1 Minute Intubation

[DwayneEMTP]

How come you say you'd have to interupt compressions to use a bag mask? I could see if you were on your own then perhaps maybe but with two or more ambo's at minimum it should be ok; heck it should be dandy right coz of the good ole ambo trick of "more is better" and by the time you get on the stickies, confirm VF and start pounding away, two cops, eight firefighters and the medical director have shown up!

Heh..I hear you. Here we'll normally run a core with 4 people, and that's more than enough.

So are you saying Kiwi that you bag during compressions? Without filling the belly with air? I've not heard of anyone doing this. The main reason that a tube is a relatively (Key word being 'relatively') early intervention is so that I can ventilate during compressions without creating abdominal distention and the issues that that involves. I don't believe that this is possible with a BVM/OPA while compressing...though I could be wrong...

Dwayne

[Kiwiology]

Heh..I hear you. Here we'll normally run a core with 4 people, and that's more than enough.

So are you saying Kiwi that you bag during compressions? Without filling the belly with air? I've not heard of anyone doing this. The main reason that a tube is a relatively (Key word being 'relatively') early intervention is so that I can ventilate during compressions without creating abdominal distention and the issues that that involves. I don't believe that this is possible with a BVM/OPA while compressing...though I could be wrong...

Dwayne

Hmm I agree with what you are saying. Now I was taught that compressions should be continious, that whoever is doing ventilations should do 8/min and that intubating is not a priority because an LMA should work just fine.

Having said all that out there in the real world we know it doesn't work like that and that it's easier to drop an ET tube and get it out of the way because it's easier to transport, provides better protection of the airway, is an alternate drug route (!) etc

I've generally seen Intensive Care Paramedics intubate fairly early, often before an IV is established if they have turned up first-in and not responding to back up another crew.

[spenac]

My problem would be the lack of compressions. If you ever get to study more in depth and hopefully observe it in a controlled setting most healthy patients after a minute still have great O2 saturation levels w/o being ventilated. Current ACLS and even lay person CPR is focused more on compressions as it takes 11-15 proper compressions to get circulation going properly so with ever 30 second stop in compressions you actually have about 38 seconds of no or limited circulation. Current ACLS guidelines do not even require intubation they state something along the lines of effective ventilation's. So if effective ventilation's can occur with an OPA,LMA, combi or other with other means w/o interrupting compressions no problem.

[Tom B.]

To what extent do you feel that taking a little over a minute to intubate a cardiac arrest pt (refractory VF scenario), whilst compressions have been ceased, is acceptable/unacceptable.

It's not acceptable at all, and a major reason the survival rate for sudden cardiac arrest is so dismal in the United States and across the World. We know that continuous chest compressions are an important part of saving more people, so anything that interrupts chest compressions is bad, including tracheal intubation. Why not intubate without interrupting chest compressions or use a King LT-D to accomplish the same thing? It's working great in Wake County, NC where the survival rate for people observed to collapse from cardiac arrest with an initial rhythm of VF/VT approaches 50% in the City of Raleigh. They start compressions immediately, drop a King LT-D (with a ResQPOD and waveform capnography), defibrillate after 2 minutes, start a couple of IOs, and induce hypothermia for patients with ROSC and persistent unconsciousness. It's a simple and repeatable formula that is not so dependent on the experience level of the paramedics. But by God, we don't care how many people die in EMS! Just don't take away our authority to intubate!

Tom

[stcommodore]

"Running" a Cardiac Arrest isn't an easy feat and is dramatically harder if your the only Paramedic (advanced skills provider) in a room filled with basic providers. My partner and I (both paramedics) can typically run a code with the assistance of 3 EMT-B's pretty routly but take one of us out of the mix and its twice the trouble.

On the topic of intubation alone there is alot that goes into a sucessful intubation and if your still in training you don't know the stress of being the only Paramedic in the room yet. Obviously the important points of:

-patient posistion, airway assessment

-suction, preoxy, equip prep

-the actual attempt

-secure/etc02

Can take alot away from running the rest of the code...

Patient posistion can be easily overlooked if you don't know how much it helps! My partner and I always bring and have the port. suction set up prior to the blade ever going into the patient's mouth. In the last 10 intubations I think all have required minimal to heavy suction use. There is nothing worse then getting into the airway and then realizing you need something you don't have and you just wasted an attempt.

Bagging the patient and setting up the equipment along with an assessment of the airway can give you 30-60 seconds to take a deep breath, relax and prepare for the intubation. When you finally make your attempt have someone set aside as your "assistant" who can hand you equipment, move the patient, apply cric pressure, tell you to stop, etc. As your in the airway a few seconds to get the lay of the land is ok if you ask me. You may have to suction, readjust, and see your landmarks clear before you actually insert the tube. I even take a second with the tube as I pass it to make sure its going through and to try and not "burry" the tube in the patient. How long does that acutally take? I don't know but the point is make everything possible in your favor before making your attempt.

And now a story...

I recently had a trauma code which at the surface appeared like a car accident. But after removing the patient we discovered a gun and turned into a gsw to the head. So what factors do we have that make this intubation difficult? Blood in the airway that will require alot of suction, c-collar, drama of the moment, oh yea and the patient was a police officer (off duty/but in uniform.) To make the story short the intubation was sucessful but some won't so learn from each.

