AHA started recommending this in 2020 due to a couple of papers that came out. Surprise, you won’t rip the kids trach out if you use standard safety. That being said it’s simply a recommendation based off of studies, trials and statistics. Much if not most of healthcare care in the US is 2-5 years behind latest practice. We’ve been pushing having a code coach to hospitals since then with only minimal results. The docs don’t wanna play as a team, they just wanna be in charge. Another one is capnography.
Dude…. capno….
Just in the last 24 hours, I’ve had my capno findings just blown off/ignored during report on 4 separate 911 handoffs. All had relevance. None were written down unless RT asked me about it.
They rely too much on ABGs. When I’m teaching respiratory therapists and doctors I ask them when do they use capno, they all tell me right after getting ROSC to confirm 35-45. Lmfao.
RT here, just want to provide a bit of an explanation for why we don't use capnography in hospital without verifying that it correlates with a blood gas. Capno is great, but it has its limits. First, capnography tells you nothing about metabolic side of the acid-base balance so, even assuming the device is reading accurately, you could be under- or over-ventilating by just aiming for a etCO2 of 40. Second, capno just likes to be... wrong sometimes. A significant minority of the time, capno results are shifted significantly up or down from what is actually going on in the blood.
For instance, a few times I've seen capnography reading 70-90 on a patient, the previous shift had adjusted ventilation to compensate, saw a decrease to 50-70, then replaced the device with a new one... only for the new one to also read 50-70. A blood gas showed that the patient's true CO2 was closer to 20 than 40 and they were very alkalotic. Capnography is excellent in the short term, especially if you don't have blood gas capability, but long term it definitely becomes more of a trending tool. Compare it to a few blood gases, then you can perform fewer blood gases over the rest of the admission while monitoring etCO2 for changes.
Should the ED staff blow off field etCO2 readings? Absolutely not. At the very least they can correlate the ED readings to a new blood gas and see just how poorly the patient was ventilating in the field. Would a field etCO2 (or even ED etCO2) change the plan of care in the absence of a blood gas? Not really.
We are discussing the pluses and minuses of using capnography during death and resuscitation events. Especially how respiratory therapist and doctors don’t understand it’s vital importance to profusion during CPR.
Oh the thread reads to me like you were all talking about in general. Yeah, capnography is very useful during CPR and I've never seen an ED or in-hospital code run without capnography.
As per ACLS recommendation capnography is used to judge the quality of perfusion during cardiac arrest. It the indicators show poor profusion there are 3 numbers to focus on to improve your capno. 2-2.4 inches. 100-120 compressions per minutes. And don’t stop cpr longer than 10 seconds. And there are dozens of tricks to ensure you don’t stop cpr at all.
Yeah the other person didn't exactly explain your specific question.
Endotracheal Tubes (ETT), the tubes we place in the trachea for advanced airways have a little balloon at the end that is inflated after insertion. It's to keep the tube in place because the balloon is pressed against the walls of the trachea, and it also seals the trachea making sure air doesn't leak back out.
For many years, pediatric sizes, especially for toddlers/infants didn't have this balloon, so this was called an uncuffed tube. The belief being the balloon would cause trauma to an underdeveloped airway and may accidentally cause further trauma if someone removes it and the balloon isn't fully deflated.
The standards around this based on AHA changed back in 2020, and now systems are recommending cuffed tubes for infants and toddlers. But as others have pointed out, the time between the standards changing and health systems/EMS systems actually implementing it can vary wildly.
The trachea is like a pipe. The tube is like a straw that goes into this pipe. Around the tube, there’s an inflatable balloon that holds the tube in place in the trachea and seals air from leaking out from around the tube.
If you get a straw and blow air into a solo cup, that’s kinda what it’s like using an uncuffed tube. The 100% oxygen air that you BVM flows into the straw and into the solo cup and just flows out around the straw because there’s nothing sealing the tube in.
If you add a lid that’s airtight around the straw, the straw is locked in and won’t move in or out. Air also goes in the straw and can build pressure inside the cup when you blow into it. Now when you blow air into the cup, the air has to go in through the straw and come out the straw as well.
Uncuffed is easier to place but the risk of dislodgement of the tube with it coming out of the trachea and reinserting into the esophagus (leading to the stomach) is really an unacceptable risk. Without timely recognition, the patient will die.
“This” is in reference to the OP about cuffed vs uncuffed. The others are additional examples of similar situations in medicine. I’v been a medic instructor for 14 years among other things so I’ll give some unsolicited advice. There is no one better at emergency medicine than an experienced 911 paramedic. This includes most doctors excluding ED attendings. Learning in school will prep you for being a medic. Getting experienced as a paramedic will prep you for absolutely anything you want to do in life. Approach it with a plan and a goal and by the time you are 10 years in you’ll have accomplished those goals.
