Definitive airway in cardiac arrest

Discussion in 'Emergency Medicine' started by msgsk, Feb 19, 2017.

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  1. DissocativFugue

    DissocativFugue 5+ Year Member

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    I think you misunderstand me. I get a neuro exam and attempt sedation. If I can reasonably get them down with sedation and not tank their pressure, then we're done and off to icu. I make a decision for a paralytic fairly quickly post rosc though and if paralysis is needed I prefer roc. I'm not saying I avoid sedation and am not using a paralytic as a pressor from attempted under sedation.


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  3. Spectre of Ockham

    Spectre of Ockham

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    Well it depends on the case but ETT has the advantage of being able to suction and put them on a ventilator. This frees up a pair of hands in case you get another code .

    Do those 10 - 20 seconds really matter ? IDK that is a question for the ages.
     
  4. migm

    migm 7+ Year Member

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    Can vent through an LMA or King
     
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  5. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    nevermind, figured it out
     
  6. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO. 7+ Year Member

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    Ohmygodyesss.... I remember now. Anesthesia did LMA cases on the vent back when I did my anes month way back in residency.

    Did they? I'm thinking they did. My shift ended at 6am... I might just be hallucinating that. Zzzz.
     
  7. migm

    migm 7+ Year Member

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    if you're being sarcastic, there's no need. I was responding to the individual stating they were worried about not having an extra set of hands.

    https://www.ncbi.nlm.nih.gov/pubmed/28118660

    Seems to point towards early ETT (in adults) and a recent similar paper in kids is not the best way to go in arrest.
     
  8. brk81144

    brk81144 Attending 2+ Year Member

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    How many of you guys actually place the patient on a vent during the arrest? We always bag until we get rosc
     
  9. migm

    migm 7+ Year Member

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    yeah i don't. don't see why you can't though, except the vent might be extra alarmy in the setting of someone pushing on the chest
     
  10. Apollyon

    Apollyon Screw the GST Lifetime Donor 10+ Year Member

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    Well, in the OR, with an already-tubed patient, if they code, the gas guys disconnect the vent and bag by hand.
     
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  11. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO. 7+ Year Member

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    No sarcasm intended. It honestly never occurred to me before why we dont regularly vent thru an LMA while *other**** gets done* if there's few hands on deck.

    My shift finished at 6am. I left the hospital at 8am after mad critical care time and the single worst COPD'er this year. I was trying to account for the fact that I might have it all wrong, and it was a dream, or something.
     
  12. migm

    migm 7+ Year Member

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    no worries. hope you got some rest :)
     
  13. migm

    migm 7+ Year Member

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    I would suspect that's more of a feature of eliminating the vent from the list of possible reasons why your previously perfectly normal NPO >8 hr patient has suddenly developed a case of the deathies
     
  14. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO. 7+ Year Member

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    Thanks. Her airway was a snap. Lol.
     
  15. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    That, plus the tactile feedback of feeling the bag's resistance gives you useful information.
     
  16. Druggernaut

    Druggernaut Lifetime Donor 7+ Year Member

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    You can code someone on the vent, but you'd have to change your settings during the code and afterwards if you get ROSC. Otherwise, it's my understanding that the elevated pressures from compressions would cause the vent to deliver no breaths. I've never seen anyone try it, though.
     
  17. TooMuchResearch

    TooMuchResearch i'm goin' to Kathmandu... Lifetime Donor 7+ Year Member

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    The deathies. Hilarious.
     
  18. EmergDoc2B

    EmergDoc2B 2+ Year Member

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    Is not tubing your patient who dies during resus a potential issue that can be litigated?
     
  19. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner SDN Moderator 10+ Year Member

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    Being in the room during resus is an issue that can be litigated.
     
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  20. gro2001

    gro2001 SOCMOB 10+ Year Member

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    Not being in the room could also probably be litigated.
     
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  21. EmergDoc2B

    EmergDoc2B 2+ Year Member

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    So, yes.

    thx
     
  22. GonnaBeADoc2222

    GonnaBeADoc2222 7+ Year Member

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    I told RT to take a patient off the vent and bag during a code (which to me is standard care) and they looked at me like I had 13 heads.

    As an aside, I get sideways glances and underhanded comments from RT when I do apneic oxygenation during a tube.

    It's 2017 people, let's get with it.
     
  23. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO. 7+ Year Member

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    +1.

    I ran the whole "delayed sequence intubation" program during my last tube. RN staff had to complain to my director about what "Dr. Rustedfox is doing".

    The same fat, (barely) literate RN goonsquad complained about my use of atropine during PEA (psst.... it was pseudo-PEA, bedside cardiac ultrasound FTW) because it wasn't "in the ACLS protocol anymore".

    Swear to Christ, they learned one thing, once, and they're sure of it.

    Once.

    Now and forever. And Ever.

    Amen.

    Pffft.
     
