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    Lightbulb Replacing ETC with ETT in matters of full cardiac arrest!

    Engine 23 arrives on the scene of a 56 -year-old male who suffered a cardiac arrest while mowing the grass. Bystanders witnessed the arrest, immediately called 911, and began cardiopulmonary resuscitation. Two firefighters take over CPR from the bystanders; one EMT begins placing the automated external defibrillator on the patient while a second EMT quickly inserts an esophageal-tracheal combitube. The AED recommends a countershock, which the EMTs deliver, and CPR resumes.

    As the medic unit arrives, one of the firefighters detects a pulse after a "no shock indicated" announcement from the AED. One of the arriving paramedics prepares to replace the ETC with an endotracheal tube. After removing the ETC, the medic has difficulty inserting the ETT. At the start of the second attempt, the patient redevelops ventricular fibrillation and the team delivers an additional countershock. CPR resumes, the medic secures the ETT, and the team completes preparation for transport. The patient never regains a pulse and the emergency department terminates the resuscitation attempt on arrival.

    The EMT-B believes that the paramedic should not have attempted to replace the ETC, arguing that the difficult intubation may have contributed to the re-fibrillation. The paramedic points out that the ETT is considered the "gold standard" of airway control. He considers the ETC a secondary airway device that provides substandard ventilation during a resuscitation effort, which may have contributed to the patient's demise.

    If the paramedic is right, cardiac arrest victims receiving the ETC should have lower survival rates compared to those who receive endotracheal intubation.




    So I just wanted to post this and let you gus post your opinions, in my opinion taking the time to replace the ETC was a bad idea but I don't believe it cost this man his life.

    Question:
    Do you think ALS should remove an ETC to apply an ETT if the ETC is working properly?

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    When I was riding the ambulance, the medic got 2 tries at the ET tube. After that, the combitube went in. I have never saw a medic pull an already in place combitube. Although, I have saw a ER doc pull a combitube put in by a medic because they couldn't get the ET tube. They worked for several minutes trying to resecure the airway that was fine upon arrival.

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    Grasshopper...
    • The medic has much more training than the EMT..1000 hours + depending on the program.
    • The medic also has standing orders and protocols from medical control.
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    These are my personal thoughts and are generalized, they do not reflect this particular situation:

    From everything I have seen, the "gold standard" is supposed to be effective ventilation. It used to be that ETT were a "must have". Often only 1 paramedic would be at the call and he/she would drop the tube, give 1 round of drugs down the tube, then attempt IV placement in time for the 2nd round of drugs. So the ETT was helpful in airway management, and allowed to paramedic to give that first dose of Epi and/or Atropine.

    Drugs down the tube are a thing of the past now, and it's either IV or a quick & easy IO. The only function of the ETT tube is to secure the airway. The way I read all the literature and all the training I have received is this: Use whatever method needed to secure the airway. If you are able to make air go in and out, then you have an effective airway. ETT takes time, time that can be better spend on other things (CPR, transport, IV, calling your medical director to terminate the code). If we get good chest rise with no resistance using the BVM and an OPA, then we will focus on other things first. If we get resistance or poor chest movement we will drop a combitube. ETT is last resort for us. The focus for airways should never be the device, it should always be the function. If air goes in and out, you are doing your job. ETT tube placement is pretty far down the list in the ACLS allogarithm (sp?).

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    Quote Originally Posted by bgfdtower1 View Post
    When I was riding the ambulance, the medic got 2 tries at the ET tube. After that, the combitube went in. I have never saw a medic pull an already in place combitube. Although, I have saw a ER doc pull a combitube put in by a medic because they couldn't get the ET tube. They worked for several minutes trying to resecure the airway that was fine upon arrival.
    I don't quite understand why they would do that, I mean yes an ET tube may provide better ventilation if ETC is in the esophagus but at the same time we are learning that blood flow is more important that ventilation especially initially so why not have pretty darn good ventilation with the ETC and not stop CPR to put in an ETT. As far as im concerned an OPA or NPA is perfectly fine as long as you are getting succesful ventilation. Someone pointed out this link to me about CPR : http://www.msnbc.msn.com/id/23884566
    No idea how to post it as a link but in this article it says that pure chest compressions until help arrives is thought to be better than the 30x2 ratio. If that's true then I wonder what was going through this medics head on removing the ETC.

