NEGATIVE correllation with in field intubation and survival in cardiac arrests

[rcdavis]

the hits just keep on coming. I sorta suspected this as more and more procedures are being done in the field. I am not so sure that, save for the unstable wide QRS tachycardia, AMS/ seizing hypoglycemic, and very few others, there is any need for EMS to do much more than "load and Go), with the "Go" part being the imperative. stopping to intubate may not be necessary , and may become optional when AHA takes a good look at the numbers and qualifications of these providers

 

 

 

 

http://pulmccm.org/2013/review-articles/intubation-in-pre-hospital-cardiac-arrest-strongly-associate-with-worse-outcomes-jama/

[ajnelson]

This doesn't actually surprise me much either. Even CPR is making the change to more compressions, less ventilation as that has been shown to have better outcomes. Intubation isn't necessarily a quick procedure and it takes time away from circulating the oxygen.

[EMEDPA]

I think we are going to see a change in protocols to insertion of a supraglottic airway like a King LT in most out of hospital arrests and similar situations in the interest of saving time and not interrupting cpr. I don't want to see medics lose the skill though because there are some difficult airways that really require intubation/adv. airway management.

[rcdavis]

I think we are going to see a change in protocols to insertion of a supraglottic airway like a King LT in most out of hospital arrests and similar situations in the interest of saving time and not interrupting cpr. I don't want to see medics lose the skill though because there are some difficult airways that really require intubation/adv. airway management.

 

I do not necessarily disagree.. But my sense is that the EMTs are spending 5-10 minutes more in the field incubating than necessary.

 

Does it make a difference? ( remember, <5% PRE hospital arrests walk out), not sure.. But this study shows even less making it with intubation being an independent variable.

 

King/ LAMs are easy to do and hard to screw up.. That may be the perfect compromise.

 

Still. Scope and go IMHO is the best.( compressing all the way)

[jdumoch]

Last I read the AHA was actually recommending bvm in UC clinics rather than intubation.

[Guest Paula]

I do not necessarily disagree.. But my sense is that the EMTs are spending 5-10 minutes more in the field incubating than necessary.

 

Do they hatch chicks?

[GreatChecko]

I think we are going to see a change in protocols to insertion of a supraglottic airway like a King LT in most out of hospital arrests and similar situations in the interest of saving time and not interrupting cpr. I don't want to see medics lose the skill though because there are some difficult airways that really require intubation/adv. airway management.

 

In the system I ran in this is what things basically went to. We dropped tons of Kings and almost never intubated. I saw this pattern in the ED as well and it almost didn't matter the experience level, vol/paid, in cardiac arrests they usually dropped a king and transported if/when they got a rhythm.

[rcdavis]

In the system I ran in this is what things basically went to. We dropped tons of Kings and almost never intubated. I saw this pattern in the ED as well and it almost didn't matter the experience level, vol/paid, in cardiac arrests they usually dropped a king and transported if/when they got a rhythm.

 

And, excepting the blue dead for obviously a long time, when would you NOT transport?

 

I would prefer you swooped, scooped and came NOW, rather than await " regaining a rhythm" in the field. It is this philosophy ( lets run down the protocol lists several times before bringing in) that I am objecting to.

 

Trust me, I want to get them sooner rather than later.

 

The only delay should be EKG to r/o STEMI ( so you can activate cath lab), Wide complex unstable rhythms or rhythms needing electricity, put 'em on the gurney, start the IV on the way to me or the lab.

 

At least, that is how I feel.

[rcdavis]

I do not necessarily disagree.. But my sense is that the EMTs are spending 5-10 minutes more in the field incubating than necessary.

 

Do they hatch chicks?

 

Sometimes that's what I think is happening.. But of course in this case was autocorrect... Cluck!

