1. Dismiss Notice
  2. Download free Tapatalk for iPhone or Tapatalk for Android for your phone and follow the SDN forums with push notifications.
    Dismiss Notice

Preoxygenation before intubation in cardiac arrest?

Discussion in 'Anesthesiology' started by zuki, May 26, 2008.

  1. zuki

    Joined:
    May 26, 2008
    Messages:
    2
    Likes Received:
    0
    Should we preoxygenate patients before a intubating a cardiac arrest patient? Why?

    Anyone have any journal articles/etc relevant?
     
  2. Note: SDN Members do not see this ad.

  3. coprolalia

    coprolalia Bored Certified
    2+ Year Member

    Joined:
    Aug 5, 2007
    Messages:
    3,084
    Likes Received:
    17
    Status:
    Attending Physician
    In the words of one of my favorite attendings in such a situation when I was an intern trying to bag-mask a moribund patient with a heavy beard and doing so quite badly... "JUST STICK THE F***ING TUBE IN!!"

    No, you don't preoxygenate. You secure the airway and give oxygen via the best route possible, the endotracheal tube.

    -copro
     
  4. dfk

    dfk Membership Revoked
    Removed 7+ Year Member

    Joined:
    Jul 5, 2006
    Messages:
    482
    Likes Received:
    0
    agree.
    intubate s/b first priority.
    current ACLS protocol is essentially doing "away"
    with the ventilation part.
    so, compress at will..
     
  5. Leinie

    Leinie ASA Member
    10+ Year Member

    Joined:
    Jun 20, 2004
    Messages:
    60
    Likes Received:
    8
    Status:
    Attending Physician
    Are you in Hershey? I recognize that quote.
     
  6. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Nov 2, 2006
    Messages:
    6,819
    Likes Received:
    1,795
    Status:
    Attending Physician
    To my knowledge there is no contraindication to mask ventilating the dying patient with 100% O2 while you get ready to intubate, and why not, you can call this preoxygenation if it makes you happy.
    Actually I think that people who are trying to die really appreciate it if you give them oxygen as fast as you can, and many times the fastest way to give oxygen is mask ventilation.
     
  7. nutmegs

    nutmegs ASA Member
    7+ Year Member

    Joined:
    Jul 15, 2003
    Messages:
    910
    Likes Received:
    0
    were I in cardiac arrest, my number one priority would be for someone to be giving me quality uninterrupted compressions. quality as in the-pulse-ox-is-reading good. if you can maintain me some sats while someone is banging on my chest uninterruptedly, hold off on el tubo - especially if it's going to take you two friggin minutes to get the damn thing in, secured, verifed, (we all know how quality CPR is during this part...) etc that I could have been having cerebral circulation.
     
  8. coprolalia

    coprolalia Bored Certified
    2+ Year Member

    Joined:
    Aug 5, 2007
    Messages:
    3,084
    Likes Received:
    17
    Status:
    Attending Physician
    No, I'm in Philly. Must be a regional thing. :laugh:

    -copro
     
  9. cchoukal

    cchoukal Senior Member
    Moderator 10+ Year Member

    Joined:
    Jul 10, 2001
    Messages:
    2,013
    Likes Received:
    153
    Status:
    Attending Physician
    This is my recollection of the latest in ACLS as well. The A stands for airway, but it doesn't specify endotracheal intubation. Just getting air in and out is the key and, like some else mentioned, the priority is chest compressions and intubating during compressions can be difficult. I generally intubate during rhythm/pulse checks btwn cycles.
     
  10. rsgillmd

    rsgillmd ASA Member
    7+ Year Member

    Joined:
    Nov 24, 2007
    Messages:
    697
    Likes Received:
    4
    Status:
    Attending Physician
    2 minutes to get the tube in and verified? Must be a difficult tube -- unless you are talking from the moment you walk in the room. I let the RT/medicine continue mask ventilation while I get my equipment together. If I have a prepared tube, I just jump right in. I've rarely had to ask the compressor to stop to get the tube in, because most patients are easy laryngoscopies. If I do ask them to stop, it's usually just for the second to push it through under visualization. The other time I told them to stop was once when I did the laryngoscopy and saw bile being pushed through the cords with each compression.
     
  11. Trisomy13

    Trisomy13 ultra
    10+ Year Member

    Joined:
    Apr 13, 2004
    Messages:
    1,245
    Likes Received:
    25
    Status:
    Attending Physician
    i tend to agree... tube or no tube, it doesn't matter if there's no cardiac output.
     
  12. BADMD

    Physician 10+ Year Member

    Joined:
    Dec 28, 2006
    Messages:
    856
    Likes Received:
    33
    Status:
    Attending Physician
    There is a consideration to avoid ventilation until ROSC is established. Ventilations increase intrathoracic pressure and thus lowering coronary perfusion pressure. In the only study that I am aware of that tried to measure it, if CPP was less than 15, ROSC could not be established.
     
  13. Noyac

    Noyac ASA Member
    SDN Advisor 10+ Year Member

    Joined:
    Jun 20, 2005
    Messages:
    7,560
    Likes Received:
    2,129
    Status:
    Attending Physician
    I think the reason that the ventilation portion of resuscitation was recommended against was b/c of the incidence of poor ventilation by the rescuers. This just took away from something that was effetive on their part, the chest compressions. If you can ventilate, then do it. Either by mask or el tubo.
     