Edited January 18, 2010 by stcommodore

[kohlerrf]

Compressions should not be stopped.It is rarely necessary to stop doing compressions while attempting to intubate.whether you are using a NRB mask to oxygenate or a BVM to ventilate look at your pulsox while attempting and when you see the rapid drop stop your attempt and begin to ventilate again. Intubation is knoced way down the list in cpr anyway if your having that much trouble just drop an LMA. Granted there are those patients that have the hump back and the bobbing head with each compression and there you may have a problem but otherwise get prepaired suction the pharynx remove the dentures stick the blade in get a good visaulization slowley advance the tube to the glottic opening time it and push, or get all set up at the 3 minute mark and at 4 minutes when you stop for your first rhythm check then stick the tube in.

[1EMT-P]

Compressions should not be stopped.It is rarely necessary to stop doing compressions while attempting to intubate.whether you are using a NRB mask to oxygenate or a BVM to ventilate look at your pulsox while attempting and when you see the rapid drop stop your attempt and begin to ventilate again. Intubation is knoced way down the list in cpr anyway if your having that much trouble just drop an LMA. Granted there are those patients that have the hump back and the bobbing head with each compression and there you may have a problem but otherwise get prepaired suction the pharynx remove the dentures stick the blade in get a good visaulization slowley advance the tube to the glottic opening time it and push, or get all set up at the 3 minute mark and at 4 minutes when you stop for your first rhythm check then stick the tube in.

Please keep in mind that a pulse oximeter may not be accurate in states of low perfusion ( cardiac arrest, hypothermia etc).

[kohlerrf]

Please keep in mind that a pulse oximeter may not be accurate in states of low perfusion ( cardiac arrest, hypothermia etc).

Point well taken, however if a reading is present it is a good guide but your right there is good possibility that you may not get a reading. To restate the answer, compressions should not be stopped to specifically allow for intubation.

[HellsBells]

The pt didn't receive any amiodarone, because it seems, the medic simply forgot. To make matters worse (IMHO) after about 15 mins they (not my crew) transported to hospital

I wonder, was the pt in asystole, or persistant V-Fib when they transported to the hospital? I assume that since you mention amiodarone, he was in V-Fib. So, it could be argued that the pt may be potentially salvagable, although quite a long shot at this point. The paramedic may have been reluctant to call a pt that wasn't presenting with PEA or asystole. Not being familiar with your system, I don't know what medications you have on truck. I suppose the hospital would be able to perform an ultrasound of the heart to determine if it is contracting at all.

As far as the issue at hand goes, I would agree that your paramedic didn't perform as prefectly as he could have in this situation. A couple mins of CPR between intubation attempts would have been ideal. Better yet, if he was considering transport, intubation in the ambulance would have been ideal. That said, I would also ask you what was done before he tried to intubate. How long had CPR been in progress? How many shocks had been given at this point? How many rounds of Epi had been administered? Was the V-Fib coarse or fine?

That said, it might be a good idea to ask the medic in question why he did what he did, see if he knew some facts that you didn't about the situation.

[melclin]

I wonder, was the pt in asystole, or persistant V-Fib when they transported to the hospital? I assume that since you mention amiodarone, he was in V-Fib. So, it could be argued that the pt may be potentially salvagable, although quite a long shot at this point. The paramedic may have been reluctant to call a pt that wasn't presenting with PEA or asystole. Not being familiar with your system, I don't know what medications you have on truck. I suppose the hospital would be able to perform an ultrasound of the heart to determine if it is contracting at all.

As far as the issue at hand goes, I would agree that your paramedic didn't perform as prefectly as he could have in this situation. A couple mins of CPR between intubation attempts would have been ideal. Better yet, if he was considering transport, intubation in the ambulance would have been ideal. That said, I would also ask you what was done before he tried to intubate. How long had CPR been in progress? How many shocks had been given at this point? How many rounds of Epi had been administered? Was the V-Fib coarse or fine?

That said, it might be a good idea to ask the medic in question why he did what he did, see if he knew some facts that you didn't about the situation.

Yes, persistent VF. Stayed the same way as he presented until shocked into asystole later in hospital. We cannot call patients who are in anything but asystole. Which is why I think that the transport occured simply because they figured it was a done deal and needed someone to call it.

I'm not sure he was necessarily considering transport when he intubated. I think someone else suggested it, which harks back to another issue I had with the management of he scene, but that is not the issue and it was not this particular medics fault. In his defence, he was not on duty when he got the call and agreed to respond POV because he lived nearby. Why, the dispatchers even bothered, I don't know, we (with another MICA medic) were not far away and he didn't have any MICA gear anyway so I'm not sure what use they thought he would be. Anyway...when we arrived with another MICA medic and MICA gear, the pt had already received 2-3 x epi, 5-6 x DCCS. We arrived with the gear but our medic didn't intubate, it was the bloke who had already arrived who intubated after two more rounds of compressions and one more DCCS (making a total of 6-7 at that stage). I think in total the pt had 5 rounds of adrenaline, but I don't recall the specifics on that. I think i mentioned the times a little earlier.

I asked about the amiodarone, and it seems it was simply forgotten. The transport, I didn't and I won't get a chance to ask anyone who was there. It was a long way from home, and even if it wasn't, the uni and the service are completely separate entities for the most part, there is no way I could really get in contact with him.