[MediMike]

Interesting, but I take some issues with drawing significant conclusions from this paper. I had some trouble finding out what Japanese CPR was...While it is true that the national standard for ETI in the US is 5 (ridiculous), the actual number required is completely region dependent (also ridiculous). There is very VERY little standardizaiton in US EMS systems. Up here in the PNW we were required to obtain 20 OR tubes and a minimum of 5 field tubes.

 

In our region we are required to obtain a minimum of 12 intubations a year to be considered competent, have access to the OR if need be as well as difficult airway labs available. During OHCA we intubate through compressions, no pausing, no waiting. To address the hyperventilation issue we currently ventilate only once every 10 compressions, whether the pt. is intubated or not. We currently have a 52% OHCA survival rate, and that is 52% with a positive neurological outcome, not simply getting ROSC and leaving them with the mental faculties of a boiled potato.

 

Now, anecdotal of course, but if needed I can provide some data. I am not one to speak volumes on the benefits of intubation, as I have seen RSI abused left and right by new medics in our area, but I do see it as beneficial in some situations. Guaranteeing an airway in circumstances where filling the gut with gas can mess with compressions, as well as allow for aspirate can be extremely valuable, when done right. (i.e. Quickly, safely, no interruptions to compressions, with placement verified by ETCO2)

 

(Our save rate is according to UTSTEIN criteria)

[MediMike]

And, excepting the blue dead for obviously a long time, when would you NOT transport?

 

 

I took too long to reply and missed this one haha...

 

What the majority of more progressive systems are moving towards is not transporting with CPR in progress. If we don't get ROSC we don't transport, plain and simple. Unless you end up with a refractory VT/VF and you're about to run out of drugs. It's been shown (I'll dig up the studies if you'd like) that moving CPR is ineffective for the patient and dangerous to the rescuers.

[rcdavis]

Yeah, I'd like to see that.

 

I prefer no intubation.. Quick look on monitor, IV and transport. Working em in the field, though more fun, has not been shown to correlate with any improved survival excepting those situations I already mentioned, that need electricity.

 

Swoop, scoop quick look, and go. Bring em to me, compress on the way...(You ARE doing this aren't you? If not, that may partially explain the dismal survival rates.. At least put on a thumper if the act is too dangerous to be doing in the back of the rig)

[rcdavis]

Interesting, but I take some issues with drawing significant conclusions from this paper. I had some trouble finding out what Japanese CPR was...While it is true that the national standard for ETI in the US is 5 (ridiculous), the actual number required is completely region dependent (also ridiculous). There is very VERY little standardizaiton in US EMS systems. Up here in the PNW we were required to obtain 20 OR tubes and a minimum of 5 field tubes.

 

In our region we are required to obtain a minimum of 12 intubations a year to be considered competent, have access to the OR if need be as well as difficult airway labs available. During OHCA we intubate through compressions, no pausing, no waiting. To address the hyperventilation issue we currently ventilate only once every 10 compressions, whether the pt. is intubated or not. We currently have a 52% OHCA survival rate, and that is 52% with a positive neurological outcome, not simply getting ROSC and leaving them with the mental faculties of a boiled potato.

 

Now, anecdotal of course, but if needed I can provide some data. I am not one to speak volumes on the benefits of intubation, as I have seen RSI abused left and right by new medics in our area, but I do see it as beneficial in some situations. Guaranteeing an airway in circumstances where filling the gut with gas can mess with compressions, as well as allow for aspirate can be extremely valuable, when done right. (i.e. Quickly, safely, no interruptions to compressions, with placement verified by ETCO2)

 

(Our save rate is according to UTSTEIN criteria)

 

I believe that they ALL had to have 30 sucessful observed intubations, and that they followed AHA standards ( virtually identical to ACLS).

 

You ought to report that 52% survival rate.. Virtually unheard of anywhere in the states.

 

IMHO, medics ought to be doing less pharmacotherapy in the field and more quickly transporting.

