Review of:Wang HE, Simeone SJ, Weaver MD, et al. Interruptions in Cardiopulmonary Resuscitation from Paramedic Endotracheal Intubation. Ann of Emerg Med. 2009:54(5):645 652.
Emergency guidelines have started emphasizing continuous uninterrupted chest compressions for the treatment of cardiac arrests. Traditionally, paramedics in the U.S. almost always perform endotracheal intubation (ETI) on cardiac arrest patients. The authors of this study examined interruptions in chest compressions due to paramedic ETIs using data from the ROC study. They defined an interruption as greater than five seconds. They excluded the period of interruptions related to rhythm analysis. Of 182 arrests, 100 cardiac arrests were analyzed and found. They also found the following:
- Median number of interruptions for ETI per cardiac arrest: 2 with a range of 1-9.
- Median time for first ETI associated CPR interruption: 46.5 seconds with a range of 7-221 seconds.
- Median time for second and subsequent intubations associated CPRF interruption: 35 seconds with a range of 21 to 58 seconds.
- Average number of intubation attempts was two2 with a range of 1 to 9
- Median total for all endotracheal intubations: 109.5 seconds.
- This total interruption time did not change significantly when interruptions where defined as 10 seconds but decreased slightly (102 seconds) when interruptions were defined as 20 seconds.
- ETI accounted for 22.8% of all CPR interruptions.
The authors conclude ETI by U.S. paramedics accounts for a significant amount of interruptions, as well as prolonged interruptions.
The authors find the results of this study on the role of intubation in prehospital airway management of cardiac arrest patients to be eyebrow-raising, but for different reasons.
Medic Marshall:I have to admit that I'm not one to jump to the laryngoscope and ET tube to manage someone's airway. But I find this research disturbing and appalling. The statistics speak for themselves. I find them staggering. Nine intubations attempts? Or almost four minutes to intubate a patient? This is exactly why I'm a strong proponent for alternative airways, such as the King LT or Combitube. They are faster and more efficient, and can still secure the airway while minimizing interruptions. Best of all though, they can still be used with an impedance threshold device, such as the ResQPod.
Again I feel the need to re-iterate that I m not against paramedics intubating in the field, just that it is really hard to justify when you have research like this. If your system is capable of giving their providers the experience and education to intubate proficiently, then by all means I think you should; I also think excellent clinical judgment needs to be used as well though know when to tube or not to tube.
Doc Wesley:I congratulate Dr. Wang and his colleagues for providing us even more compelling reasons to not perform ETI in the cardiac arrest victim. Research clearly shows that interruptions in chest compression greater than 10 seconds results in a significant decrease in coronary perfusion. This loss occurs not from the interruption alone but from the fact that it takes at least 30 seconds of chest compression to "re-prime" the heart.
Although many will scoff at the apparently long interruptions and multiple intubation attempts and say, "this could not happen in my system," to them I say, "you are wrong." This study was from multiple high performance systems with excellent medical oversight and quality improvement.
Regions Hospital in St. Paul will soon be publishing their data, which shows that they were able to insert the King LT within one minute of patient contact without chest compression interruptions.
While there may be value for prehospital endotracheal intubation, the evidence is growing daily that for victims of cardiac arrest and multiple trauma, alternative airways used with appropriate monitoring may be more beneficial and avoid significant complications.
The goal now is to further reduce the chest compression interruptions with faster rhythm analysis and defibrillation.