Comments on: ET Interruptions http://medicscribe.com/2010/04/et-interruptions/ Peter Canning's EMS Journal Sun, 20 May 2012 07:22:09 +0000 hourly 1 http://wordpress.org/?v=3.3.2 By: Michelle http://medicscribe.com/2010/04/et-interruptions/comment-page-1/#comment-9452 Michelle Tue, 20 Apr 2010 00:58:39 +0000 http://medicscribe.com/?p=3621#comment-9452 I agree that initial intubation isn't necessary for witnessed arrest but you are going to reach a point when you have to decide what are you doing the compressions for. Isn't the point of CPR to move oxygen enriched blood to the necessary organs? From previous studies we see that the chance of survival decreases by 10% after each minute after 5 minutes from the initial 50%. After 10 minutes that's a very small chance for patient survival. Are those numbers based on how many blood cells are you providing oxygen to? If you watch a patient being tubed in an ER/OR that still have a pulse and are hooked up to the SpO2 you can see after a few minutes during a difficult intubation attempt the SpO2 start dropping. The attempt is stopped and the patient is bagged again until the SpO2 increases back to 100% before a second attempt is made. 4 breaths a minute given to a patient with CPR that still requires a pause in CPR to deliver the breaths with the BVM after 5-10 minutes to me does seem like it will provide adequate perfusion to tissues. I'm not saying it has to be an ETT but an advanced airway like a KingLT, LMA, or a CombiTube to me should be inserted so an appropriate ventilation rate can be achieved. I could care less how I provide the oxygen to the patient as long as it's quick and "effective". However, we do use our laryngoscope for choking as well so don't take it out of my bag quite yet. I agree that initial intubation isn’t necessary for witnessed arrest but you are going to reach a point when you have to decide what are you doing the compressions for. Isn’t the point of CPR to move oxygen enriched blood to the necessary organs? From previous studies we see that the chance of survival decreases by 10% after each minute after 5 minutes from the initial 50%. After 10 minutes that’s a very small chance for patient survival. Are those numbers based on how many blood cells are you providing oxygen to? If you watch a patient being tubed in an ER/OR that still have a pulse and are hooked up to the SpO2 you can see after a few minutes during a difficult intubation attempt the SpO2 start dropping. The attempt is stopped and the patient is bagged again until the SpO2 increases back to 100% before a second attempt is made. 4 breaths a minute given to a patient with CPR that still requires a pause in CPR to deliver the breaths with the BVM after 5-10 minutes to me does seem like it will provide adequate perfusion to tissues. I’m not saying it has to be an ETT but an advanced airway like a KingLT, LMA, or a CombiTube to me should be inserted so an appropriate ventilation rate can be achieved. I could care less how I provide the oxygen to the patient as long as it’s quick and “effective”. However, we do use our laryngoscope for choking as well so don’t take it out of my bag quite yet.

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]]> By: medicscribe http://medicscribe.com/2010/04/et-interruptions/comment-page-1/#comment-9373 medicscribe Sat, 10 Apr 2010 14:49:59 +0000 http://medicscribe.com/?p=3621#comment-9373 Great comments, Mystery medic- I think a quick insertion of the alternate airway right away may be best. I am going to make a concerted attempt to see that the bag valve mask is done well on my next code, but it is so poor most of the time, plus there is the delay in CPR. What I am struggling with is the idea if I don't get to intubate, then I won't be able to intubate when I really need to intubate -- a burn or anaphylactic patient with a quickly closing airway. But I don't want to harm one patient by hoping to better aid another. So I fight this clash between what I intellectually feel is the right thing to do, and what my body as a trained paramedic wants to do. Will I manage good bag/valve? Will I slam in a quick LMA? or will I try to get my tube? I feel recently I have reached this tipping point where the need to intubate has finally started to lose out to the need to do what is right, so I am anxious to see how I will handle the conflict in the next heat of battle. Thanks again for your thoughts, Peter C Great comments, Mystery medic-

I think a quick insertion of the alternate airway right away may be best. I am going to make a concerted attempt to see that the bag valve mask is done well on my next code, but it is so poor most of the time, plus there is the delay in CPR. What I am struggling with is the idea if I don’t get to intubate, then I won’t be able to intubate when I really need to intubate — a burn or anaphylactic patient with a quickly closing airway. But I don’t want to harm one patient by hoping to better aid another. So I fight this clash between what I intellectually feel is the right thing to do, and what my body as a trained paramedic wants to do. Will I manage good bag/valve? Will I slam in a quick LMA? or will I try to get my tube? I feel recently I have reached this tipping point where the need to intubate has finally started to lose out to the need to do what is right, so I am anxious to see how I will handle the conflict in the next heat of battle.

