Another Article on Prehospital Intubation

[docB]

This article in the Jan/March 2011 Prehospital Emergency Care studied non-traumatic out of hospital cardiac arrest. They only looked at patients who were successfully intubated, i.e. they excluded patients who could not be intubated due to difficult airways. They did that to try to focus the study on the question of whether or not intubation helps and not on issues of procedural competence.

They found that in general patients did not benefit from prehospital intubation and that VF/VT arrests did worse when intubated.

In their discussion they speculate that the reasons might be unrecognized, misplaced tubes, accidental hyperventilation, positive pressure ventilation in general and the fact that the intubation procedure takes away from other actions such as defibrillation, compressions and medication administration.

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[csmmedic]

All I saw was "another article on..." and I could already complete the sentence in my mind. Predictable results. It's just not working out in the arrest setting. My county is doing a trial, king tubes with an ITD (resqpod I believe). I am thinking this is going to be superior to ETI for the cardiac arrest patients. Easier, faster, more time for good compressions.

 

[leviathan]

I read that study but I have to wonder, why were the patients in the control group NOT intubated? I have a feeling these two groups (those who were intubated vs. not even an attempt) have very different characteristics.

I do agree though, intubation in the hands of anyone will affect arrest outcomes when it takes away from the fraction of time chest compressions are being done. A King or other supraglottic airway seems to be the way to go until you get ROSC, or maybe if there are compounding airway issues that might affect the chances of ROSC like someone who has aspirated and needs suctioning.

Anyway, I don't think it's necessarily a product of provider inexperience but the simple fact that anyone who intubates in an arrest will affect survival outcomes, unless they are able to get the tube in without interrupting compressions.

 

[docB]

Anyway, I don't think it's necessarily a product of provider inexperience but the simple fact that anyone who intubates in an arrest will affect survival outcomes, unless they are able to get the tube in without interrupting compressions.

I think you're right. We're getting to the point where there is enough literature to say that we need to change the criteria for prehospital intubation, i.e. reserve it for certain situations. It's starting to look like we need to consider looking at in hospital arrests. Should we be delaying intubation until later on in the code or until ROSC.

 

[Altruist]

Generalizing from this, I have to wonder (again) where pre-hospital intubation is headed. It's hard enough making sure ALS providers are proficient at intubation now! If larger studies generalize these results to more cardiac arrest patients, the number of intubations per medic per year will get awfully small (especially if the results on pre-hospital RSI keep turning up negative, and that falls out of favor). How much more will it take before agencies give up on the expense of training and equipping all their medics to intubate?

In cardiac arrest, I'm also curious to see if intubation + ResQpod is as helpful as has been advertised, and whether there's any benefit over supraglottic airway + ResQpod, or no intubation at all. There's still a lot of work to be done, that's for sure.

It'll be interesting to see how this all shakes out.

 

[joeDO2]

where I currently work we have implemented a different approach to airway management in arrest. for the first 8 minutes of a vf/vt arrest, we perform CCR which involves:

1. compressions only with Lucas device (no manual compressions)
2. non-rebreather mask is placed, no ventilations
3. IO line is established and epi is given every 3 minutes

At the end of the first 8 minutes we revert to basic ACLS medications with the addition of amiodarone and ruling out reversible causes. Airway management is then performed in the following sequence:

1. Briefly attempt DL ONCE with bougie ready, Lucas continues compressions
2. Second attempt at ET performed with Airtraq optical laryngoscope
3. KingLT or i-gel LMA is placed
4. Quik trach if unable to secure airway or ventilate with mask

When an advanced airway has been established, the ResQPod is attached.

Once a perfusing rhythm is identified the patient has a esophageal temperature probe placed and therapeutic hypothermia is initiated.

Using this sequence we have found that outcomes have improved and in most cases advanced airways can be placed without adverse outcomes.

 

[docB]

where I currently work we have implemented a different approach to airway management in arrest. for the first 8 minutes of a vf/vt arrest, we perform CCR which involves:

1. compressions only with Lucas device (no manual compressions)
2. non-rebreather mask is placed, no ventilations
3. IO line is established and epi is given every 3 minutes

At the end of the first 8 minutes we revert to basic ACLS medications with the addition of amiodarone and ruling out reversible causes. Airway management is then performed in the following sequence:

1. Briefly attempt DL ONCE with bougie ready, Lucas continues compressions
2. Second attempt at ET performed with Airtraq optical laryngoscope
3. KingLT or i-gel LMA is placed
4. Quik trach if unable to secure airway or ventilate with mask

When an advanced airway has been established, the ResQPod is attached.

Once a perfusing rhythm is identified the patient has a esophageal temperature probe placed and therapeutic hypothermia is initiated.

Using this sequence we have found that outcomes have improved and in most cases advanced airways can be placed without adverse outcomes.

That's really interesting. Are you giving amiodarone to everyone or just those who had VF/VT at some point?

On the TH side are you chilling every ROSC? We have stopped chilling the asystoles and PEAs with ROSC and only do the VF/VTs. I'm pretty sure this is due mainly to cost concerns and a lack of literature on benefits for non-VF/VT ROSCs.