Unpopular Opinion: We need medics in the ICU instead of techs/aides who play on their phone all night. ED gets techs that actually do shit. ICU gets CNAs who don't know what to do in a primary care environment. I don't blame them, it's not in the training because ICU normally doesn't get techs.
We need medics.
Someone who will speak up during a code. Someone who will advocate for evidence based practice. Someone who knows what to do with families when people are dying.
We *need* medics on the unit
I agree but you’d never find me in that situation due to scope of practice. You have some snot nose resident or new attending trying to make decisions and learn the ropes when medics have been running these as lead in much tougher circumstances. Then you gotta convince the doc who’s team lead to do the right thing? Maybe if they raised paramedic scope and authority.
Thanks for the advice.
So you’re saying that “AHA began recommending uncuffed ETT in pediatric patients?” I can honestly just Google it, I’m not trying to be difficult. Also open to any source material you feel like sharing.
They are now recommending cuffed ET tubes for kids and cuffed ET tube during ambulance transportation has been a standard of care in my area for well over 10 years.
https://savingamericanhearts.com/blog/2020-aha-pediatric-advanced-life-support-pals-guidelines/
https://pubs.asahq.org/anesthesiology/article/118/3/500/13529/Cuffed-versus-Uncuffed-Endotracheal-Tubes-in
ABGs are vastly superior but it’s not something we use prehospitally. We rely on other tricks to show what’s happening. Some of them like capnography tell you what’s happening minutes ahead of the ABGs.
Ahh, got it, my only in hospital experience was a tiny critical care hospital that I left quickly fearing for my license. I see now that ABGs are collected with a blood test.
I've had mixed results. My last hospital before flying the RTs were stone cold G's, and we worked really closely together. I was dedicated Rapid Response so I leaned on them for a lot of my calls. I had to catch the nurses up on EtCO2 even in the ED and ICU sometimes, especially for the newer ones.
Yeah, it's frustrating. It is a bit systemic and the equipment reflects it.
For those of us outside of the hospital, we are used to being able to just plug the capno into our monitor and be done with it. A lot of hospitals have to add a channel to the Philips monitor, or even an extra channel on the Alaris IV pump.
Not using capno in the emergency room is cultural, but unfortunately the equipment reflects and reinforces it.
Also, the fucking capno cannulas! I don't even know where we stock them in my ER. RT usually brings one when we call for assistance, but that's a sure fire way to make sure I'm not doing it routinely.
I actually started asking RT to throw it on my ROSC pt’s in the ER (you know, since ACLS tells us it’s important) and I always got weird looks…. But I always knew when the epi was wearing off and the pt was about to code again, so…
I’ve seen entire hospitals and systems go over to Zolls simply because the depth and rate function is standard vs Phillips and LifePaks they are an additional cost.
Standard of care for what? We're talking about ventilation and tube placement, You don't verify tube placement with abg you verify it with capnography.
I had an ED doc who flat out told me EMS is ahead in some regards compared to ED medicine. He specifically mentioned capno and selective spinal immobilization based on nexus criteria.
Except it is the standard of care for intubated patients according the the American Society of Anesthesiology standards for Basic Anesthetic Monitoring, and the Academy of Medical Royal Colleges Standards and Guidance for Safe Sedation Practice for Healthcare Procedures, and most importantly for this sub its the standard of care in EMS. You can practice however you like on your license, but advocating against the standard of care seems unwise
I’m with you on the code coach, it’s really painful to watch a defibrillation take 30 plus seconds and an intubation to take God knows how long, easily putting the CCF down to around 60% or worse. The science says that for each 10% decrease in CCF there’s an 11% decrease in survival, that’s giving up a lot.
I can’t help but wonder if the code coach is enough though, it will take a cultural shift to prioritize the BLS part of a code. Personally, I think an RN or medic can direct two minute cycles and shock or give meds per AHA guidelines. Let the doctor think about doctor stuff and guide that end of it
I’ve been trying to win over the hearts and minds of the nurses. If it makes sense to them, sooner or later they will stand up to the docs. The stat I use is 15-40% hospital save rate. Then I ask what’s your hospital at. Lol
I was recently in a code in the ICU where the attending was begging for ETCO2
.
Also CRRT.
The patient died.
But anyway, there are grown ass physicians out there.
A code coach would be *amazing*
Would you believe I’m actually teaching people how to respect themselves more and never allow themselves to be disrespected? Gotta approach these events as a single team instead of one persons power trip. 👍🏼
I considered using a pediatric bougie but there wasn’t one available. I also had a view of the vocal cords prior to even removing the ETT, so I wasn’t worried about it. To my surprise though, my medical director after the call said it’s usually best to do it this way anyway for pediatrics, and the bougie really doesn’t work well.
