Preoxygenation before intubation in cardiac arrest?

[zuki]

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Should we preoxygenate patients before a intubating a cardiac arrest patient? Why?

Anyone have any journal articles/etc relevant?

 

[coprolalia]

Should we preoxygenate patients before a intubating a cardiac arrest patient? Why?

Anyone have any journal articles/etc relevant?

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

 

[dfk]

agree.
intubate s/b first priority.
current ACLS protocol is essentially doing "away"
with the ventilation part.
so, compress at will..

 

[Leinie]

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

Are you in Hershey? I recognize that quote.

 

[Planktonmd]

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.

 

[nutmegs]

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.

 

[coprolalia]

Are you in Hershey? I recognize that quote.

No, I'm in Philly. Must be a regional thing.

-copro

 

[cchoukal]

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.

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.

 

[rsgillmd]

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.

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.

 

[Trisomy13]

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.

i tend to agree... tube or no tube, it doesn't matter if there's no cardiac output.

 

[BADMD]

i tend to agree... tube or no tube, it doesn't matter if there's no cardiac output.

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.

 

[Noyac]

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.

 

[zuki]

thats for the replies but does anyone have any articles/books etc that i can reference from? Thanks

 

[BISof60]

"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?

 

[Planktonmd]

"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?

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.

 

[coprolalia]

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.

Yeah, well, if I'm there, I'm sticking the f***ing tube in.

-copro

 

[Frank Rizzo]

Should we preoxygenate patients before a intubating a cardiac arrest patient? Why?

Anyone have any journal articles/etc relevant?

Please tell me you are not serious.

 

[BISof60]

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?No.
Even if the ventilation is not optimal isn't it better to have 100 % oxygen in front of the patient's airway?Yes.
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.

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.

 

[j fizz]

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

 

[SleepIsGood]

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".

 

[dfk]

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".

what's more important, oxygenation or ventilation?

 

[Planktonmd]

what's more important, oxygenation or ventilation?

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.

 

[coprolalia]

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

 

[leviathan]

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.

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.