Mounting evidence against intubating cardiac arrest patients...

[HellsBells]

I think its a matter of how proficient one gets with the skill to begin with. In my carrer I must have preformed a thousand or more IV starts, I think I would retain that skill no matter how much time I took off.

Generally, I am successful with intubation, however, I have not had the opportunity to lay the amount of et tubes as I've with iv's. So I don't have the same level of confidence that I can take all comers, but, I think once one reaches a certain threshold of competence, its not necessary to practice the skill as frequently.

[ClutzyEMT]

I think its a matter of how proficient one gets with the skill to begin with.

You took the words right out of my mouth Hellsbells.....I've always felt that the 'initial' proficiency level of a certain skill will remain the single most important factor of whether the providers experiences atrophy of that skill or not when not given the chance to use it often~~

I border more on relying on excellent BLS skills on an out of hospital arrest and making sure we are doing excellent compression, getting the AED hooked up and attached as soon as possible, and ventilating with a BVM before worrying about putting in an airway. If there is good chest rise and lung sounds with the BVM then most likely I am not going any further with the airway at that point and time. The last time I did need to tube someone I did it during compressions....can't see the reason to stop if I have my landmarks. But that's just my two cents...

[chbare]

At this point there are many suggestions for studies that can better focus potential causal and effect questions. However, at this point, I also think a good case exists for making traditional intubation in a cardiac arrest patient a potentially unhelpful if not harmful action. Additionally, we are now just starting to gather evidence suggesting supraglottic placement may not be as efficacious as we currently think. The next AHA guidelines announcement in a couple of years will be interesting. Perhaps it's time to let go of the old "gold standard" in certain situations regardless of your personal bias or n=1 anecdotal experiences?

Edit: ","

Edited February 5, 2013 by chbare

[rock_shoes]

At this point there are many suggestions for studies that can better focus potential causal and effect questions. However, at this point, I also think a good case exists for making traditional intubation in a cardiac arrest patient a potentially unhelpful if not harmful action. Additionally, we are now just starting to gather evidence suggesting supraglottic placement may not be as efficacious as we currently think. The next AHA guidelines announcement in a couple of years will be interesting. Perhaps it's time to let go of the old "gold standard" in certain situations regardless of your personal bias or n=1 anecdotal experiences?

Edit: ","

I have major concerns regarding bias potential of the study presented.

1) Proficiency of the intubator. Are the providers included all bark and no bite so to speak (i.e. great didactic without any practical experience).

2) Techniques used. Was CPR interrupted for airway placement? Was airway placement given greater priority than treatable causes at any point?

3) Algorithm bias. As previously mentioned early ROSC is a well-known indicator of likely survival to discharge. If ROSC comes early in the resuscitation it's less likely that the patient be intubated. It must therefore be considered that intubation could be an incidental finding in failed survival to discharge as opposed to a causal factor.

As for supra-glottic devices, the very design of them should be suspect to anyone with knowledge of vascular anatomy. The early evidence gathered thus far indicates they impair cerebral circulation. Shocker! Let me tamponade your throat and see how long you stay conscious. These devices by nature of design have the potential to do exactly that from the inside out. Not exactly ideal for an already circulation starved brain.

[chbare]

An editorial by Dr. Wang, a much loved person by the American EMS community.

http://jama.jamanetwork.com/article.aspx?articleid=1557717

Regardless of concerns and potential weaknesses, there is now a significant amount of evidence that does not support traditional endotracheal intubation for patients in cardiac arrest. The literature is now being published by the JAMA, no small player in terms of their representation of the medical community as a whole. All concerns aside, physicians and presumably medical directors may start taking note as contemporary studies continue to illustrate trends of decreased survival and neurological outcomes and their association with traditional airway management techniques.

I have major concerns regarding bias potential of the study presented.

1) Proficiency of the intubator. Are the providers included all bark and no bite so to speak (i.e. great didactic without any practical experience).

2) Techniques used. Was CPR interrupted for airway placement? Was airway placement given greater priority than treatable causes at any point?