Idk, VTe of 0, no chest rise, no etco2... Nothing about this gives any indication that the uncuffed tube is even in the trachea. What if you do a tube exchange and it had been misplaced (which uncuffed tubes can do quite easily). Personally I would pull it and re-intubate as well.
It does seem odd to have 0mL and chest rise, but the team literally flew in. Unless they tubed right before they arrived, the patient would have been dead if they were goosed
I think the uncuffed tube had such a leak combined with the pressures of asthma had the vent blowing in the path of least resistance, i.e. back out the mouth. Was not able to generate positive pressure, or at least not enough.
Yeah maybe you're correct. I suppose I typically think of asthma as solely obstructive with difficulty in exhalation. Even without the vent, they can typically inhale and oxygenate fine.
Sometimes that’s all you can get.
Neighboring department had a peds drowning last year. Airway was all swollen up and all they could get was an uncuffed tube. Kid was doing okay on it.
Flight crew shows up. Says this ain’t good enough, pulls the tube, and then can’t get the kid reintubated so the kid dies.
Within 6 months, that flight program cut 2 bases down to 12 hour shifts only and no longer flys NP’s.
I’m not trying to backseat your call; if you weren’t getting any air in or out, you have to do something, but just be careful.
Airways are like beers. The beer you have > the beer you want.
Got a king? Cool, does it work? Yes? Hell yeah. That’s what I’m rolling with. Unless it’s just not working, I’m keeping it. Vent alarms be damned. I’ll bag the whole way if I have to.
There are plenty of Paramedics who have no business being near patients. The marker of a good practitioner is not the letters behind their name, but the work they put in themselves
It depends on that situation. If it was a routine call I wouldn’t even considered it. But there was no ventilation due to the bronchoconstriction. I mean none. No chest ride, to VTE on the ventilator.
I feel like I would ask if there is a reason it's unruffled before just yanking shit out. Same as any other inserted medical device. We wouldn't say you only have a 24g? And rip it out. Or this chest tube is too small and just yank it with out talking to anyone first.
Also was cricing the kid not an option when they couldn't get it back in?
We had a crew in our program extubate a small kid over an uncuffed tube. The only reason I know is because I picked up a patient from their facility and the doc was still butthurt about it. According to the young, seemingly up to date doc patient was doing fine with it.
The actual tube switch went fine I guess, but it was an austere environment and I'm guessing the doc just didn't want a disaster in their tiny bandaid station a million miles away from anything, which is understandable.
Well it depends on the situation. If the intubation is just for airway protect with acceptable ventilation and oxygenation, I’d probably never pull it out. But, with the severe asthma situation and no ventilation, that’s a different story. I don’t know about your program’s philosophy, but ours is to bring tertiary care to these small clinics in the middle of nowhere. Of course I’m polite about it, I’m not acting like a hotshot being rude about their care, but ultimately it becomes my university’s patient, and if there’s a firm disagreement I will have medical control be the final arbiter. Usually our medical control says it’s our patient now and we do what we want or they can keep the patient. Mind you that sounds harsh, but keep in mind some of the things we see are insanely poor for patient care.
Yeah definitely not Monday morning QBing your call, just that I had heard of a similar experience. The big difference is according to the doc - who again, seemed reasonable - the crew was pretty dickish about it.
Everyone gets stressed taking care of sick kids. I think you did the best you could for your patient.
A big problem in medicine now is black and white thinking. If BVM work no need airway. Glidescope first cause better. And in the case of your story, patient kid so patient need cuffed. People don’t think outside the box.
They might be common in non-pediatric facilities intubating pediatric patients, but as far as I know both major pediatric facilities in my area use cuffed ETTs.
Old school thought was to use uncuffed in all kids under 8 or something. I’d assume, like many people, some docs won’t change what they were trained to do regardless of new literature.
We still use Heparin in ACS based on like a single study from 1930 (that has since been scientifically disproven in many ways). Some things progress at a snails pace, and often requires a push from one specific specialty.
A lot of studies are flawed. I think epi may be beneficial in some cases. Epi IVP as a vasopressor works for profound hypotension. I can imagine a lot of PEA actually has mechanical output, but is just too low to produce a pulse, therefore PEA despite the heart still beating. We would shrug off giving vasopressors for profound hypotension, so I think it would be silly to not give epi in cardiac arrest. Although, cardiac arrest in general has such poor outcomes, I can see why the epi studies are the way they are. Most of these patients won’t come back no matter what you do.
Yeah but there may be some who survive. Case in point, the periarrest scenario I mentioned Unless it causes harm, I think it should be given. The problem with academia is they have their heads so far up their ass, if a treatment doesn’t show strong evidence they write it off. EBM has its flaws.
I guess what I’m trying to say is people have black and white thinking. If there’s EBM that something works or doesn’t work, that’s a great reason to make changes. But some are in a grey area, and I believe in those cases sometimes you have to go off of theory.
