Intubation in Cardiac Arrest - Spin Off From Pain Mgmt EMTB

[Kiwiology]

A dermatologist is a good pick y'know mate, I hear dermo is the most competitive and one of the highest paid specialities in US

So I filled in this University of Virginia medical specialist thing; I think that thing is on crack; it said I should be an oncologist, OB/Gynae or interventional radiologist; none of which I have even the slightest interest in, well OB/Gynae I probably wouldn't mind, except that's a surgical speciality, me being a surgeon is not a good idea ....

Edited April 12, 2012 by Kiwiology

[croaker260]

OK, time to steer this back on track....

LOL funny ... what I said was it's not a good idea to knock crook people down a couple levels with some midazolam and try to tube them

And yes you can aspirate without being ventilated

I'm still not keen on intubating people in cardiac arrest and wouldn't consider it until well into the resuscitation attempt or ROSC has been achieved

This is the beauty of medicine. There is more than one way to do it. I do agree with some of the points you bring up over there. I think the danger of sux has been overestimated in the inpt setting. I also feel the same way you do about RSI. If they are still breathing, they are getting paralyzed. If I paralyze someone I'm going to sedate them regardless of how out of it they are. The more optimal I can make the intubation conditions, the better. Obviously there are exceptions to this but that is generally the way I look at it.

Both good points, one additional one to consider:

Ventilation may or may not be a priority for the first tenminutes of ARREST, but remember that arrest is not the same as rescusitation efforts. I work in a well developed system with a tiered response, and it remains quite common for the first reponder general term here) to still arrive 4 - 6 minutes after the actual arrest, assuming the calling party witnessed the arrest, had a cell phone in their pocket, and called 911 correctly the first time.

If you look REALISTICALLY, We as EMS providers are arriving at the patients side (Different than when we just mark ourselvs "on scene") and starting comprssions in the 6 minute mark of arrest (or later).

I would submit to you that EVEN IF you use the 10 minute mark of arrest tme as a guide for when to use advanced airway mnagement, then that is still likely only 4 minutes into your actual patent care/contact time...at best.

Respectfully submitted.

Edited April 12, 2012 by croaker260

[Kiwiology]

You raise a valid point sir, one I did not consider.

[mikeymedic1984]

I agree that science is a good thing, but I have been around long enough to see multiple changes in ACLS and AHA recommendations throughout the years, BASED ON THE LATEST SCIENTIFIC STUDIES, and guess what --- there has still not been any substantial change in survival rates. So yes, you can find a study by now that says intubation is bad, but in 8 years we will be putting it back in. I will boldly predict now that the next ACLS changes will bring back pushing 2 amps of bicarb and a D50 in every code (lol, along with some D5W TKO says gage).

I also agree that we should not do things just because we always have, but in this case, "intubation" (when done right) has served patients well for many decades, so I am not willing to just throw it out the window.

Lastly, many scientific studies that are done outside of the university setting, are done by drug or equipment company that may or may not use that study to push a product. I can not tell you how many times I have watched a doctor write a script because the big-boobed drug rep showed him scientific proof that this new med was better, only to have the patient come back or call back to the doc to say hey I cant afford this $200 drug, give me the 30 year old $10.00 drug that works just as well, which it does.

[ERDoc]

There has not been a substanial survival rate, but those studies have shown us a few things. They've shown that it is the first few minutes (usually before the ambulance gets there) that are the most important. This has led to a push for public education and the current public AED availablitiy. We are also learning more about coronary perfusion pressure. These studies take a long time and it takes a while to figure out what the next step is.

[Kiwiology]

The good ole ambo trick of "more is better" does not always work, and the evidence seems to point away from doing fancy things because we think it will help or it will make us feel better for doing them; lidocaine, bicarb, calcium, atropine, pacing asystole, on and on it goes

The only things that have ever worked are CPR and defibrillation; the rest is just physiologically plausible theories wrapped up in voodoo psychological spin that makes the person administering them feel good "about doing everything I could!" but have never been subjected to any sort of rigorous scientific analysis or if they had been they'd be out of fashion years ago by now

My limited resuscitation order is for no adrenaline, no intubation prior to ROSC, no ventilations for the first ten minutes of my arrest and for somebody chant black magic while dancing around; hey that might be biologically plausible too right?

[systemet]

I agree that science is a good thing,

Me too. Clearly superior to homeopathy, tea-leaf reading, astrology or wild-ass guessing.

but I have been around long enough to see multiple changes in ACLS and AHA recommendations throughout the years, BASED ON THE LATEST SCIENTIFIC STUDIES, and guess what --- there has still not been any substantial change in survival rates.