 

[leviathan]

I think the best solution is a targeted EMS system where there are only a few ALS units and they only respond to high acuity calls. That way they spend 12 hours a day going to arrests, ACS, respiratory failure calls etc etc and get really good at managing the sickest patients and doing frequent intubations. I worked in that kind of system for a while and the only arrests I saw they were able to get the tube in without stopping CPR, which was awesome. Sadly I still never saw anyone survive, except one guy who went into VT right in front of us.

 

[leviathan]

where I currently work we have implemented a different approach to airway management in arrest. for the first 8 minutes of a vf/vt arrest, we perform CCR which involves:

1. compressions only with Lucas device (no manual compressions)
2. non-rebreather mask is placed, no ventilations
3. IO line is established and epi is given every 3 minutes

At the end of the first 8 minutes we revert to basic ACLS medications with the addition of amiodarone and ruling out reversible causes. Airway management is then performed in the following sequence:

1. Briefly attempt DL ONCE with bougie ready, Lucas continues compressions
2. Second attempt at ET performed with Airtraq optical laryngoscope
3. KingLT or i-gel LMA is placed
4. Quik trach if unable to secure airway or ventilate with mask

When an advanced airway has been established, the ResQPod is attached.

Once a perfusing rhythm is identified the patient has a esophageal temperature probe placed and therapeutic hypothermia is initiated.

Using this sequence we have found that outcomes have improved and in most cases advanced airways can be placed without adverse outcomes.

Cool, good to know! Where I worked we didn't do anything like that but there was apparently a 30% increase in survival to discharge a year after we changed the way we did CPR (focusing on early CPR start, and minimizing time off the chest).

 

[joeDO2]

That's really interesting. Are you giving amiodarone to everyone or just those who had VF/VT at some point?

On the TH side are you chilling every ROSC? We have stopped chilling the asystoles and PEAs with ROSC and only do the VF/VTs. I'm pretty sure this is due mainly to cost concerns and a lack of literature on benefits for non-VF/VT ROSCs.

amiodarone is only given if there was VF/VT or if there is significant ventricular ectopy noted.

we do chill almost every patient with ROSC, but there are a few exceptions: age under 16, traumatic arrest (excluding hanging and drowning), core temperature already below 35 degrees, pulmonary edema, or purposeful movement

 

[Farmer2DO]

I think the best solution is a targeted EMS system where there are only a few ALS units and they only respond to high acuity calls. That way they spend 12 hours a day going to arrests, ACS, respiratory failure calls etc etc and get really good at managing the sickest patients and doing frequent intubations. I worked in that kind of system for a while and the only arrests I saw they were able to get the tube in without stopping CPR, which was awesome. Sadly I still never saw anyone survive, except one guy who went into VT right in front of us.

That's a great idea in theory, but in my system, the 911 center over-triages a large percentage of the calls. Anyone with a "cardiac history" (I had a stent placed 12 years ago), abnormal breathing, not-alert, or chest pain is given the highest priority, (regardless of the true complaint) so all of our ALS units spend most of the shift going lights-and-sirens across the city for BS. The problem is that they ask closed ended questions and the local citizens have learned that answering yes gets a fire truck and an ambulance a lot quicker.

I would love to work in the system you describe. I love being a paramedic and I love patient care. I'm just so tired of the 3 am back pain calls that have been going on for 3 months, or the toothache for 2 weeks, or the 6 year old with a rash for a week on a school night. And they flash their Medicaid card at you like they're entitled to the gold treatment, and you're their humble public servant.

 

[WestcoastMedicine]

amiodarone is only given if there was VF/VT or if there is significant ventricular ectopy noted.

we do chill almost every patient with ROSC, but there are a few exceptions: age under 16, traumatic arrest (excluding hanging and drowning), core temperature already below 35 degrees, pulmonary edema, or purposeful movement

Why do you not chill under 16 years of age? Our hypothermia protocol includes patients from birth on up in our NICU/PICU.

 

[joeDO2]

Why do you not chill under 16 years of age? Our hypothermia protocol includes patients from birth on up in our NICU/PICU.

I'm not sure there is a reason other than insufficient data in that population to support or reject the practice

 

[leviathan]

That's a great idea in theory, but in my system, the 911 center over-triages a large percentage of the calls. Anyone with a "cardiac history" (I had a stent placed 12 years ago), abnormal breathing, not-alert, or chest pain is given the highest priority, (regardless of the true complaint) so all of our ALS units spend most of the shift going lights-and-sirens across the city for BS.

We have the same problem, but then there is usually a good clinical judgment by the BLS crews to cancel ALS ahead of time after they do their assessment. Usually that works out pretty well.

 

[Farmer2DO]

We have the same problem, but then there is usually a good clinical judgment by the BLS crews to cancel ALS ahead of time after they do their assessment. Usually that works out pretty well.

Our Fire Department that does first response WON'T cancel ALS (in fact, I think their upper management won't allow it). In addition, it's almost always an ALS ambulance that's taking the call. Our dispatchers are smart; if the call sounds dumb, and they have a BLS crew in the area, they will send it also, but the contract with the city requires an ALS crew respond to priority 1 and 2 calls, and the vast majority of the time, it's a paramedic ambulance that takes the job.