3) Algorithm bias. As previously mentioned early ROSC is a well-known indicator of likely survival to discharge. If ROSC comes early in the resuscitation it's less likely that the patient be intubated. It must therefore be considered that intubation could be an incidental finding in failed survival to discharge as opposed to a causal factor.

As for supra-glottic devices, the very design of them should be suspect to anyone with knowledge of vascular anatomy. The early evidence gathered thus far indicates they impair cerebral circulation. Shocker! Let me tamponade your throat and see how long you stay conscious. These devices by nature of design have the potential to do exactly that from the inside out. Not exactly ideal for an already circulation starved brain.

The early evidence from an animal study involving less than a dozen animals is not particularly noteworthy. Evidence from a large and seemingly well designed study is a bit more compelling.

[mikeymedic1984]

Have you guys actually ever worked an arrest, and had copious amount of vomit coming up the airway from compressions ? How in the hell could you suggest that an unsecured airway is ever a good thing. I don't care what one study suggests, anyone who has actually worked in the field knows that this is a bunch of crap. As stated earlier, I am sure that I can produce a study that shows anything I want it to.

[ERDoc]

Have you guys actually ever worked an arrest, and had copious amount of vomit coming up the airway from compressions ? How in the hell could you suggest that an unsecured airway is ever a good thing. I don't care what one study suggests, anyone who has actually worked in the field knows that this is a bunch of crap. As stated earlier, I am sure that I can produce a study that shows anything I want it to.

This is the anecdotal evidence that chbare was talking about. Have you ever worked an arrest where there wasn't a copious amount of vomit coming up the airway? I have, I have had more like this than I have where there was vomiting (maybe it is just the quality of EMS providers where I am but I doubt that). We are already moving to compression only CPR, I think that in the next few years/decade we may see that for all arrests and not just for layperson. Perfusion of cardiac tissue is the name of the game and they only way to do that is with compressions.

[island emt]

A lot of the copious vomiting is caused by providers blowing air into the stomach and insuflating it. Hence when compressions are done it burps up all the contents with the air pushing out the load. Yes I have worked codes where there was no vomit.

[Kiwiology]

Airway and ventilation are the second-lowest priorities in primary cardiac arrest in the 2013 CPG; the lowest is IV drugs so we are already as close to compression only CPR as we can get. Intubation is no longer recommended and in fact it is discouraged over preference to a well fitted LMA while ventilation is now taught to be 8-10 breaths per minute and not more.

Intubation is still practiced in cardiac arrest however it is more the engrainings of the individual ICP than the formal view of the Clinical Working Group; clearly old habits die hard and something you have done for 10 or 20 years is hard to break. CWG acknowledge this and are working hard on it.

When more evidence comes out then I believe we will move to compression only CPR without ventilations and that we are already as close to this as the current evidence base will allow. It has also been stated that IV drugs are going to be removed but there is not enough evidence for that either at the moment.

[Bieber]

We've moved to doing CCR for the first 6 minutes of a code here, combined with a greatly decreased emphasis on intubation (as usual, to the chagrin of many paramedics). As a result of this, our ROSC rate has I believe doubled. As far as intubation or PPV, I'm still waiting to see evidence that they are beneficial to the vast majority of SCA victims... It seems like from what I understand of the science and from having listened to Dr. Ewy (one of the creators of CCR) that there's really not a tremendous need for PPV in the vast majority of SCA patients. (And it sounds like avoiding PPV also helps to avoid a "vomitcano" as well.)

The tube is fun, the drugs are fun, but where's the evidence to support their use? We can mix and mash the data however we want, but the fact is cardiac arrest survival rates have stayed dismally low since we first began resuscitating people... the only systems I have heard of who have managed to defy this trend are those with either very high laypeople CPR rates, or places where CCR, therapeutic hypothermia, etc are being done.

If we have to get all of the stars lined up just right to try and make intubation of SCA patients something beneficial, and its benefit isn't so great as to be intrinsic to most cardiac arrest scenarios, and if survival rates haven't improved since we've been doing it, is it really this horse we ought to keep beating to death?