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    Quote Originally Posted by CaptainGonzo View Post
    Grasshopper...
    • The medic has much more training than the EMT..1000 hours + depending on the program.
    • The medic also has standing orders and protocols from medical control.
    The patient already had an ETC succesfuly put in providing adequate ventilations, in IL protocal the medic would not remove an ETC on a full arrest to replace it with an ETT. This is exactly what I see as a problem, just because the medic has more training he should remove a perfectly good airway to insert his superior training ETT? I was under the impression time is of the essence in cardiac arrest and taking 3 minutes to remove the ETC and insert an ETT seems like needless time waisted...
    Last edited by FireEMT712; 01-23-2010 at 03:21 PM.

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    Quote Originally Posted by FireEMT712 View Post
    I don't quite understand why they would do that, I mean yes an ET tube may provide better ventilation if ETC is in the esophagus but at the same time we are learning that blood flow is more important that ventilation especially initially so why not have pretty darn good ventilation with the ETC and not stop CPR to put in an ETT. As far as im concerned an OPA or NPA is perfectly fine as long as you are getting succesful ventilation. Someone pointed out this link to me about CPR : http://www.msnbc.msn.com/id/23884566
    No idea how to post it as a link but in this article it says that pure chest compressions until help arrives is thought to be better than the 30x2 ratio. If that's true then I wonder what was going through this medics head on removing the ETC.
    It wasn't the medic who removed it. It was the Doc once the patient was rolled into the ER. I don't understand either, but fact of the matter is, it doesn't matter if I understand. He is the Doc, I'm just a little bity ole EMT. That's why he gets the big bucks.

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    Quote Originally Posted by bgfdtower1 View Post
    It wasn't the medic who removed it. It was the Doc once the patient was rolled into the ER. I don't understand either, but fact of the matter is, it doesn't matter if I understand. He is the Doc, I'm just a little bity ole EMT. That's why he gets the big bucks.
    In the Scenario it was the medic that removed the ETC. I guess what I'm looking for is a good enough reason to do somethin like removing a functioning airway?

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    If the paramedic was operating under a post-arrest hypothermia protocol, or was planning on transporting to a hospital that did, an ETT is required to be in place before initiating such measures. Just a possibility.

    It's also a possibility that the Combi-Tube placement caused airway damage that resulted in the paramedic's difficulties securing the airway with an ETT. This is not uncommon. Many ERs bring out their crash airway cart and page an anesthesiologist when they hear a Combi-Tube has been placed because of the mangled airways that have been dropped in their lap from EMS use of these devices.

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    Why wasn't a bolus of Lido and a Lido drip started?
    That could have prevented the V-Fib.

    Just my 2 cents.....
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    Quote Originally Posted by emt161 View Post
    If the paramedic was operating under a post-arrest hypothermia protocol, or was planning on transporting to a hospital that did, an ETT is required to be in place before initiating such measures.
    Could you go into a little bit more detail with me about this postarrest hypothermia protocal? Sorry, I'm not familiar with this at all.
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    Ditto on the Lido.

    Combi Tubes tubes F-ducking Blow they are a Airway trauma inducing Pile-o-Crap. Not to mention a pain in the arse all the way around. a ET tube is the Best airway you can give to Patient hands down. That would be reason enough for me. The better question is, Why in the hell are you Still using them and not King Air ways?
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    Quote Originally Posted by Bushwhacker View Post
    Ditto on the Lido.

    Combi Tubes tubes F-ducking Blow they are a Airway trauma inducing Pile-o-Crap. Not to mention a pain in the arse all the way around. a ET tube is the Best airway you can give to Patient hands down. That would be reason enough for me. The better question is, Why in the hell are you Still using them and not King Air ways?
    This scenario isn't from my area but we are just starting to introduce the King tubes which I can't wait to get on our trucks. I am not a huge fan of ETC's period OPA, NPA, BVM are my prefered airways and if they don't work around here ALS could probably be on seen by the time i get done trying these. We did have an arrest lately that the lungs were so full of fluid that we could not get air in. I was suctioning during compressions then trying to BVM and could not get anything in. When ALS arrived and dropped the ETT in and gave the first dose of atro it came right back out... Any of you guys ever seen a case like this? I mean there was so much fluid in the lungs that while bagging, the side cap blew off the BVM imbetween the bag and mask.... maybe this was just junk equipment?
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    Quote Originally Posted by FireEMT712 View Post

    So I just wanted to post this and let you gus post your opinions, in my opinion taking the time to replace the ETC was a bad idea but I don't believe it cost this man his life.