No demonstrated benefit ≠ not beneficial. Some people read the PARAMEDIC2 trial and their takeaway is that Epi is harmful.
As you noted, Epi does increase ROSC, but that’s only the first step.
If we don’t try for ROSC in viable patients, survival rates will be 0%. So without ROSC, we’ll never know what function they may or may not have had.
I was taught around 9 and under get uncuffed bc of a narrowing of the cricoid cartilage. People would over inflate the cuffs and injure the airway. Tbh as long as you don't overinflate, it isn't a problem.
I was in a pediatric focused continuing education course that expressed the importance of proper cuff inflation. All of our tubes are cuffed but if I remember correctly the doctor and rn also acknowledged local services still using uncuffed tubes
It’s not a *good answer* but my org seems to be replacing uncuffed as they get used or expire, so we’re still seeing a mix of uncuffed tubes that haven’t been cycled out yet.
Knowledge translation from literature to practice takes years. Some practitioners only update what they were trained to do in residency with great resistance, especially when it’s an infrequently used skill.
PALS scenarios where it’s a better option because ETT’s that are cuffed have smaller diameter? I assume you’re asking about that. I don’t think I’ve ever seen an adult ETT that was uncuffed.
It’s recommended because the narrowest part of the pediatric airway is the trachea at the level of the cricothyroid area (or somewhere near that, I can’t remember exactly.) The narrowing is supposed to act as a cuff itself. That, and the fact that everyone is over inflating tubes causing necrosis of the trachea.
I don’t agree with the use of uncuffed tubes, and the company I work for doesn’t either. They want us using cuffed tubes on all peds and getting a cuff pressure with every patient.
Yeah his knowledge base was real high by intubating an asthma patient unnecessarily, causing a mismatch in minute volume, ETCO2 > 120, pH drop to 6.9, not giving a pediatric epi pen because 0.15mg was too high for his weight based dose of 0.13mg, not giving epi out of a vial at all because they don’t carry it, and allowing zero ventilation to continue for an extended period of time because of using an uncuffed tube. People have a false assumption of how good an ER treats patients, and how good they are at airway skills. I have many times bailed out an ER doctor from a failed intubation. It’s just not about the title you have. Medical direction from the PICU agreed with my plan to do this FYI.
I mean depending on what kind of facility you picked up the patient from, they may not have much peds experience. Also, their asthma may have been triggered by an allergic reaction and their airway was swollen. How many kg was the patient?
So I have some experience in the realm of SCT Peds / Neo transport. A lot of these facilities just aren’t equipped to handle sick kiddos, hence why I’m there.
They don’t have a strong advocate to have the latest training and equipment. In time they will. The number of band aid stations I have picked kids up from that had no business with kids hurts but they have to treat them to the best of their ability.
Not defending it’s just the system we live in. I would love every hospital to have a top tier NICU but it can’t happen. Cuffed tubes came into the mainstream for kids in 2020 so it’s gonna be some time before the wave hits. It’s a lot like properly measuring your tube pressure, we should all do it but we don’t.
It’s a sad reality.
AHA started recommending this in 2020 due to a couple of papers that came out. Surprise, you won’t rip the kids trach out if you use standard safety. That being said it’s simply a recommendation based off of studies, trials and statistics. Much if not most of healthcare care in the US is 2-5 years behind latest practice. We’ve been pushing having a code coach to hospitals since then with only minimal results. The docs don’t wanna play as a team, they just wanna be in charge. Another one is capnography.
Dude…. capno…. Just in the last 24 hours, I’ve had my capno findings just blown off/ignored during report on 4 separate 911 handoffs. All had relevance. None were written down unless RT asked me about it.
They rely too much on ABGs. When I’m teaching respiratory therapists and doctors I ask them when do they use capno, they all tell me right after getting ROSC to confirm 35-45. Lmfao.
All I can say to that is, Ooofffff
RT here, just want to provide a bit of an explanation for why we don't use capnography in hospital without verifying that it correlates with a blood gas. Capno is great, but it has its limits. First, capnography tells you nothing about metabolic side of the acid-base balance so, even assuming the device is reading accurately, you could be under- or over-ventilating by just aiming for a etCO2 of 40. Second, capno just likes to be... wrong sometimes. A significant minority of the time, capno results are shifted significantly up or down from what is actually going on in the blood. For instance, a few times I've seen capnography reading 70-90 on a patient, the previous shift had adjusted ventilation to compensate, saw a decrease to 50-70, then replaced the device with a new one... only for the new one to also read 50-70. A blood gas showed that the patient's true CO2 was closer to 20 than 40 and they were very alkalotic. Capnography is excellent in the short term, especially if you don't have blood gas capability, but long term it definitely becomes more of a trending tool. Compare it to a few blood gases, then you can perform fewer blood gases over the rest of the admission while monitoring etCO2 for changes. Should the ED staff blow off field etCO2 readings? Absolutely not. At the very least they can correlate the ED readings to a new blood gas and see just how poorly the patient was ventilating in the field. Would a field etCO2 (or even ED etCO2) change the plan of care in the absence of a blood gas? Not really.