Well, things aren't getting worse, and we know more about what doesn't help

What's the alternative to changing the guidelines? We could do whatever currently doesn't work, and just keep doing it, forever?

The fact that the approach to resuscitation changes reflects that science is an ongoing process, and not a static fixed system of rigid beleifs. Trying something, finding out that it doesn't work, and then trying something else, seems pretty reasonable.

So yes, you can find a study by now that says intubation is bad, but in 8 years we will be putting it back in.

Maybe, maybe not. It's impossible to know what's going to happen in 8 years. Just because the guidelines change periodically doesn't mean all treatments are equal, or that the guidelines process, however fallible, doesn't work.

I will boldly predict now that the next ACLS changes will bring back pushing 2 amps of bicarb and a D50 in every code (lol, along with some D5W TKO says gage).

It's difficult to know what's going to happen. I don't think it's been shown that intubation is bad, as much as that it doesn't help (I think ERDoc said that already in this thread). The bigger message seems to be that even brief interruptions in CPR (whatever the reasons for the interruptions) produce dramatic decreases in survival.

What's more surprising to me is that we've had the ability to measure this effect in experimental animals for decades, yet no one seems to have focued on it until we realised that anti-arrhythmics weren't doing much to help. I guess everyone was too busy looking for the new super-bretylium.

I also agree that we should not do things just because we always have, but in this case, "intubation" (when done right) has served patients well for many decades, so I am not willing to just throw it out the window.

I also think that we should keep intubation, because it's life-saving in a limited set of circumstances, e.g. asthma, airway burns, airway trauma, anaphylaxis, etc. (I agree that RSI'ing asthmatics or patients with potentialy laryngedema is terrifying, but it is sometimes necessary). I don't think there's any evidence for ETT over BIAD in cardiac arrest. The best evidence right now is non-inferiority of BIADs. So I don't think intubation is the most important thing in cardiac arrest management, especially now that we have better tools.

Given that placing an advanced airway allows asynchronous compressions, and the whole move to 30:2 and >100 compression rates is supposed to maximise "hands-on" time, and the number of compressions per minute, I'm surprised that the AHA isn't advocating an early KIng, or ETT, then asynchronous compressions.

There's also little evidence that paramedic intubation has served patients well in the past. Most of us like to think that it has, and that we're working in systems that are the exception, and that the available data doesn't apply to us. But it's looking more likely that even the good systems aren't having a big impact on morbidity / mortality (see: RSI trial, Melbourne?, very well trained paramedics, intubating a lot, very small reduction in morbidity in closed head injury, no reduction in mortality).

Lastly, many scientific studies that are done outside of the university setting

Relatively few. Pretty much everything published has to go through an ethics committee, and primary investigators almost always hold a professorship somewhere. Any reputable journal requires that conflicts of interest be disclosed.

A bigger problem is that commercial companies often invest substantial amounts of money into research projects, and then delay / obstruct or refuse the publication of negative data. There's been a lot of situations recently where several drug companies have got slammed for not publishing internal data that shows that drugs under patent are dangerous.

While you could argue that companies providing equipment or research drugs or training, etc. might give an incentive for researchers for find a positive result, any outright academic fraud, or even the simple appearance of it, can ruin a career quickly.

, are done by drug or equipment company that may or may not use that study to push a product. I can not tell you how many times I have watched a doctor write a script because the big-boobed drug rep showed him scientific proof that this new med was better, only to have the patient come back or call back to the doc to say hey I cant afford this $200 drug, give me the 30 year old $10.00 drug that works just as well, which it does.

I agree that a lot of physicians prescribe more expensive brand name medications when a generic may be cheaper. But they're making this judgment on the data available to them. While the drug companies should take responsibilty for situations where they've withheld data that shows their product in a negative light, they can hardly be blamed for promoting their own products.

Big pharma needs to get paid -- it costs a ridiculous amount of money for 1-2 novel clinical entities / year. It just needs to be ethical about how it does it.

Edit: isn't for is ! Oops.

Edited April 12, 2012 by systemet

[Just Plain Ruff]

and for somebody chanting black magic while dancing around;

So will insurance cover that?

[Kiwiology]

You know I never thought of this but the ambulance service sends a bill for attending a cardiac arrest as medical calls are not covered under government subsidy

We saved your life now you owe us $90 sort of thing lol

Edited April 12, 2012 by Kiwiology

[Happiness]

http://uwmedicine.washington.edu/Research/Clinical-Research/Translational-Research/ROC/Cardiac-Arrest/Pages/FAQ.aspx

I cant remember if this study is complete or ongoing.