Tag Archive | "intubation"

Intubation for Cardiac Arrest Patients

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The debate over whether to intubate cardiac arrest patients remains strong. Photo Kevin Link

The debate over whether to intubate cardiac arrest patients remains strong. Photo Kevin Link

Recently, I came across a destitute colleague who had just responded to a code for a cardiac arrest. During the arrest, the patient was intubated successfully, without interruption of compressions. I was puzzled. Why was my colleague distressed? Surely, she had done her job well, securing the airway in a prompt and efficient manner.

As it turns out, another provider had questioned numerous elements of her care. First, the other provider debated whether to give a paralytic. The other provider vehemently argued that a paralytic was indicated to “best optimize the chance of success.” My colleague did not feel that a paralytic was indicated in cardiac arrest, and intubated without the use of any additional medications.

After the argument about the paralytic, the other provider then had the nerve to question whether the patient should have even been intubated at all! In point of fact, intubation in cardiac arrest is quite controversial, and my downtrodden colleague had every right to feel frustrated.

Should all patients with cardiac arrest be intubated?

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Although endotracheal intubation has long been regarded as the “gold standard” for cardiac arrest, recent guidelines de-emphasize the procedure, especially if intubation is to be achieved at the expense of other evidence-based interventions (i.e., CPR and electrical therapy) associated with improved survival and better neurological outcomes.(1,2)

Now I will admit that when I first read this recommendation, it was difficult to digest. As a paramedic, anesthesiologist, and intensivist, I’ve never thought twice about securing an airway with an endotracheal tube during a cardiac arrest. Historically, to do otherwise would be considered malpractice! However, when one examines the recent literature, it is understandable why intubation for cardiac arrest remains a provocative topic. For starters, the reader is referred to a comprehensive and well-written review on this topic by Dr. J.V. Nable et al.(1)

Intubation has not been shown to positively impact outcomes for cardiac arrest patients, and there are several explanations for this somewhat counterintuitive finding.

First, intubation during cardiac arrest is not always straightforward, and in at least one study, 30% of patients required more than one attempt.(3)

Second, the learning curve to attain competence is steep—one study suggests up to 60 intubations are required to become proficient—and in some systems, EMS providers do not have opportunities maintain this skill.(4) As Nable et al write, “maintaining proficiency in endotracheal intubation is a significant barrier for many prehospital providers.”(1) In Wang et al, intubation success by medics was only 78%.(3)

Third, intubation is followed by positive pressure ventilation (PPV), and PPV has been shown to decrease preload, lower cardiac output, and negatively impact the effectiveness of chest compressions.(1)

Fourth, intubation may require interruption of chest compressions, and this has clearly been linked with worse outcomes.(5) For the abovementioned reasons, in some countries, such as the U.K., a case has been made for abandoning intubation altogether in cardiac arrest.(6)

Coming back to my colleague’s dilemma regarding paralysis for intubation in cardiac arrest, this is also a contentious topic. On one hand, paralysis may enhance intubating conditions and facilitate prompt control of the airway, thereby avoiding airway trauma with multiple laryngoscopic attempts, and preventing aspiration. Moreover, the most feared complication of paralysis—the “can’t intubate, can’t ventilate” scenario—is relatively rare. In one study of more than 6,000 trauma patients at our institution (University of Maryland R Adams Cowley Shock Trauma Center in Baltimore), only four patients required a surgical airway.(7)

On the other hand, the hazards of positive pressure ventilation, hyperkalemia associated with succinylcholine, and the rare instance of failed intubation in a paralyzed patient with a difficult airway, all pose an unacceptable risk/benefit in cardiac arrest. The decision to use paralytics is as difficult as deciding to intubate in cardiac arrest, and the use of these agents can only be recommended for the most highly trained providers.

Should patients in cardiac arrest be given muscle relaxants to facilitate intubation?

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What about supraglottic airways? This class of airways includes the laryngeal mask airway (LMA), Combitube, laryngeal tube and other various proprietary devices. Although these devices do not represent a “definitive airway,” several studies have shown equivalent outcomes when these devices were compared to endotracheal intubation in cardiac arrest.(1,8) Supraglottic airways have several advantages over intubation. Learning curves are easier, the devices can be placed faster, and there may be fewer complications during device insertion.(9)

To date, no one device has been shown to be conclusively superior to another. Patients eligible for placement of a supraglottic airway require adequate mouth opening, no underlying severe lung disease (i.e., decreased lung compliance), and low risk for aspiration.(1)