    Question:
    Do you think ALS should remove an ETC to apply an ETT if the ETC is working properly?
    I guess my answer would be, it depends.

    Without actually having been there, it's pretty hard to make a judgment one way or the other on a specific case. I'll preface this with saying that you are certainly asking some valid questions, but at the same time if I'm not mistaken you are still pretty much brand new as an EMT, so what you believe to be true may not be the same as someone with a lot more training and experience.

    I've been on several calls in which my training and experience as a Paramedic has allowed me to identified/recognize problematic signs & symptoms that my EMTs did not recognized.

    The paramedic in question is correct that ETI (endotracheal intubation) IS the standard in terms of securing the airway. Whether or not it's a good idea to remove a secondary airway device like the combi-tube in favor of ETI is debatable if ventilation is good.

    The use of oral/nasal airways only is fine initially if you are able to maintain control of the airway and have adequate ventilation. However, the airway should be controlled in a more definitive fashion as soon as possible. A very real by-product of ventilation without a secured airway is gastric distention. A by-product of that can be regurgitation of the stomach contents. This can then result in aspiration into the lungs and further complications if resuscitation is successful.

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    Quote Originally Posted by CaptainGonzo View Post
    Grasshopper...
    • The medic has much more training than the EMT..1000 hours + depending on the program.
    • The medic also has standing orders and protocols from medical control.

    1.) just because they have more training I've seen many a paramedic that was a dope.

    2.) valid point.

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    Quote Originally Posted by nameless View Post
    1.) just because they have more training I've seen many a paramedic that was a dope.
    Amen to that.
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    Quote Originally Posted by FireEMT712 View Post
    This scenario isn't from my area but we are just starting to introduce the King tubes which I can't wait to get on our trucks. I am not a huge fan of ETC's period OPA, NPA, BVM are my prefered airways and if they don't work around here ALS could probably be on seen by the time i get done trying these. We did have an arrest lately that the lungs were so full of fluid that we could not get air in. I was suctioning during compressions then trying to BVM and could not get anything in. When ALS arrived and dropped the ETT in and gave the first dose of atro it came right back out... Any of you guys ever seen a case like this? I mean there was so much fluid in the lungs that while bagging, the side cap blew off the BVM imbetween the bag and mask.... maybe this was just junk equipment?
    Yes, it's called pulmonary edema.


    The Hypothermia Protocol is still sort of new in many places. My service has it for no more than a year now. Basically it entails to administration of cold IV fluids to a patient in order to lower their body temp. This slows down metabolism and reduces the brain's need for oxygen.

    My protocol is to start the infusion after ROSC has occurred following cardiac arrest, but I've read that some protocols initiate the infusion immediately.

    Various studies have shown that doing this and then continuing the hypothermic state at the hospital for 24 hours or so (forget off hand the actual time amount) has produced significantly improved arrest to discharge results.

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    Quote Originally Posted by nameless View Post
    1.) just because they have more training I've seen many a paramedic that was a dope.
    True, but I've also seen many an EMT that were dopes too.

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    [QUOTE=FireMedic049;1138255]

    1. I'll preface this with saying that you are certainly asking some valid questions, but at the same time if I'm not mistaken you are still pretty much brand new as an EMT, so what you believe to be true may not be the same as someone with a lot more training and experience.


    2.The use of oral/nasal airways only is fine initially if you are able to maintain control of the airway and have adequate ventilation. QUOTE]

    1. Exactly why I asked, seeings as how I'm new if there's a piece i could be missing I would like to know for future reference. Thanks for the info.

    2. Where I'm from ALS is usualy 10 minutes away with a max time of about 30 minutes. I would prefer to never need to use a combitube just because it's a royal pain for both pt and provider. I think once we get king airways that intubation of arrest will become a lot more common with those, but for now I'll stick to OPA NPA unless I have no choice. Again thanks for the info I really like to have you vets teach me things in the field that we don't have time to explain to me when it happens, it helps A LOT.
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    Quote Originally Posted by FireMedic049 View Post
    Yes, it's called pulmonary edema.


    The Hypothermia Protocol is still sort of new in many places. My service has it for no more than a year now. Basically it entails to administration of cold IV fluids to a patient in order to lower their body temp. This slows down metabolism and reduces the brain's need for oxygen.