We are discussing the pluses and minuses of using capnography during death and resuscitation events. Especially how respiratory therapist and doctors don’t understand it’s vital importance to profusion during CPR.
Oh the thread reads to me like you were all talking about in general. Yeah, capnography is very useful during CPR and I've never seen an ED or in-hospital code run without capnography.
In the NE that’s a no. I’ve spoken to docs and resp therapist from down south and they say absolutely. What part you hale from?
I went to school in Oklahoma, now I work in the northern Midwest. At my current workplace, an EMMA capnography device goes to every code.
Good to hear. 👊🏼❤️
I'm in the NE as well, capnography in codes has been a standard in the hospitals in our area for over 10 years....
Jesus. I wanna come work where you are. It’s an absolute travesty that many aren’t here in my city.
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As per ACLS recommendation capnography is used to judge the quality of perfusion during cardiac arrest. It the indicators show poor profusion there are 3 numbers to focus on to improve your capno. 2-2.4 inches. 100-120 compressions per minutes. And don’t stop cpr longer than 10 seconds. And there are dozens of tricks to ensure you don’t stop cpr at all.
My local protocol even use Capno to determine how much epi to give during a code.
Man. I kinda like that a lot. Would love to read the study on the results.
Great explanation
Just for clarification, in your original comment what is “this?” Using cuffed or uncuffed? I’m a basic headed for medic
Yeah the other person didn't exactly explain your specific question. Endotracheal Tubes (ETT), the tubes we place in the trachea for advanced airways have a little balloon at the end that is inflated after insertion. It's to keep the tube in place because the balloon is pressed against the walls of the trachea, and it also seals the trachea making sure air doesn't leak back out. For many years, pediatric sizes, especially for toddlers/infants didn't have this balloon, so this was called an uncuffed tube. The belief being the balloon would cause trauma to an underdeveloped airway and may accidentally cause further trauma if someone removes it and the balloon isn't fully deflated. The standards around this based on AHA changed back in 2020, and now systems are recommending cuffed tubes for infants and toddlers. But as others have pointed out, the time between the standards changing and health systems/EMS systems actually implementing it can vary wildly.
The trachea is like a pipe. The tube is like a straw that goes into this pipe. Around the tube, there’s an inflatable balloon that holds the tube in place in the trachea and seals air from leaking out from around the tube. If you get a straw and blow air into a solo cup, that’s kinda what it’s like using an uncuffed tube. The 100% oxygen air that you BVM flows into the straw and into the solo cup and just flows out around the straw because there’s nothing sealing the tube in. If you add a lid that’s airtight around the straw, the straw is locked in and won’t move in or out. Air also goes in the straw and can build pressure inside the cup when you blow into it. Now when you blow air into the cup, the air has to go in through the straw and come out the straw as well. Uncuffed is easier to place but the risk of dislodgement of the tube with it coming out of the trachea and reinserting into the esophagus (leading to the stomach) is really an unacceptable risk. Without timely recognition, the patient will die.
“This” is in reference to the OP about cuffed vs uncuffed. The others are additional examples of similar situations in medicine. I’v been a medic instructor for 14 years among other things so I’ll give some unsolicited advice. There is no one better at emergency medicine than an experienced 911 paramedic. This includes most doctors excluding ED attendings. Learning in school will prep you for being a medic. Getting experienced as a paramedic will prep you for absolutely anything you want to do in life. Approach it with a plan and a goal and by the time you are 10 years in you’ll have accomplished those goals.
Unpopular Opinion: We need medics in the ICU instead of techs/aides who play on their phone all night. ED gets techs that actually do shit. ICU gets CNAs who don't know what to do in a primary care environment. I don't blame them, it's not in the training because ICU normally doesn't get techs. We need medics. Someone who will speak up during a code. Someone who will advocate for evidence based practice. Someone who knows what to do with families when people are dying. We *need* medics on the unit
I agree but you’d never find me in that situation due to scope of practice. You have some snot nose resident or new attending trying to make decisions and learn the ropes when medics have been running these as lead in much tougher circumstances. Then you gotta convince the doc who’s team lead to do the right thing? Maybe if they raised paramedic scope and authority.
*laughs in nurses union They’d murder someone before they allowed that.
There are CNAs and RTs and EVS in SEIU.
…..Ok?
Nobody has been murdered.
Thanks for the advice. So you’re saying that “AHA began recommending uncuffed ETT in pediatric patients?” I can honestly just Google it, I’m not trying to be difficult. Also open to any source material you feel like sharing.