At the end of the day, airway management for cardiac arrest may be achieved according to the proficiency and resources available to the provider. EMS providers should not be discouraged by the literature! Airway management is still important. In one study by Wong et al, the best short-term survival was seen in patients who had an advanced airway placed within five minutes of the arrest.(10)

Other studies have failed to show any difference between intubation and use of bag-valve mask ventilation (BVM).(11) However the airway is managed, current recommendations still emphasize the importance of providing ventilatory support during cardiac arrest.(2) In jurisdictions where intubation is used for cardiac arrest, providers should perform the procedure with “sufficient frequency to maintain competence within a highly managed system that actively monitors success rates, complications and patient outcomes.”(9)

If intubation is to be considered in cardiac arrest, it should only be attempted if:

  • The provider is proficient;
  • There are no interruptions in chest compressions; and
  • The attempt takes no more than 10 seconds.(2)

Survivors of cardiac arrest who require intensive care management will usually require definitive airway management with endotracheal intubation at some point, but early in the arrest, providers should focus on providing high-quality CPR.(12)

1. Nable JV, Lawner BJ, Stephens CT. Airway management in cardiac arrest. Emerg Med Clin N Am. 2012;30:77–90.

2. Neumar RW, Otto CW, Link MS. Part 8: Adult advanced cardiac life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation. Circulation. 2010;1222(183):S727–S767.

3. Wang HE, Yealy DM. How many attempts are required to accomplish out-of-hospital endotracheal intubation? Acad Emerg Med. 2006;13:373–377.

4. West MR, Jonas MM, Adams AP, et al. A new tracheal tube for difficult intubation. Br J Anaesth. 1996;76:673–679.

5. Kellum MJ, Kennedy KW, Ewy GA. Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest. Am J Med. 2006;119:335–340.

6. Deakin CD, Clarke T, Nolan J. A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group. Emerg Med J. 2008;27:226–233.

7. Stephens CT, Kahntroff S, Dutton RP. The success of emergency endotracheal intubation in trauma patients: A 10-year experience at a major trauma center. Anesth Analg. 2009;109:866–872.

8. Kajino K, Iwami T, Ktamura T, et al. Comparison of supraglottic airway verus endotracheal intubation for the pre-hospital treatment of out-of-hospital cardiac arrest. Critical Care. 2011;15:R236.

9. Thomas MJC. Prehospital intubation in cardiac arrest: The debate continues. Resuscitation. 2011;82:367-368.

10. Wong ML, Carey S, Mader TJ, et al. Time to invasive airway placement and resuscitation outcomes after inhospital cardiopulmonary arrest. Resuscitation. 2010;81:182–186.

11. Shin SS, Ahn KO, Song KJ, et al. Out-of-hospital airway managemetn and cardiac arrest outcomes: A propensity score matched analysis. Resuscitation. 2011. Accessed 18 Feb 2012.

12. Morley PT. The key to advanced airways during cardiac arrest: Well trained and early. Critical Care. 2012;16:104.

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Samuel M. Galvagno Jr., DO, PhD

Dr. Galvagno has been involved with prehospital care for more than 19 years. He started his EMS career as a National Ski Patroller in upstate New York, and became an EMT in 1992 in Maryland. Before and while attending medical school at the New York College of Osteopathic Medicine, he was a paramedic in Maryland and New York. He completed his internship at Saint Vincent’s Midtown Hospital in Hell’s Kitchen, New York before working as an emergency physician and flight surgeon in the U.S. Air Force. On leaving active duty, Dr. Galvagno received residency training at Harvard Medical School, Brigham and Woman’s Hospital, followed by a fellowship in Critical Care Medicine at the Johns Hopkins School of Medicine. He also completed a research fellowship and extensive training in epidemiology and biostatistics at the Johns Hopkins Bloomberg School of Public Health; he is due to receive his PhD in 2012 with a thesis focused on helicopter emergency medical services for adults with major trauma. Dr. Galvagno is the author of numerous publications and book chapters, including his own textbook, Emergency Pathophysiology. He is currently an assistant professor in the Divisions of Trauma Anesthesiology and Adult Critical Care Medicine at the R Adams Cowley Shock Trauma Center, Baltimore. He remains active in the U.S. Air Force, and is the director of critical care Air Transport Team (CCATT) operations and assistant chief of professional services at Joint Base Andrews, Maryland. He is board-certified in anesthesiology, adult critical care medicine and public health.

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When the Primary Assessment Requires Priority Care

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The focus of EMS remains bringing the severely injured trauma patient and physician together as quickly as possible. (Photo: Mark C. Ide)

She never saw the truck. She had just dropped the kids off at school and was hoping to run some errands before she had to be at work. She edged her Escort out of the school parking lot to make a left turn onto the four-lane, trying to see around the truck parked on the northbound shoulder. She pulled out, and an F-150 impacted the driver’s door on the Escort. The collision was over in micro-seconds, with both vehicles coming to rest in the southbound lane.