  14. zuki

    Joined:
    May 26, 2008
    Messages:
    2
    Likes Received:
    0
    thats for the replies but does anyone have any articles/books etc that i can reference from? Thanks
     
  15. BISof60

    BISof60 A polite young man
    2+ Year Member

    Joined:
    May 13, 2007
    Messages:
    40
    Likes Received:
    0
    "I think the reason that the ventilation portion of resuscitation was recommended against was b/c of the incidence of poor ventilation by the rescuers. This just took away from something that was effetive on their part, the chest compressions. If you can ventilate, then do it. Either by mask or el tubo."
    Exactly. The RT's at my institution "mask" the coding patients until anesthesia can tube them. In my experience, there is very little ventilation accomplished. Poor mask seal and stomach inflation are far more common than adequate ventilation.

    Also. Its tough to hold a good seal with a mask on the airway when the chest is jumping up and down from compressions on a crappy hospital bed.

    "JUST STICK THE F***ING TUBE IN!!"

    There is real wisdom in this statement.

    Who needs an article when you can reference this quote?
     
  16. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Nov 2, 2006
    Messages:
    6,819
    Likes Received:
    1,795
    Status:
    Attending Physician
    So, if they can't hold a mask correctly should they just stand there and wait for someone to show up and intubate the patient?
    Even if the ventilation is not optimal isn't it better to have 100 % oxygen in front of the patient's airway?
    The answer to crappy mask ventilation techniques is certainly not skipping ventilation, maybe people need to be trained better on how to hold a mask.
     
  17. coprolalia

    coprolalia Bored Certified
    2+ Year Member

    Joined:
    Aug 5, 2007
    Messages:
    3,084
    Likes Received:
    17
    Status:
    Attending Physician
    Yeah, well, if I'm there, I'm sticking the f***ing tube in.

    -copro
     
  18. Frank Rizzo

    Frank Rizzo Member
    10+ Year Member

    Joined:
    May 13, 2005
    Messages:
    471
    Likes Received:
    3
    Please tell me you are not serious.
     
  19. BISof60

    BISof60 A polite young man
    2+ Year Member

    Joined:
    May 13, 2007
    Messages:
    40
    Likes Received:
    0
    Agreed.
    My point was that in a code environment, there are enough variables. Airway should not be one of them. In a code environment, I think mask ventilation is often suboptimal due to a variety of factors-definitely not the same as masking a guy on the OR table for a couple minutes. So, no preoxygenation from me, just the tube.
     
  20. j fizz

    5+ Year Member

    Joined:
    Jul 31, 2005
    Messages:
    12
    Likes Received:
    0
    Status:
    Resident [Any Field]
    To me it makes sense to ventilate at the normal rate (30 compressions to 2 breaths) without any extra "preoxygenation" prior to intubation. As another poster stated, over-ventilation increases intrathoracic pressure which will adversely affect your cardiac output.

    The following AHA science advisory discusses compression-only CPR, including a review of the available animal and human studies. At this point compression only CPR is only recommended for lay rescuers in an out of hospital, witnessed adult arrest. I think the article is still interesting (and maybe relevant).

    http://circ.ahajournals.org/cgi/content/full/117/16/2162
    Circulation. 2008;117:2162-2167
     
  21. SleepIsGood

    SleepIsGood Support the ASA !
    5+ Year Member

    Joined:
    Apr 15, 2006
    Messages:
    1,965
    Likes Received:
    2
    Status:
    Fellow [Any Field]
    Just wanted to throw this into the mix. An attending of mine once stated," No matter what the medicine resident/attending says. A patient has never died because someone could not be intubated, however, they can die if they are not ventilated".
     
  22. dfk

    dfk Membership Revoked
    Removed 7+ Year Member

    Joined:
    Jul 5, 2006
    Messages:
    482
    Likes Received:
    0
    what's more important, oxygenation or ventilation?
     
  23. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Nov 2, 2006
    Messages:
    6,819
    Likes Received:
    1,795
    Status:
    Attending Physician
    In order to carry oxygen through the airway into the lungs and down to the alveoli where it can be exchanged you need some form of ventilation, even the chest movements caused by chest compressions are ventilation.
    So, unless you are talking about oxygenation through CPB and without using the lungs I say that oxygenation and ventilation are equally important and you can not achieve oxygenation without ventilation.
     
  24. coprolalia

    coprolalia Bored Certified
    2+ Year Member

    Joined:
    Aug 5, 2007
    Messages:
    3,084
    Likes Received:
    17
    Status:
    Attending Physician
    What Plank said.

    And...

    Secure the airway as quickly as possible during a code. Period. If you can't, you better have a back-up plan.

    -copro
     
  25. leviathan

    leviathan Drinking from the hydrant
    Physician Moderator Emeritus 10+ Year Member

    Joined:
    Sep 30, 2003
    Messages:
    2,418
    Likes Received:
    48
    Status:
    Fellow [Any Field]
    That is part of the reason, but the intrathoracic pressure is the main reason.

    Higher ventilation rates lead to a decrease in ROSC and survival to discharge. Lots of lit out there to back that up if you search for it.
     

Share This Page