Thanks again for your thoughts,

Peter C

]]> By: MysteryMedic http://medicscribe.com/2010/04/et-interruptions/comment-page-1/#comment-9371 MysteryMedic Fri, 09 Apr 2010 13:36:59 +0000 http://medicscribe.com/?p=3621#comment-9371 I agree that initial intubation isn't necessary for witnessed arrest but you are going to reach a point when you have to decide what are you doing the compressions for. Isn't the point of CPR to move oxygen enriched blood to the necessary organs? From previous studies we see that the chance of survival decreases by 10% after each minute after 5 minutes from the initial 50%. After 10 minutes that's a very small chance for patient survival. Are those numbers based on how many blood cells are you providing oxygen to? If you watch a patient being tubed in an ER/OR that still have a pulse and are hooked up to the SpO2 you can see after a few minutes during a difficult intubation attempt the SpO2 start dropping. The attempt is stopped and the patient is bagged again until the SpO2 increases back to 100% before a second attempt is made. 4 breaths a minute given to a patient with CPR that still requires a pause in CPR to deliver the breaths with the BVM after 5-10 minutes to me does seem like it will provide adequate perfusion to tissues. I'm not saying it has to be an ETT but an advanced airway like a KingLT, LMA, or a CombiTube to me should be inserted so an appropriate ventilation rate can be achieved. I could care less how I provide the oxygen to the patient as long as it's quick and "effective". However, we do use our laryngoscope for choking as well so don't take it out of my bag quite yet. I agree that initial intubation isn’t necessary for witnessed arrest but you are going to reach a point when you have to decide what are you doing the compressions for. Isn’t the point of CPR to move oxygen enriched blood to the necessary organs? From previous studies we see that the chance of survival decreases by 10% after each minute after 5 minutes from the initial 50%. After 10 minutes that’s a very small chance for patient survival. Are those numbers based on how many blood cells are you providing oxygen to? If you watch a patient being tubed in an ER/OR that still have a pulse and are hooked up to the SpO2 you can see after a few minutes during a difficult intubation attempt the SpO2 start dropping. The attempt is stopped and the patient is bagged again until the SpO2 increases back to 100% before a second attempt is made. 4 breaths a minute given to a patient with CPR that still requires a pause in CPR to deliver the breaths with the BVM after 5-10 minutes to me does seem like it will provide adequate perfusion to tissues. I’m not saying it has to be an ETT but an advanced airway like a KingLT, LMA, or a CombiTube to me should be inserted so an appropriate ventilation rate can be achieved. I could care less how I provide the oxygen to the patient as long as it’s quick and “effective”. However, we do use our laryngoscope for choking as well so don’t take it out of my bag quite yet.

]]> By: medicscribe http://medicscribe.com/2010/04/et-interruptions/comment-page-1/#comment-9367 medicscribe Tue, 06 Apr 2010 21:45:55 +0000 http://medicscribe.com/?p=3621#comment-9367 Thanks for the great comments, I think the audio recordings and data review of all carda arrests wouldbe a great wayto keep us all honest on the scene. We don't do that around here. Medics may think they are being judged on the patient they bring in to the hospital as oppossed to how they did on the scene. An ET tube thattook ten minutes to get will no longer be more impressive than the LMA tht took 10 seconds to place. With regard to training, when I went to medic school in 1992, we had to do 10 tubes in the OR. I amnotcetain what the areed upon state number is nowdays. It may still be 10, but it could be as low as six. As an EMS coordinator, the services I oversee have access to an OR to help maintain their skills, but one problem there is is that the OR does more an more LMAs now where in the past they intuated everyone. I do agree that the hospitals could set a better example for the medics, by not yanking the LMAs and combi-tubes and then intubating or trying to intubate. I have seen many examples of the combitube in the obese patient being pulled and the ED then not being able to intubate. Once the patient has been stabilized, I can see them switching, but in the middle of a code if the alternative airway is working, there is no need to switch. Thanks again foall the comments, Peter C Thanks for the great comments,

I think the audio recordings and data review of all carda arrests wouldbe a great wayto keep us all honest on the scene. We don’t do that around here. Medics may think they are being judged on the patient they bring in to the hospital as oppossed to how they did on the scene. An ET tube thattook ten minutes to get will no longer be more impressive than the LMA tht took 10 seconds to place.

With regard to training, when I went to medic school in 1992, we had to do 10 tubes in the OR. I amnotcetain what the areed upon state number is nowdays. It may still be 10, but it could be as low as six.

As an EMS coordinator, the services I oversee have access to an OR to help maintain their skills, but one problem there is is that the OR does more an more LMAs now where in the past they intuated everyone.

I do agree that the hospitals could set a better example for the medics, by not yanking the LMAs and combi-tubes and then intubating or trying to intubate. I have seen many examples of the combitube in the obese patient being pulled and the ED then not being able to intubate. Once the patient has been stabilized, I can see them switching, but in the middle of a code if the alternative airway is working, there is no need to switch.

Thanks again foall the comments,

Peter C

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