Start the clock.

’60 Precious Minutes’
The “Golden Hour” was first described by R Adams Cowley, MD, at the University of Maryland Medical Center in Baltimore.1 From his personal experiences and observations in post-World War II Europe, and then in Baltimore in the 1960s, Dr. Cowley recognized that the sooner trauma patients reached definitive care—particularly if they arrived within 60 minutes of being injured—the better their chance of survival.

Field hospitals, MASH units and medevac helicopters in the Korean and Vietnam Wars contributed to increasing survival rates. Improvements in medications, techniques and instruments were key to survival, but none of these were of any value if the patient remained separated from the surgeon.

Over the years, we’ve debated whether the Golden Hour is actually 60 minutes, but Dr. Cowley’s concept remains true. Thirty-eight years after Maryland State Police Helicopter 1 picked up its first patient on Falls Road in Baltimore County and delivered him to Dr. Cowley’s team, the focus of EMS remains bringing the severely injured trauma patient and physician together as quickly as possible.

In this effort, we’ve gone from “load and go” to “stay and play” and back again. The ideal level of street medicine versus scene time remains somewhere in the middle. Time spent on scene changes each year with the advent of new tools and techniques and the results of valid studies.

Our job in EMS is threefold: 1) get to the patient quickly, 2) fix what we can fix and 3) quickly get the patient to the right hospital. Anything we can do to compress each of these time periods is good for the patient. We’ve known this in the traumatically injured, and now we use it for STEMI and stroke patients; more are sure to follow.

At 12 Minutes
She was unconscious and unresponsive when the medic unit arrived. Her head slumped to the side and frothy blood came from her mouth with each shallow breath. While Rescue Squad 7 worked to free her, the medics brought her head into neutral alignment and tried to open her airway. With a clenched jaw and obvious facial fractures, both an oropharyngeal airway (OPA) and naso­pharyngeal airway (NPA) were out of the question. Working together, the medics used a bag-valve mask, suction and cricoid pressure to optimize oxygenation and ventilation.

LOC: Unconscious; grimace to sternal rub with an occasional moan; GCS 6. Airway: Compromised by clenched jaw, poor gag reflex, blood in mouth. Breathing: Respirations shallow and rapid; frothy blood present; breath sounds full on right and slightly diminished on left; crepitus on left. Circulation: Radial pulse strong, regular, rapid; no major external bleeding noted. Vitals: HR 144, RR 42, BP 112/62, SaO2 85%.

It’s About Perfusion
I used to use the term “airway management,” but the words seem to imply our job is done when we successfully get air through the glottis and into the lungs. I tried “respiratory management.” Yes, that’s it; secure an air passage, inflate and deflate the lungs. No, that’s not it either.

I’ve settled, for now at least, on “perfusion management.” Our lifesaving job is to return and maintain our patient’s cellular perfusion, and then get them promptly to the right facility.

How are the Golden Hour and perfusion management related? Without prudent management of both, we fail our patient. Almost every lifesaving intervention we perform has to do with establishing or maintaining cellular perfusion. An AED allows the heart to return to a perfusing rhythm. Allowing the hypotensive patient to breathe on their own instead of paralyzing them encourages blood return to central circulation. Decompressing the chest, stopping bleeding, capturing the airway and ventilating patients with poor oxygen saturation all improves perfusion.

So, in the field, the burden of responsibility is on us. With the critically sick or injured patient, we must look at on-scene interventions with a cynical eye. Does the procedure enhance perfusion? Must it be done now?

Prehospital Intubation—A Good Thing, Sometimes
We’ve all read and heard that paramedics shouldn’t intubate: “It’s a skill better left for those in the hospital.” But field intubation is a good thing. It secures our patient’s airway. It allows us to properly oxygenate and ventilate patients. It’s usually completed swiftly and appropriately.

But field intubation can be a bad thing. When we make poor decisions and fail to execute the skills we were taught, we extend scene time and create hypoxic patients. When we fail to give post-intubation management the proper attention, it leads to unrecognized misplaced tubes, inappropriate ventilation and poor oxygenation.

We intubate patients in the prehospital environment for three primary reasons: 1) establish and maintain an airway, 2) normalize oxygenation, and 3) establish appropriate ventilation.2 Although field intubation can be a good thing for the patient, it’s not always the right thing for them.

