Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

You had me at ‘Controversial post for the week’ – Part I

 
What kind of trouble would an Ambulance Chaser be up to?

 

Time to stir up some controversy here.

I would no longer require any resuscitation “card courses.” No more ACLS, CPR, or PALS.[1]

 

The saddest part about this is that this is controversial.
 


Image credit.
 

First, I disagree with some of the points about how slow the AHA (American Heart Association) is. The AHA is not as bad as portrayed, but much of this is the failure of the AHA to communicate effectively.
 

Heck, it wasn’t even until this go-round of ACLS revisions that waveform capnography was added.[1]

 

To protect against unrecognized esophageal intubation, confirmation of tube placement by an expired CO2 or esophageal detection device is necessary.[2]

 

That is from the 2000 ACLS (Advanced Cardiac Life Support) guidelines.

Necessary is not an ambiguous word, but the guidelines were not taught this way by many people.

If our attitude is that unrecognized esophageal intubation is only a problem for our patients, then we can get away with lesser means of tube confirmation.
 

The following is from the 2005 ACLS guidelines.
 

In the patient with ROSC, continuous or intermittent monitoring of end-tidal CO2 provides assurance that the endotracheal tube is maintained in the trachea. End-tidal CO2 can guide ventilation, especially when correlated with the PaCO2 from an arterial blood gas measurement.[3]

 

The AHA guidelines did not stress continuous waveform capnography until 2010. Maybe the attitude of the AHA was unrecognized esophageal intubation is only a problem for someone else’s patients.
 

    Key changes from the 2005 ACLS Guidelines include

  • Continuous quantitative waveform capnography is recommended for confirmation and monitoring of endotracheal tube placement.[4]

 

What is the key change?

Continuous

or

quantitative waveform

or

recommended

or

confirmation and monitoring

of endotracheal tube placement.

Why was the AHA not stressing this Class I, LOE (Level Of Evidence) A assessment?

There is no good reason.
 

Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, LOE A). Providers should observe a persistent capnographic waveform with ventilation to confirm and monitor endotracheal tube placement in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement.[4]

 

If a medic, emergency nurse, emergency physician, . . . disconnects waveform capnography from an intubated patient is that a sign of incompetence?

EtCO2 in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement.

Probably.

Feel free to disagree, but any such argument should avoid logical fallacies.

What else?

What else will be covered in Part II.

Footnotes:

[1] Controversial post for the week
October 9, 2013
The Ambulance Chaser
Article

[2] Tracheal Intubation
2000 American Heart Association Guidelines
Part 6: Advanced Cardiovascular Life Support
Section 3: Adjuncts for Oxygenation, Ventilation, and Airway Control
Free Full Text from Circulation.

[3] End-Tidal CO2 Monitoring
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.4: Monitoring and Medications
Monitoring Immediately Before, During, and After Arrest
Free Full Text from Circulation.

[4] Part 8: Adult Advanced Cardiovascular Life Support
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Free Full Text from Circulation.

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