  24. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner SDN Moderator 10+ Year Member

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    An aside. Did they have a pulse? If not, it's PEA. That's the definition. It doesn't mean contractionless electrical activity. At least, not today. Maybe another version will come out and changes the order to UCAB, but until then, it's still PEA.
    Also, they should know ACLS are guidelines, not protocols. Otherwise, we wouldn't have to be there. The goonsquad could run it. I'm sure they talk about how good they would do on facebook already.
     
  25. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO. 7+ Year Member

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    I used to think that "no pulses = PEA" as well. What if the pulse is there, but we just can't find it?

    http://lifeinthefastlane.com/ccc/pulseless-electrical-activity-pea/

    https://www.ncbi.nlm.nih.gov/pubmed/25891961

    http://edecmo.org/pseudo-pea-emd-and-such/
     
  26. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner SDN Moderator 10+ Year Member

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    I'm curious as to what degree of contractility you require for it to not be PEA then? Are just eyeballing the kinesis? Measuring EFs?
    I mean, I get it, but at the same time, PEA means no carotid or femoral pulses. If they're so fat you can't find these, well they're likely to die anyway. And probably too fat for my ultrasound to find their heart.

    At the same time, is there an atropine indication for low blood pressure? I mean, if I can't feel their pulses, and they've got a slow rate, they're getting epi. And then more epi.
     
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  27. brk81144

    brk81144 Attending 2+ Year Member

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    Since we are already off topic... hypokalemic arrest. How fast and how much potassium are you giving? Had this one time where I got an istat showing k of 2.0 and me and pharmacist just kind of looked at each other
     
  28. GonnaBeADoc2222

    GonnaBeADoc2222 7+ Year Member

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    Probably speaking to my inexperience but I have not seen a hypokalemic arrest in my 4 years as an MD, or at least have not gotten labs during such a possible arrest to know it. My feeling is that hypokalemia of 2.0 likely isn't your source unless there was an R on T from QT prolongation, in which case 100 mEq of K should raise the serum K by 1.0 mg/dl. I'd probably give Mg as well.
     
  29. GonnaBeADoc2222

    GonnaBeADoc2222 7+ Year Member

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    Yup. Tried this (delayed sequence intubation) once as an intern with an attending who was a badass. However, know-all RNs not up on the literature put the kibosh on it even though attending explained the entire procedure at the beginning. As a result, pt starting O2 sat prior to induction was 75%. Attending to intern Dr. GonnaBeADoc: "You have one shot." Was my second tube attempt in residency and I missed it.

    Another favorite: RN pushes RSI sedative. Me: "Did you push the paralytic?" RN: "No, did you want that?" Me: Facepalm

    Or even better, RN pushes RSI paralytic with no sedative first. Can't do DSI, but we can sure torture the poor patient with paralysis without sedation.
     
  30. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO. 7+ Year Member

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    Short answer: I'm eyeballing the kinesis. If it looks like it should result in a pulse, then that's useful data.

    Sometimes they're too fat.
    Sometimes, they're vasculopathic and been stented and CEA'd and all that.
    Sometimes, they've got a pacer, so the rhythm strip is worthless.
    But all those sometimes are becoming more and more common.
     
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  31. alpinism

    alpinism Give Em' the Jet Fuel 5+ Year Member

    Eyeballing the EF is probably your best option during an arrest.

    Another option is just to slide the probe up and look at the carotid.

    If its pulsating then they've got perfusion and are not technically in PEA (aka PREM)
    If its not pulsating then they've got no perfusion and are technically in PEA (aka PRES)

    As an aside our ability to detect pulses during an arrest is horrible. If you look at the literature its somewhere around 55% and probably even worse in your overweight patients...
     
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  32. migm

    migm 7+ Year Member

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    I really hope you're not saying to give 100 meq of IV push K. You need to know how to raise potassium acutely in someone who is dying from sequlae of profound hypok, what's the answer?
     
  33. GonnaBeADoc2222

    GonnaBeADoc2222 7+ Year Member

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    My apologies. Was mixing up maximal PO dosing and IV dosing in my head. In a code/peri-code situation, would likely give max ~40 mEq / hr IV. Thanks for pointing out my mistake.
     
  34. migm

    migm 7+ Year Member

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    Totally reasonable via central line, in a code situation, i'd push 10 meq IV over a few minutes then another 10 a few minutes later if still dying. Mag is a must
     
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  35. dchristismi

    dchristismi Gin and Tonic 10+ Year Member

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    A hypokalemic arrest? Never seen one, and been out for 9 years. Not that it doesn't happen, but I've never caught one, so it's much lower on my list of badness.
    HYPERkalemic? That's more like it.


    (A Fat RN? Are you sure it wasn't masquerading as TTP?)
    (Yeah, that's the wine typing... which that nurse probably desperately wanted by then...)
     
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  36. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    Hey-oooooh!
     