So, when do you intubate the patient? When it will make them better or keep them from getting worse. Do you intubate at the scene or during transport? Both. We should intubate when it’s most appropriate. Consider these factors:

  • How sick is your patient? Is the airway patent? What is their level of oxygen saturation? Are they adequately ventilated? Will they survive transport without intubation?
  • What’s your transport time? If scene time exceeds transport time, will the intubation make a difference? Is good BLS and rapid transport a better option?
  • What’s your intubation skill and experience? Do you have the resources and skills necessary? How are you making decisions—with your head or your ego?

If you get the patient to the hospital bagging them to sats of 96% with an OPA in place and no gastric inflation, you’re my perfusion management hero. Ditto if you do it with an ET tube. But if you spend 20 minutes on scene, rooting and digging in a patient’s throat, making multiple intubation attempts and letting their sats drop to 85%, we need to have a talk. “Do what’s best for the patient,” says Maryland State Aeromedical Director Douglas Floccare, MD, “and you can’t go wrong.”2

What if it’s a difficult tube? Some of my colleagues say that the difficult intubation is the typical intubation, and an easy intubation is a gift. They’re right. Anything that precludes our ability to see the cords or pass the tube has been broadly defined as a “difficult laryngoscopy” or “difficult intubation.”3

Studies on the frequency of difficult intubations are almost completely limited to operating room (OR) or intensive care unit (ICU) patients. The number of studies regarding EMS and ED intubations pales drastically in comparison. Those that have been done focus primarily on the rate of undetected esophageal intubations received at EDs and complications associated with intubations done outside the OR.

Until we have studies that focus on difficult intubations in the prehospital arena, we have to rely on these OR and ICU reports. Do the results of these studies reveal poor intubation technique or poor post-intubation management? Are poor intubation outcomes the result of training, technique, tools, experience or conditions? And do these factors negatively affect the time to definitive care?

At 32 Minutes
The helicopter landed as the patient was freed from the car and moved to the medic unit. It was a 42-minute drive to the only hospital in the county or an 18-minute flight to the trauma center. Seemed like an easy choice, but she was now incredibly combative, so much so that the crew could hardly secure her to the backboard let alone safely fly her out.

As the minutes ticked away, the easy choice was becoming a tough decision. Tough, until the senior paramedic on scene was able to get an 18 gauge IV?in the patient’s hand; holding it securely as lidocaine, etomidate and succinylcholine were pushed.

The intubation was performed using a GlideScope® Ranger video laryngoscope, with a clear view on first attempt. Her sats rose to 98% and EtCO2 to 35. She was secured to the board and loaded in the aircraft. As the succinylcholine wore off, the two helicopter paramedics assisted her ventilations enough to maintain high sats, but didn’t over-ventilate her and drive blood from her central circulation.

Now Versus Next
I’m a dinosaur. I look at new technology with a suspicious eye. I see no reason to change for the sake of change. For instance, I finally purchased a PDA cell phone recently, and I realized what everyone seems to have known for years—they’re amazing.

The first time I saw a video laryngoscope, I felt much the same way I initially did about the PDA: That’s a lot of money for a camera and some lights. I also thought, I’ve done just fine with my bent metal stick for the past two decades, why should I change now? However, having used the device, I know why. Because it’s a better way to deliver patient care, with less opportunity for physical trauma to the patient, quicker visualization of the glottis and enhanced verification of endotracheal tube placement.

Straight or curved direct laryngoscopy blades are de­signed to move the anatomy to obtain a line-of-sight glottic view. Head-neck manipulation, tongue displacement, direct contact with laryngeal structures, and impacting teeth are all opportunities to injure a patient.

Unlike classic laryngoscope blades, video laryngoscope blades are shaped to match the pharyngeal anatomy. The acute blade angle allows the blade’s tip (and camera) to follow the patient’s anatomy to view the glottis. Multiple studies have found that 20­–40 lbs. of force is required during direct laryngoscopy, and it takes about 45 lbs. of pressure to fracture a tooth during laryngoscopy.4,5 My own, purely subjective, experience with video laryngoscopy is that much less force is needed to obtain a glottic view. I’d like to see studies that validate or dispute my experience.

If you’ve ever had to do a belly flop on the ground to see the cords of a patient, you’ll appreciate video laryngoscopy. The blade goes in the patient’s mouth and the video monitor is placed where you can see it. This makes visualization easier in a moving ambulance or helicopter, and has the potential to save scene time by allowing you to intubate easier during transport. The image on the monitor is larger than the view afforded by direct visualization. The clear detail provided on the screen allows for confident and quick landmark identification.