    My protocol is to start the infusion after ROSC has occurred following cardiac arrest, but I've read that some protocols initiate the infusion immediately.

    Various studies have shown that doing this and then continuing the hypothermic state at the hospital for 24 hours or so (forget off hand the actual time amount) has produced significantly improved arrest to discharge results.
    Ah, I see, thank you very much for the detailed explaination of what it is that helps a lot with understanding! Oh and also thanks for clarifying the Pulmonary Edema, not going to lie, it was quite awhile after my class that i got certified and another 6 months before i got on the local BLS department so refreshers are always nice!
    Last edited by FireEMT712; 01-23-2010 at 06:00 PM.
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    Quote Originally Posted by FireEMT712 View Post
    Question:
    Do you think ALS should remove an ETC to apply an ETT if the ETC is working properly?
    I'll answer with some more questions:

    Is there a time and place to replace the Combitube?
    Yes.

    Is the proper time and place to do it immediately after ROSC, while still in the living room?
    Maybe. Depends on a very dynamic situation. Can't give an absolute "always/never" answer. This is why medics need more education, to be able to make good clinical decisions. There is no cookbook answer to situations like this.

    Will the Combitube be replaced with an ETT eventually?
    Yes, absolutely. Just a matter of when and where (ED or field).

    Did the replacing of the Combi with the ETT cause VF to occur again?
    Highly doubtful, and impossible to prove or disprove in this situation.

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    We also run a hypothermia protocol here for probably over 2 years now and its just as described above.

    Like Gonz said, the paramedic has so much more training than an EMT its not even funny. I'm not saying that you shouldnt speak up if you feel that an intervention is going to harm a patient, but most times, the paramedic knows what the pt needs and what his/her protocol calls for. IMHO, an EMT with 6 months of experience has no business second guessing a paramedic. Both in person or on the world wide web. If anything, go to the medic once you get back to quarters and ask him to explain what he did and why so that you can learn.

    An ET tube is pretty much the only definitive way to secure an airway and many protocols want it.

    And not to be a jackass, but in the CPR success thread you said that you have only worked 6 codes or something like that? While you are entitled to an opinion I dont think that you have had sufficent experience on codes to say for sure that removing the combitube killed the pt. Maybe thats not what youre trying to say, but thats how its coming across my computer screen. I hate the combitube and I do not think that I have ever seen one used, so even as an EMT-Intermediate I would forget the combitube and go for a tube assuming that good CPR was continuing and we had other ALS providers on scene.


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    Quote Originally Posted by FireEMT712 View Post

    2. Where I'm from ALS is usualy 10 minutes away with a max time of about 30 minutes. I would prefer to never need to use a combitube just because it's a royal pain for both pt and provider. I think once we get king airways that intubation of arrest will become a lot more common with those, but for now I'll stick to OPA NPA unless I have no choice. Again thanks for the info I really like to have you vets teach me things in the field that we don't have time to explain to me when it happens, it helps A LOT.
    Easy to say now, much different scenario when the pt is vomiting. The OPA, NPA does not really protect against the pt aspirating, they just help to keep the airway open. A combitube is not difficult to insert to say you won't use it because it is a pain.
    The thoughts and opinions posted here are mine and mine alone and do not reflect the thoughts and or views of city or dept affiliation.

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    Quote Originally Posted by jccrabby3084 View Post
    Easy to say now, much different scenario when the pt is vomiting. The OPA, NPA does not really protect against the pt aspirating, they just help to keep the airway open. A combitube is not difficult to insert to say you won't use it because it is a pain.
    I said that combitube is a pain for the pt and provider, provider being hospital or medic when they show up, either way the combitube comes out sometime. Also now that we are starting to implement the King airways the combitube will soon become a thing of the past IMO. I think a combitube should be a last resort for a basic much as it is for a medic, they try ETI a few times them drop a combi, I trie OPA NPA then I will drop a combi as needed depending on the situation. Good point about the aspirating though, thanks for the feedback.
    Last edited by FireEMT712; 01-23-2010 at 07:22 PM.
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    Personally, if I have a secure airway I don't mess with it. I'm not a fan of combitubes, but they can provide a secure airway and that's what we're after. If it's in and the airway is good and secure, I'll work with it.

    We're moving away from the combi-tubes to the LMA-type devices. Our medical director is a fan of them and has his reasons, so I'm waiting to see how it goes. To be honest, I've never used one outside of my OR clinical time, so I'm curious to see how they work in the field.

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