Mounting evidence against intubating cardiac arrest patients...

[Kiwiology]

Let me clarify, I think it is a valid question from the point of view that if the practice of using an endotracheal tube or any other sort of airway (in this case an LMA) is harming patients by decreasing their chance of survival then it needs to be studied and practice changed to reflect the results. I don't think, as I have said earlier, that the device matters, I think the 100% oxygen and/or the amount that is put down it (tidal /minute volume) does.

[fab]

Does anyone have access to the whole study, since it's hard to judge a study simply by the abstract. Do we know anything about their approach, say: if BVM fails --> supraglottic airway, if that fails --> ETI... which would explain the results. Assuming ETI is as good as BVM in delivering oxygen to the patient, why would there be a difference in outcome? Do we know enough about the (patho-)physiology? All we are doing is guessing.

Interestingly survival with good neurological outcome is as low as 2.9% in this study. Whereas in other systems it's as high as 10%...

[triemal04]

1.

I think we spend too much time valuing our jobs and existence on these patients, lets spend more time on patients that we can have a positive outcome on.

We do, probably for a variety of reasons, which are a topic for another thread, as is whether or not cardiac arrest survival should be used as a measure of how "good" a service is. Short answer would be because it's an easily measurable statistic, and, if you look at the history of paramedics and EMS, going all the way back to Dr. Pantridge in Ireland, this is why we came to be: MI's and cardiac arrest.

I am "old school" and disagree. I dont think the "device" used matters, I still believe "proper ventilation does". I can not tell you how many times I have watched Para-Gods dig in someone's throat for minutes in an attempt to get the tube in, versus just ventilating with a BVM. I do not see how the deprevation of oxygen improves anyone's survival chances. I have been around long enough to see "new studies" that prove what we have been doing for years is now somehow wrong, but the success rates never improve. I say go back to two rounds of Epi, Bicarb, and D50 for any arrest; it worked just as good as what we are doing today.

Hell, I'd say that's new school and the more appropriate mindset. Although they aren't perfect and have their own drawbacks, there are enough types of airways out there that ETI does not need to be the only one available, or the only one that someone is "willing" to do. (this is ignoring that you can easily ventilate most patient's with a BVM if you do it right). Tracheal intubation, when done correctly, is probably still the best and most efficient way, but it's not the only one, and no matter what's done, the end goal is, as you said, proper ventilation by any means.

Does anyone have access to the whole study, since it's hard to judge a study simply by the abstract. Do we know anything about their approach, say: if BVM fails --> supraglottic airway, if that fails --> ETI... which would explain the results. Assuming ETI is as good as BVM in delivering oxygen to the patient, why would there be a difference in outcome? Do we know enough about the (patho-)physiology? All we are doing is guessing.

Interestingly survival with good neurological outcome is as low as 2.9% in this study. Whereas in other systems it's as high as 10%...

Just a guess, and I doubt this is something that would be included, or even could be included in the full study, but my guess would be that the insertion of an ET tube or supraglottic caused, in at least some cases:

1- a pause in compressions

2- hyperventilation of the patient

3- caused whoever was in charge to neglect their other duties; ie defibrillation, ensuring effective compressions were happening, and medical therapies

Whether or not that would be responsible in any part for the difference I have no clue.

[island emt]

We all know that cardiac arrest is on the publics radar: The causation of arrest vary widely and the response to arrests vary even more.

In a large urban area the chance of someone seeing the arrest and reporting it are greater, the odds of someone doing citizen CPR are greater and the odds of a responder arriving sooner are greater, whether it's a cop , Firefighter, or EMS crew.

The results of almost all studies done in the past two decades , show that early CPR and early defibrillation are the best way to get a save to release from hospital neurologically intact.

[1EMT-P]

I have seen many trends in EMS over the years and I think the time has come to focus all of our efforts on improving how we educate and train providers using evidence based medicine. The simple fact of the matter is that most providers aren't proficient in skills like intubation because they simply do not get a chance to practice their skills on a regular basis. I think the time has come for us to seriously consider removing intubation from the scope of practice of most EMS providers with the exception of aeromedical and critical care paramedics.

[Kiwiology]

I have seen many trends in EMS over the years and I think the time has come to focus all of our efforts on improving how we educate and train providers using evidence based medicine. The simple fact of the matter is that most providers aren't proficient in skills like intubation because they simply do not get a chance to practice their skills on a regular basis. I think the time has come for us to seriously consider removing intubation from the scope of practice of most EMS providers with the exception of aeromedical and critical care paramedics.

I disagree, it is time to do like other nations in the world such as New Zealand, Australia, Canada (Alberta and Ontario more specifically) and South Africa that have removed superflorious levels , heavily up-educated and up-skilled their base level practitioners and ensured that the top level ("ALS") get sufficient exposure to crook people so they use their specific skillset as frequently as possible.

It's also time to get rid of a Paramedic (ALS) on every ambulance or on every fire truck where the IAFF is concerned, and for as little as sixteen weeks' Paramedic "training" plus a couple hundred hours of "skills internship" to be acceptable.

Intubation generally, I think ICP in New Zed gets about 1 tube per month per Officer, RSI is slightly less however we have consistently, for a decade now, exhibited > 97% success with (as of 2009) all failed intubations managed without cricothyrotomy. How is this possible? By having people who are extremely well educated and ensuring maximum possible on-going exposure.

And no, we shouldn't be intubating, or I don't think even ventilating, primary cardiac arrest patients.

Edited February 3, 2013 by Kiwiology

[Arctickat]

Do skills really atrophy though? Are there any studies to prove that infrequent intubations or IV starts lead to a high failure rate? I mean I work in a place where I might do 3 or 4 tubes a year and 25 - 30 IV starts. In 20 years as a medic I've never failed an intubation and I believe my IV success rate is on par with my urban counterparts.

Am I an anomaly?

Shut up Ben, that's rhetorical.

[mobey]

Less of an anomaly, and more of an abnormality.

I am also curious as to why so few et intubations in this study? Was it just downplayed in the education? or is a tube only put in place as a medication route if IV can't be placed?

Cardiac arrest management is so variable it is hard to gain relevant data.

Unless you are using EtC02 or better yet monitoring perfusion pressures invasively - to measure the quality of CPR, all the other data is skewed terribly.

[ERDoc]

Do skills really atrophy though? Are there any studies to prove that infrequent intubations or IV starts lead to a high failure rate? I mean I work in a place where I might do 3 or 4 tubes a year and 25 - 30 IV starts. In 20 years as a medic I've never failed an intubation and I believe my IV success rate is on par with my urban counterparts.

Am I an anomaly?

Shut up Ben, that's rhetorical.

That is a good question that I have wondered about myself. We see plenty of studies comparing paramedics/ER docs/anestheisologist/etc. I'd be curious to see a study that evaluated the skills of providers that took time off to see if there is a difference. Is it the ongoing experince that makes the difference or is it the intital training?

[island emt]

Trevor: I'm in the same boat as you with few chances to intubate per year and have only run into 1 pt that no matter what couldn't get a tube. He was a mallaptti grade 4 ,hugely obese pt that even the ER doc had to go several attempts to place a tube. We went with OPA after the second attempt.

IV's not a problem get plenty of opportunity for them. I've done two already this morning and it's only 9 AM.