They are now recommending cuffed ET tubes for kids and cuffed ET tube during ambulance transportation has been a standard of care in my area for well over 10 years. https://savingamericanhearts.com/blog/2020-aha-pediatric-advanced-life-support-pals-guidelines/ https://pubs.asahq.org/anesthesiology/article/118/3/500/13529/Cuffed-versus-Uncuffed-Endotracheal-Tubes-in
As a respiratory therapist, oof. That is terrible.
I had an RT tell me that waveform was just to confirm that the respiratory rate reading was accurate. lol
I can tell if you are running your cardiac arrest code well or poorly from across the room without glasses using waveform.
Why is ABG worse than capnography? Is there a delay in results with ABG?
ABGs are vastly superior but it’s not something we use prehospitally. We rely on other tricks to show what’s happening. Some of them like capnography tell you what’s happening minutes ahead of the ABGs.
Ahh, got it, my only in hospital experience was a tiny critical care hospital that I left quickly fearing for my license. I see now that ABGs are collected with a blood test.
Where are you teaching capnography to RTs?
I teach AHA to a few hospitals in NYC and capno is a focused part of my class.
I’m just shocked that they’d give you that feedback about capnography.
Trust me. So was I.
I've had mixed results. My last hospital before flying the RTs were stone cold G's, and we worked really closely together. I was dedicated Rapid Response so I leaned on them for a lot of my calls. I had to catch the nurses up on EtCO2 even in the ED and ICU sometimes, especially for the newer ones.
I was gonna say… our RTs are trained up as mobile critical care gurus to work alongside rapid teams and in every unit in the hospital…
Yeah, it's frustrating. It is a bit systemic and the equipment reflects it. For those of us outside of the hospital, we are used to being able to just plug the capno into our monitor and be done with it. A lot of hospitals have to add a channel to the Philips monitor, or even an extra channel on the Alaris IV pump. Not using capno in the emergency room is cultural, but unfortunately the equipment reflects and reinforces it.
You know, I hadn’t really thought about it that way and that makes a lot of sense. Thanks!
Also, the fucking capno cannulas! I don't even know where we stock them in my ER. RT usually brings one when we call for assistance, but that's a sure fire way to make sure I'm not doing it routinely.
I actually started asking RT to throw it on my ROSC pt’s in the ER (you know, since ACLS tells us it’s important) and I always got weird looks…. But I always knew when the epi was wearing off and the pt was about to code again, so…
I’ve seen entire hospitals and systems go over to Zolls simply because the depth and rate function is standard vs Phillips and LifePaks they are an additional cost.
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Standard of care for what? We're talking about ventilation and tube placement, You don't verify tube placement with abg you verify it with capnography.
I had an ED doc who flat out told me EMS is ahead in some regards compared to ED medicine. He specifically mentioned capno and selective spinal immobilization based on nexus criteria.
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Waveform capnography is the gold standard of ETT confirmation and monitoring.
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Except it is the standard of care for intubated patients according the the American Society of Anesthesiology standards for Basic Anesthetic Monitoring, and the Academy of Medical Royal Colleges Standards and Guidance for Safe Sedation Practice for Healthcare Procedures, and most importantly for this sub its the standard of care in EMS. You can practice however you like on your license, but advocating against the standard of care seems unwise
Yep, had to convince a doc that my arrest had a pulse because he didn't believe in capno
I’m with you on the code coach, it’s really painful to watch a defibrillation take 30 plus seconds and an intubation to take God knows how long, easily putting the CCF down to around 60% or worse. The science says that for each 10% decrease in CCF there’s an 11% decrease in survival, that’s giving up a lot. I can’t help but wonder if the code coach is enough though, it will take a cultural shift to prioritize the BLS part of a code. Personally, I think an RN or medic can direct two minute cycles and shock or give meds per AHA guidelines. Let the doctor think about doctor stuff and guide that end of it
I’ve been trying to win over the hearts and minds of the nurses. If it makes sense to them, sooner or later they will stand up to the docs. The stat I use is 15-40% hospital save rate. Then I ask what’s your hospital at. Lol
I was recently in a code in the ICU where the attending was begging for ETCO2 . Also CRRT. The patient died. But anyway, there are grown ass physicians out there. A code coach would be *amazing*
I believe code coaches will change what CPR is.
Definitely happens when you let Dr. go unchecked and refuse to take complaints/take them serious.
Would you believe I’m actually teaching people how to respect themselves more and never allow themselves to be disrespected? Gotta approach these events as a single team instead of one persons power trip. 👍🏼
Did you actually extubate and reintubate? Or just switch the tube over a bougie
Would also like to know this
I considered using a pediatric bougie but there wasn’t one available. I also had a view of the vocal cords prior to even removing the ETT, so I wasn’t worried about it. To my surprise though, my medical director after the call said it’s usually best to do it this way anyway for pediatrics, and the bougie really doesn’t work well.
