and I am willing to be much more conservative if the conservative modalities are working. Additionally, I am not a paramedic and have no patch to turn in.

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