 

In an unconscious patient with no pulse, there is no need for RSI.. They are not clenched.. They are essentially dead. A king lma Is just as effective.. Takes no time and provides more than adequate oxygenation.

 

Again, why wait to tube? Lma = 10 seconds.

 

Start the line, compress, lma and transport.. Maybe you could incrase that 52% to 60%!!!!

[dmdpac]

 

I would prefer you swooped, scooped and came NOW, rather than await " regaining a rhythm" in the field. It is this philosophy ( lets run down the protocol lists several times before bringing in) that I am objecting to.

 

Except you're not doing anything for the cardiac arrest patient by transporting immediately.

 

If there is a chance to get the person back quality and effective CPR is what has been shown to offer the person the best chance. CPR can't be done effectively carrying a person from where they went down to the ambulance. CPR cannot be done effectively in the back of a moving ambulance.

 

This says nothing of the risk to the EMS crew and others on the roads by running lights and sirens to transport a dead person.

 

This is why many EMS systems are moving towards a stay and play approach to cardiac arrest patients.

 

 

Trust me, I want to get them sooner rather than later.

 

To do... what?

 

The only delay should be EKG to r/o STEMI ( so you can activate cath lab)

 

In an increasing number of areas with ALS (i.e. paramedic... not EMT) coverage this is becoming the standard. Of course, most of the time this precludes a cardiac arrest patient.

 

Wide complex unstable rhythms or rhythms needing electricity...

 

If they're still perfusing then yes. If they're not perfusing then CPR first then electricity. Because effective CPR is what's needed to offer the best chance of returning to a perfusing rhythm post shock.

 

At least, that is how I feel.

 

Fair enough.

 

 

 

edit: repaired a quote coding error

[MediMike]

You're referring to a 52% OHCA survival rate as dismal? It's one of the best in the country.

 

http://www.ncbi.nlm.nih.gov.offcampus.lib.washington.edu/pubmed/10155415 (Older study)

 

http://www.ncbi.nlm.nih.gov.offcampus.lib.washington.edu/pubmed/23816898 (Study comparing non-moving v. moving v. moving with some sort of stability device)

 

In regards to the mechanical CPR device, the pilot studies didn't show much if any difference in outcomes, I haven't kept up on any of the newer studies (if there are any)

[MediMike]

I think we got off track there RC, or ended up on different pages somehow. We are getting close to the vaunted King County save rate, although we have a much smaller n.

 

The RSI comment was in regards to other airway management cases, not OHCA.

 

And argument for ETI performed correctly v. LMA (in my opinion), would be no issues dealing with aspiration post ROSC. Doesn't do much good to get 'em back then have them croak from a pulmonary issue.

 

Remember...just a medic speaking here haha

[rcdavis]

You're referring to a 52% OHCA survival rate as dismal? It's one of the best in the country.

 

http://www.ncbi.nlm.nih.gov.offcampus.lib.washington.edu/pubmed/10155415 (Older study)

 

http://www.ncbi.nlm.nih.gov.offcampus.lib.washington.edu/pubmed/23816898 (Study comparing non-moving v. moving v. moving with some sort of stability device).

 

In regards to the mechanical CPR device, the pilot studies didn't show much if any difference in outcomes, I haven't kept up on any of the newer studies (if there are any)

 

Not dismal at all... Unbelievable. I know of no system that reports such a high survival rate for ohca patient's.

 

Clearly you are doing something (better)(different) than everyone else... And we should be doing it.

 

The aha and CDC reported ohca survival rates are ~ 5%, not 50.

 

I will read your references...

[medic25]

Except you're not doing anything for the cardiac arrest patient by transporting immediately.

 

If there is a chance to get the person back quality and effective CPR is what has been shown to offer the person the best chance. CPR can't be done effectively carrying a person from where they went down to the ambulance. CPR cannot be done effectively in the back of a moving ambulance.

 

This says nothing of the risk to the EMS crew and others on the roads by running lights and sirens to transport a dead person.