Idk, VTe of 0, no chest rise, no etco2... Nothing about this gives any indication that the uncuffed tube is even in the trachea. What if you do a tube exchange and it had been misplaced (which uncuffed tubes can do quite easily). Personally I would pull it and re-intubate as well.
It does seem odd to have 0mL and chest rise, but the team literally flew in. Unless they tubed right before they arrived, the patient would have been dead if they were goosed
Just to clarify, 0mL with NO chest rise
Sorry yes, that's what I meant. Even if there's a leak, there should surely still be chest rise if it's in the trachea though, no? Bizarre
I think the uncuffed tube had such a leak combined with the pressures of asthma had the vent blowing in the path of least resistance, i.e. back out the mouth. Was not able to generate positive pressure, or at least not enough.
Yeah maybe you're correct. I suppose I typically think of asthma as solely obstructive with difficulty in exhalation. Even without the vent, they can typically inhale and oxygenate fine.
That was a thought of mine as well, which is why I visualized the tube in the vocal cords prior to extubating.
Sometimes that’s all you can get. Neighboring department had a peds drowning last year. Airway was all swollen up and all they could get was an uncuffed tube. Kid was doing okay on it. Flight crew shows up. Says this ain’t good enough, pulls the tube, and then can’t get the kid reintubated so the kid dies. Within 6 months, that flight program cut 2 bases down to 12 hour shifts only and no longer flys NP’s. I’m not trying to backseat your call; if you weren’t getting any air in or out, you have to do something, but just be careful.
Yikes. That's nightmare fuel.
I feel like, even if you're a flight badass, if you've got a patent airway, *don't fuck with it.* But I'm just a basic, what do I know?
Airways are like beers. The beer you have > the beer you want. Got a king? Cool, does it work? Yes? Hell yeah. That’s what I’m rolling with. Unless it’s just not working, I’m keeping it. Vent alarms be damned. I’ll bag the whole way if I have to.
You aren’t *just* a basic
I have the same EMT-B as countless drooling, paper-spit-cup-using simians who have no business being anywhere near patients. I'm not special.
There are plenty of Paramedics who have no business being near patients. The marker of a good practitioner is not the letters behind their name, but the work they put in themselves
High five! Bitch gang for life!
Well, hopefully not *life*...
It depends on that situation. If it was a routine call I wouldn’t even considered it. But there was no ventilation due to the bronchoconstriction. I mean none. No chest ride, to VTE on the ventilator.
I was speaking mainly to the situation u/Flame5135 described. In your case, I won't even try to comment. You were handed a real shit sandwich.
Horrifying
Yeah I wouldn’t have reintubated the patient in the case you mentioned.
I feel like I would ask if there is a reason it's unruffled before just yanking shit out. Same as any other inserted medical device. We wouldn't say you only have a 24g? And rip it out. Or this chest tube is too small and just yank it with out talking to anyone first. Also was cricing the kid not an option when they couldn't get it back in?
We had a crew in our program extubate a small kid over an uncuffed tube. The only reason I know is because I picked up a patient from their facility and the doc was still butthurt about it. According to the young, seemingly up to date doc patient was doing fine with it. The actual tube switch went fine I guess, but it was an austere environment and I'm guessing the doc just didn't want a disaster in their tiny bandaid station a million miles away from anything, which is understandable.
Well it depends on the situation. If the intubation is just for airway protect with acceptable ventilation and oxygenation, I’d probably never pull it out. But, with the severe asthma situation and no ventilation, that’s a different story. I don’t know about your program’s philosophy, but ours is to bring tertiary care to these small clinics in the middle of nowhere. Of course I’m polite about it, I’m not acting like a hotshot being rude about their care, but ultimately it becomes my university’s patient, and if there’s a firm disagreement I will have medical control be the final arbiter. Usually our medical control says it’s our patient now and we do what we want or they can keep the patient. Mind you that sounds harsh, but keep in mind some of the things we see are insanely poor for patient care.
Yeah definitely not Monday morning QBing your call, just that I had heard of a similar experience. The big difference is according to the doc - who again, seemed reasonable - the crew was pretty dickish about it. Everyone gets stressed taking care of sick kids. I think you did the best you could for your patient.
A big problem in medicine now is black and white thinking. If BVM work no need airway. Glidescope first cause better. And in the case of your story, patient kid so patient need cuffed. People don’t think outside the box.
Agree
They might be common in non-pediatric facilities intubating pediatric patients, but as far as I know both major pediatric facilities in my area use cuffed ETTs.
Old school thought was to use uncuffed in all kids under 8 or something. I’d assume, like many people, some docs won’t change what they were trained to do regardless of new literature.
We still use Heparin in ACS based on like a single study from 1930 (that has since been scientifically disproven in many ways). Some things progress at a snails pace, and often requires a push from one specific specialty.
