How does this apply to ET drug administration in cardiac arrest?
Before looking at the research, let’s look at the theory behind this.
ALS (Advanced Life Support – drugs, IVs, intubation, . . .) improves outcome from cardiac arrest.
In one recent and very large study of this, Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest[1], the claim that ALS saves lives in cardiac arrest is shown to be not supported, at least not with the ALS that was used at the time of the study. That ALS has not changed much, but the BLS (Basic Life Support – CPR, defibrillation, . . . generally non-invasive treatments) has changed significantly.[2] There is one ALS treatment that is promising, therapeutic hypothermia,[3] but that was not being used at the time and is not the reason for this post.
The research on ALS in cardiac arrest does not show an improvement in resuscitation. Resuscitation is the ability for the patient to leave the hospital with brain function similar to the brain function they had prior to the cardiac arrest. Resuscitation is not arriving at the hospital with a pulse.
While arriving at the hospital with a pulse is important for resuscitation, focus on this is bad patient care. If we were only interested in arriving at the hospital with a pulse, we could just shock the patient into asystole, use a pacemaker and drive fast. we might have to upgrade the pacemakers from milliAmps to Amps and use thicker rubber gloves, but this could improve the number of patients arriving at the hospital with pulses. That does not mean it would improve the number of patients leaving with good brain function. A focus on pulses is not good for patient care. Even Dr. Frankenstein would feel silly yelling, It’s Alive, for a monster with just a pulse. Even the fictional doctor, in a book almost 200 years old, knew that the brain was essential to resuscitation.
If you think that arriving at the hospital with a pulse is a big deal, you probably would have done well as a banker up until this year, thinking that making reckless loans is conservative, because you wear a suit and tie. Either way, other people pay for your mistakes. With all of the increase in resuscitation rates following the improved focus on continuous good compressions, how many thousands of deaths have the get a pulse back crowd been responsible for by distracting paramedics, nurses, and doctors with ineffective and harmful drugs?
So, what research is there on ET drug administration in cardiac arrest?
One study does compare IV (Intravenous) medication administration with ET medication administration in cardiac arrest. Endotracheal drug administration during out-of-hospital resuscitation: where are the survivors?[4] There are some differences between the groups. The endotracheal drug group was 5 times larger, 5 years older, much more likely to be female, twice as likely to be in a nursing home, much less likely to have VF and much more likely to have asystole as the initial rhythm. The results still should not be ignored.
Why not?
Although this is a retrospective study with a lot of variables that have not been controlled for, it is the largest only study to look at survival to discharge.
Why does that matter?
There is no other study on ET administration worth looking at. Unless you are interested in something that looks at the change in blood level of epinephrine in a pig in a laboratory. Since I do not treat pigs in a laboratory, this is not really relevant to what I do. Even if I do find a pig in cardiac arrest under a spider web that reads, Humble, I will not be regretting that I am not more familiar with these studies. Besides the IO (IntraOsseous) needle has become standard in cardiac arrest treatment.
What were the results of the study?
Of the IV drug group, 5% survived to discharge.
That sounds typical for the resuscitation rates back then. What about the ET drug group?
Nobody survived.
If you have good circulation, you may absorb medication from the lungs without complication.
If you have circulation by way of chest compressions, that may not be the case.
If you have to stop the compressions in order to deliver the medication, you are doing more harm than any possible good that could come from providing these drugs that are not research based. Since none of the drugs are research based, apparently not even oxygen, that means all of the drugs are a problem.
There is not even evidence that providing oxygen down the ET tube is good for the patient, but we still have people who think that making Mr. Bubble in the lungs is good patient care.
Footnotes:
^ 1 N Engl J Med. 2004 Aug 12;351(7):647-56.
Comment in:N Engl J Med. 2004 Dec 9;351(24):2553-4; author reply 2553-4.
Advanced cardiac life support in out-of-hospital cardiac arrest.
Stiell IG, Wells GA, Field B, Spaite DW, Nesbitt LP, De Maio VJ, Nichol G, Cousineau D, Blackburn J, Munkley D, Luinstra-Toohey L, Campeau T, Dagnone E, Lyver M; Ontario Prehospital Advanced Life Support Study Group.
Free Full Text
One interesting aspect of the OPALS criteria is an attempt to evaluate the quality of the paramedics participating in the study. Listed among the criteria is “and paramedics had to successfully perform an endotracheal intubation in 90 percent of patients. These criteria were monitored regularly, and the three communities that failed to meet the standards were excluded.”
^ 2 Just one example of the improved resuscitation rates is provided in this post from Ambulance Driver and the comments.
Does This Mean I’m Fully Assimilated?
^ 3 Therapeutic Hypothermia
Wikipedia article
^ 4 Niemann JT, Stratton SJ, Cruz B, Lewis RJ.
Endotracheal drug administration during out-of-hospital resuscitation: where are the survivors?
Resuscitation. 2002 May;53(2):153-7.
PMID: 12009218 [PubMed – indexed for MEDLINE]
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