So, what’s the role of video laryngoscopy in prehospital medicine? Time for my predictions. It will become the standard of care, just like AEDs and 12-lead monitors. When our EMS children visit us in nursing homes, we’ll tell them tales of wasting precious minutes lying on the floor of someone’s home, using a light bulb and a metal stick to intubate patients.

At 65 Minutes
The aircraft settled onto the roof, and its rotors slowed to flight idle. She was moved to the waiting stretcher and then down the elevator to the trauma room. Masked, gowned and gloved, the trauma team swarmed around her—65 minutes from impact to surgeon.


For video laryngoscopy to truly enter the world of prehospital medicine, a paradigm shift must occur—a shift away from direct visualization. Cliff Boehm, MD, an attending anesthesiologist and assistant professor of trauma anesthesiology at the R Adams Cowley Shock Trauma Center, describes how it worked in his department: “There used to be two camps when direct laryngoscopy failed: the Bullard (rigid fiber-optic laryngoscope) and the LMA (laryngeal mask airway). Now there’s pretty much one camp—video laryngoscopy.”

Boehm adds that when video laryngoscopy first appeared as an anesthesia tool in his department, “that camera thing” was used when all other means failed. He and his colleagues now routinely use their GlideScope units as first-line tools, not just as a backup.6

As video laryngoscopy continues to evolve, I’d like to see the ability to digitally record images for QA, patient records and education. I’d like to see the camera and light in a standalone handle, and the image beamed to the multi-function display on our vital signs monitor. Better yet, maybe we could have it recorded on our monitor and also transmitted to the heads-up display on our safety glasses, so we can view the glottis and simultaneously see the patient’s heart rate and oxygen saturation.
We live at an incredibly exciting time in history, especially in medicine. Da Vinci robotic surgery, STEMI intervention, laparoscopic surgery and a multitude of other tools and procedures are developed each week. Video laryngoscopy is one of them. It’s a great tool for us in medicine, and it’s an important tool for our patients.

Although I’m not ready to put my 4 Mac or 3 Miller on eBay, I can’t wait to see what awaits us.

Disclosure: The author has received no monetary support from Verathon Inc. He has received support from Verathon in the form of a video laryngoscope for evaluation and research purposes.


  1. Franklin F, Doelp A: Shock-Trauma. St. Martin’s Press: New York City, N.Y., 1980.
  2. Douglas Floccare, MD, Maryland State Aeromedical Director. Personal communication, 2004–2008.
  3. American Society of Anesthesiologists Task Force on Management of the Difficult Airway: “Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.” Anesthesiology. 98(5):1269–1277, 2003.
  4. Givol N, Gershtansky Y, Halamish-Shani T, et al: “Perianesthetic dental injuries: Analysis of incident reports.” Journal of Clinical Anesthesia. 16(3):173–176, 2004.
  5. Ghabash MB, Matta MS, Mehanna CB: “Prevention of dental trauma during endotracheal intubation.” Anesthesia and Analgesia. 84(1):230–231, 1997.
  6. Clifford Boehm, MD, Assistant Professor of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center. Personal communication, 2008.

Reprinted from JEMS Vol. 33, Issue 9 with the permission of Elsevier Inc., copyright 2008. For more information or to subscribe, visit www.jems.com.

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Charlie Eisele, BS, NREMT-P

Charlie Eisele, BS, NREMT-P has been active in EMS since 1975. After 22 years of service, he recently retired from the Maryland State Police, Aviation Command where he served as a State Trooper, flight paramedic, instructor, flight operations supervisor, director of training, and tactical paramedic.

For over 25 years, Charlie has been a collegiate level educator and curriculum developer. He has served numerous programs including the University of Maryland, and its R Adams Cowley Shock Trauma Center, College of Southern Maryland, Grand Canyon National Park, Marine Corps Base Quantico, Virginia Department of Fire Programs, and Maryland State Police.

Charlie is the co-developer of the internationally delivered advanced airway program at the R Adams Cowley Shock Trauma Center. He is the Airway and Cadaver Lab Course manager for the University of Maryland critical care emergency medical transport program. He’s the co-developer of the EMS Today airway and cadaver lab program. Charlie has been recruited nationally to provide airway management curriculum and education for a variety of private, federal, state and local organization.

Charlie is an Eagle Scout and a published author. He serves on the Journal of Emergency Medical Services Editorial Board and is a member of the program board for the EMS Today Conference & Exposition.

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In the Goose?

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Another way to check for ET tube positioning...

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Video Laryngoscopy 4-Step Technique Tutorial


This 4-Step Technique tutorial video demonstrates proper intubation techniques using the GlideScope Video Laryngoscope.

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Tips on Advancing the Endotracheal Tube


Learn more about successful techniques for advancing the ET tube.

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