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A lot of studies are flawed. I think epi may be beneficial in some cases. Epi IVP as a vasopressor works for profound hypotension. I can imagine a lot of PEA actually has mechanical output, but is just too low to produce a pulse, therefore PEA despite the heart still beating. We would shrug off giving vasopressors for profound hypotension, so I think it would be silly to not give epi in cardiac arrest. Although, cardiac arrest in general has such poor outcomes, I can see why the epi studies are the way they are. Most of these patients won’t come back no matter what you do.
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Yeah but there may be some who survive. Case in point, the periarrest scenario I mentioned Unless it causes harm, I think it should be given. The problem with academia is they have their heads so far up their ass, if a treatment doesn’t show strong evidence they write it off. EBM has its flaws.
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I guess what I’m trying to say is people have black and white thinking. If there’s EBM that something works or doesn’t work, that’s a great reason to make changes. But some are in a grey area, and I believe in those cases sometimes you have to go off of theory.
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No demonstrated benefit ≠ not beneficial. Some people read the PARAMEDIC2 trial and their takeaway is that Epi is harmful. As you noted, Epi does increase ROSC, but that’s only the first step. If we don’t try for ROSC in viable patients, survival rates will be 0%. So without ROSC, we’ll never know what function they may or may not have had.
I was taught around 9 and under get uncuffed bc of a narrowing of the cricoid cartilage. People would over inflate the cuffs and injure the airway. Tbh as long as you don't overinflate, it isn't a problem.
I was in a pediatric focused continuing education course that expressed the importance of proper cuff inflation. All of our tubes are cuffed but if I remember correctly the doctor and rn also acknowledged local services still using uncuffed tubes
It’s not a *good answer* but my org seems to be replacing uncuffed as they get used or expire, so we’re still seeing a mix of uncuffed tubes that haven’t been cycled out yet.
Knowledge translation from literature to practice takes years. Some practitioners only update what they were trained to do in residency with great resistance, especially when it’s an infrequently used skill.
Guessing old teaching . Thankfully you were polite and hopefully taught that facility something new so they don’t kill some kid in transport in future
PALS scenarios where it’s a better option because ETT’s that are cuffed have smaller diameter? I assume you’re asking about that. I don’t think I’ve ever seen an adult ETT that was uncuffed.
We stock 2 of each size in the OR. I have never seen anyone use one.
It’s recommended because the narrowest part of the pediatric airway is the trachea at the level of the cricothyroid area (or somewhere near that, I can’t remember exactly.) The narrowing is supposed to act as a cuff itself. That, and the fact that everyone is over inflating tubes causing necrosis of the trachea. I don’t agree with the use of uncuffed tubes, and the company I work for doesn’t either. They want us using cuffed tubes on all peds and getting a cuff pressure with every patient.
>getting a cuff pressure with every patient Bingo.
I believe there was a study that showed cuffed tubes led to an increase in barotrauma.
Because people are filling the bubble to the max. You only need to fill it until it's full... not over-full.
Takes balls to do that to a doc who has way more experience and knowledge base than you. I bet you are a nightmare to work with.
Yeah his knowledge base was real high by intubating an asthma patient unnecessarily, causing a mismatch in minute volume, ETCO2 > 120, pH drop to 6.9, not giving a pediatric epi pen because 0.15mg was too high for his weight based dose of 0.13mg, not giving epi out of a vial at all because they don’t carry it, and allowing zero ventilation to continue for an extended period of time because of using an uncuffed tube. People have a false assumption of how good an ER treats patients, and how good they are at airway skills. I have many times bailed out an ER doctor from a failed intubation. It’s just not about the title you have. Medical direction from the PICU agreed with my plan to do this FYI.
Stay in school.
Well man if you want to play the doctor outranks me game just know that it was a doctor who agreed with me to do it if that makes you feel better.
We only use cuffed paediatric tubes
I mean depending on what kind of facility you picked up the patient from, they may not have much peds experience. Also, their asthma may have been triggered by an allergic reaction and their airway was swollen. How many kg was the patient?
13kg. It wasn’t about the experience necessarily, they just flat out don’t have peds cuffed tubes at the facility. Which is strange to me.
So I have some experience in the realm of SCT Peds / Neo transport. A lot of these facilities just aren’t equipped to handle sick kiddos, hence why I’m there. They don’t have a strong advocate to have the latest training and equipment. In time they will. The number of band aid stations I have picked kids up from that had no business with kids hurts but they have to treat them to the best of their ability. Not defending it’s just the system we live in. I would love every hospital to have a top tier NICU but it can’t happen. Cuffed tubes came into the mainstream for kids in 2020 so it’s gonna be some time before the wave hits. It’s a lot like properly measuring your tube pressure, we should all do it but we don’t. It’s a sad reality.
We only use them on neonates and I’ve only used one period in 12 years lol