 

This is why many EMS systems are moving towards a stay and play approach to cardiac arrest patients.

 

edit: repaired a quote coding error

 

This. Anyone who has ever seen a cardiac arrest patient being extricated from a house knows how useless it is to attempt CPR during transit. Even a 10 second break in compressions causes a loss of the coronary perfusion generated by CPR, and this takes time to re-generate. We encourage our medics to work the code on the scene; if they get ROSC they transport, and if not the patient gets terminated in the field. The hardest thing is getting the medics to drop their old habits, since they are so used to packing up the patient and transporting.

[MediMike]

That's correct, you look nationwide and some of the rates are downright terrible. Utilizing the UTSTEIN criteria though we are only evaluating witnessed OHCA with an initial shockable rhythm.

 

The absolute biggest changes we've made have included no interruption of compressions except for a quick glance at the monitor at 2mins, our Zoll monitors have the see-through CPR add-on along with active feedback on compression rate and depth (allows us to pre-charge for shock delivery and minimize the pause at 2mins), and some pretty heavy interagency training.

 

King County Medic One just released their latest report with #s at about 57% if I read right, and they have a MUCH larger demographic than us (although there's also the benefit of a HUGE number of CPR trained citizens in that region).

[rcdavis]

gain, we got off track.

 

I am not trying to argue against CPR and ACLS in witnessed arrests.

 

What the study says is that there is a negative correlation between experienced performer intubation and survivability.

 

The study had large numbers.

 

Is counterintuitive, I know, but the study stands.

 

Even AHA has de-emphasized ventilation over compression.

 

The other aspects of our debate ( scoop and go versus stay and play) are my opinions.. Too many times I have received patients incorrectly incubated, inadequate lines,... And been played with...

 

Here in the south we have pretty good EMT and paramedics.. But I do not feel comfortable with the EMTs pronouncing someone who did not get a spontaneous return of pulses after Acls. Do you fellas in the NE or NW do pericardiocenteses? Empirically try calcium? TPA for saddle embolus? I dunno...

 

If you are limiting your survivability rate to,only those patient's with a shockable rhythm, then I would imagine a better than 5% survivability is reasonable. But the national averages for all ohca are no where near that number.

 

If the study is validated, perhaps we ought not take time to incubate...

 

A possible exception might be to put a tube as a poor man's vascular access (NAVEL) delivery.. Though with the ezIO interosseous availability pretty much wipes this reason out.

 

The study is provocative.. The discussion is stimulating.

 

Frankly I think the real reason you stay and play is that generally you only have two players on the truck..l and someone has to drive if one guy is compressing, and the other guy is pushing drugs and bagging....

 

I guess you don't want to hear about the study showing prehospital epi ain't so good for you, huh? :)

[EMEDPA]

What about the australian study that shows that ALL acls drugs are no better than placebo? (yes, they did a placebo arm with nl saline).

only electricity and compressions showed value

[GreatChecko]

And, excepting the blue dead for obviously a long time, when would you NOT transport?

 

I would prefer you swooped, scooped and came NOW, rather than await " regaining a rhythm" in the field. It is this philosophy ( lets run down the protocol lists several times before bringing in) that I am objecting to.

 

Trust me, I want to get them sooner rather than later.

 

The only delay should be EKG to r/o STEMI ( so you can activate cath lab), Wide complex unstable rhythms or rhythms needing electricity, put 'em on the gurney, start the IV on the way to me or the lab.

 

At least, that is how I feel.

 

Having worked in both EMS and in the ED, my experience pretty much lines up with the national survival rates of patients arriving to the ED with CPR (IIRC its below 5%) and I was at a Level I receiving hospital with all the toys. Except for those lucky few that coded on the way to the hospital and had something that could be reversed, most of them were called called pretty quickly. A patient that had ROSC then crashed, there was something left to work with, and I saw more of those patients worked and leave the ED with a pulse and a pressure.