  37. littlejuan

    littlejuan 7+ Year Member

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    What is their major issue? Where I am at in residency the nurses are all mostly pretty great and never question the things we do (unless it is a legitimate question for learning purposes) so I haven't had issues with DSI. They just have issues with giving ketamine first and waiting a bit while you oxygenate the patient? Don't you guys sometimes use ketamine or ketofol for procedural sedation without the need to intubate someone? What exactly is their concern?
     
  38. d2305

    d2305 2+ Year Member

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    How can you get a BMP back that fast?
     
  39. WildcatS11

    WildcatS11 7+ Year Member

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    Blood gas w lytes. 5 minute turn around at most. Faster if you have POC
     
  40. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner SDN Moderator 10+ Year Member

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    iStats take minutes.
     
  41. d2305

    d2305 2+ Year Member

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    I took more than 5 minutes to walk to the lab. Guess stat means stat now.
     
  42. gro2001

    gro2001 SOCMOB 10+ Year Member

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    To be fair, 100 mEq K IV push will certainly raise the potassium. Acutely.
     
  43. engineeredout

    engineeredout Lightning Ballseeker 7+ Year Member

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    Agreed with this. All "PEA" is not equal and ultrasound is changing it. How many times have you gone to feel for a pulse on an awake talking patient and you're having trouble locating it? Do you really trust your code situation pulse checks?

    Now I'm not advocating the quiver that you might see the walls do because you've given 18 rounds of code dose epi, but if I see some reasonable contractile effort (and no sorry I don't have specific objective cutoffs for this - I'm not measuring a specific EF nor do I care to), it changes things.

    Money is if you can obtain an A-line in these patients, especially if they keep recoding or you have this heart thats moving but can't find a definitive pulse. Arterial line transducers will only be functioning if there is some sort of cardiac output. Even if it is crappy.

    Something else I've seen recently that people tend to forget about - Pulse oximeter. Modern day pulse Ox functions because the two infrared lights which measure the absorbance of oxy and deoxy hemoglobin are looking for flow (moving blood) so they don't get confused by all the other surrounding tissues. If you see a pulse oximetry waveform on your monitor, no matter what the number is, you by definition have to have ROSC. The SpO2 itself might not be accurate in the pinkey post-arrest after infinity-epinephrine, but some forward flow has to be occurring for you to have a waveform.
     
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  44. FutureDOdr

    FutureDOdr

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    What is the result of complaints like this? Do they actually result in you having to justify your actions to anyone? This sounds ridiculous. As someone about to start my EM residency, presuming the upcoming match week goes as it should, I am pretty sure I will be pretty frustrated when this type of stuff happens to me. I guess it is bound to happen to everyone at some point though, so I won't be surprised.
     
  45. FutureDOdr

    FutureDOdr

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    Similar to my response to rustedfox, is this type of interaction normal? I get the whole teamwork idea and realize you have to listen to everyone on the team, but this is just dumb.

    Is there any recourse for the RN refusing to do it? Seems like an RN pushing back or refusing to implement medication orders when a patient needs intubated should be a pretty serious concern to all parties involved. Would it have been reasonable as a resident (I suppose probably not as resident) or attending to bring this up after the fact and perhaps discuss with nursing admin in an effort to ensure drugs during intubation are given in a timely manner as ordered by the physician?

    I hope this kind of stuff isn't the norm. I kind of expected everyone to question my decisions as a medical student. That's why med students aren't responsible for making important decisions. That makes sense. But I didn't know this happens so much to attendings. I've seen several RNs avoid giving basic meds as ordered and am not surprised anymore when it happens. Everyone has to pick their battles, and if the med isn't crucial at that moment, it's usually not a battle worth having. But the situation you described seems much worse. What do others think? If an RN refuses to give medications during a code or intubation setting is this a battle worth having? Or would you let it slide? As someone who hasn't made it far enough in my training or career to experience this specific scenario, I'm curious what others would do or have done.
     
  46. shoal007

    shoal007 2+ Year Member

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    it may be from their experience with benzos in these copders. for some reason they always ask due to intolerance of the bipap facemask and my answer is always no if im not trying to tube.

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  47. brk81144

    brk81144 Attending 2+ Year Member

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    Most times when you get pushback from nursing over issues like this it's a communication issue. Whenever I do something that isn't "normal" I give a brief reason for why we are doing it that way and then after the case go into more detail with the nurses about my reasoning/physiology/etc. Most nurses are eager to learn and willing to work with you but communication is a must vs just being a dictator
     
  48. Arcan57

    Arcan57 Junior Member 10+ Year Member

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    If you're ever having difficulty deciding what to let slide and what to hill to die on, the best rule of thumb is "Was the patient's health endangered?" Not giving code meds (if you believe they work) would be a firm yes. Now it's still possible to be right and end up as the bad guy so if you can get through the situation without throwing things or screaming insults at the nurse, that's ideal.
     
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  49. gro2001

    gro2001 SOCMOB 10+ Year Member

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    I feel like we each legitimately get one thing. One issue we can be stubborn on and push to change the system in our departments around. Any more than one, and you become "that guy".
     
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