 

The only time that I would have considered a load and go arrest would have been a kid because I want to give them all I had (in direct contradiction with protocol). However, the guy that had the big one 15 minutes from the hospital, I'm going to work until ROSC or an end point as written in my protocol. I've done CPR in the back of an ambulance and it's no fun and exceptionally unsafe.

 

To answer your question of what I would not transport, here's a link to the Denver Metro Protocol. Protocol 0005 is what you want to read.

 

I always felt that guideline was fair, prudent, and was written to allow us to do the best for our patients while avoiding unnecessary risk.

 

http://www.dmemsmd.org/sites/default/files/Denver%20Metro%20Protocols%208_5_13.pdf

[MediMike]

gain, we got off track.

 

I am not trying to argue against CPR and ACLS in witnessed arrests.

 

What the study says is that there is a negative correlation between experienced performer intubation and survivability.

 

The study had large numbers.

 

Is counterintuitive, I know, but the study stands.

 

Even AHA has de-emphasized ventilation over compression.

 

The other aspects of our debate ( scoop and go versus stay and play) are my opinions.. Too many times I have received patients incorrectly incubated, inadequate lines,... And been played with...

 

Here in the south we have pretty good EMT and paramedics.. But I do not feel comfortable with the EMTs pronouncing someone who did not get a spontaneous return of pulses after Acls. Do you fellas in the NE or NW do pericardiocenteses? Empirically try calcium? TPA for saddle embolus? I dunno...

 

If you are limiting your survivability rate to,only those patient's with a shockable rhythm, then I would imagine a better than 5% survivability is reasonable. But the national averages for all ohca are no where near that number.

 

If the study is validated, perhaps we ought not take time to incubate...

 

A possible exception might be to put a tube as a poor man's vascular access (NAVEL) delivery.. Though with the ezIO interosseous availability pretty much wipes this reason out.

 

The study is provocative.. The discussion is stimulating.

 

Frankly I think the real reason you stay and play is that generally you only have two players on the truck..l and someone has to drive if one guy is compressing, and the other guy is pushing drugs and bagging....

 

I guess you don't want to hear about the study showing prehospital epi ain't so good for you, huh? :)

 

Hahaha! Someone's trying to paint me as a an EMS cowboy not open to new ideas... ;)

 

I don't particularly believe in the whole ACLS drug regimen. I've read the studies, and in no way am close minded. I would like to know whether they paused compressions for intubation and if so for how long, and what their first time pass success rate was. If they can show some causality behind this I think it'd be a lot easier for me to understand, rather than simply correlation.

 

You are incorrect your assumption about why we stay 'n play. We have, on average, between 4-6 people on scene at a minimum for each arrest, with the BLS crews in charge of compressions/ventilations while the 1-2 medics run the ACLS side of things. We stay on scene and manage the cardiac arrest because it's the most effective way to provide patient care, with proven outcomes.

 

In regards to pericardiocentesis if it is a traumatic arrest we can perform it. We carry calcium and are able to use it as deemed necessary. And in regards to tPA, in 10 years (not a huge amount of time, I know :) ) I have never seen it used by ED staff at any hospital, and have yet to see a study show it's effectiveness in arrest. In the peri-arrest time frame sure, otherwise not so much. (http://www.nejm.org/doi/full/10.1056/NEJMoa012885#t=articleResults) <-- Again an older study, but I'm lazy and couldn't find much else with a quick pubmed search!

 

And I agree, good discussion!

[dreatx]

MediMike, we must work in the same system. Work your arrests onscene. Compressions are what saves the person. Our medical director made this choice and he watches very closely for any evidence to support or refute what we are doing. Per protocol, we drop kings as well and keep interruption of compressions to a minimum.

 

I'd say that a cardiac arrest is one of the few things in medicine that can be scripted. If the Dr in charge holds people to the script, it seems like working CAs in the field is the way to go.