EMCrit Podcast 69 – The Future of CPR with Keith Lurie and Demetris Yannopoulos

The Future of CPR

I got to interview two cutting edge researchers on what CPR will look like in the next decade; their answers were fascinating.

Flow-Enhanced CPR

They discuss the use of the impedance threshold device and the active-compression/decompression device to augment flow during CPR. See the results of the ResQ trial listed below to see what this does in cardiac arrest patients.

Note: Dr. Lurie is the founder, chief medical officer, and a major shareholder of the company that manufactures these two devices. Dr. Yannopoulos has no conflicts of interest.

Reperfusion Injury Protection

Stutter CPR is giving 3 cycles of 20 seconds of compressions/ventilations, 20 seconds of pause. In pigs, this has markedly reduced the reperfusion injury when resuscitating a patient with prolonged arrest.

New Medications

Sodium nitroprusside (in addition to small doses of epi and flow-enhanced CPR) increases flow to the heart and the brain. May also blunt reperfusion injury to heart and brain. In addition adenosine and cyclosporine A may have a role as well.

Note: None of this is ready for clinical use–this may be the future, it is not the present

Want More?

Supplemental Audio

More on the ROC-Primed Trial and the ResQ Trial (MP3 File–Right Click and choose Save As)

More on Dosing and Intra-Arrest Hypothermia and Cath (MP3 File–Right Click and choose Save As)

Update

Recent 15-minute pig cardiac arrest study provides continued evidence of ischemic post-conditioning (Resuscitation  Volume 84, Issue 8, August 2013, Pages 1143–1149)

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Comments

  1. We have successfully done PCI on several out-of-hospital cardiac arrest patients during ongoing CPR using LUCAS, a gas driven sternal compression device. Outcomes have been good; had a patient just recently who was discharged after a couple of days with no neurological sequelae. There are some published similar cases. It’s amazing how effective the compressions are, some patients have to be sedated as they become awake and aware.

    • Absolutely Simon. In fact Dr. Lurie believes that integrating the active-compression decompression device into the LUCAS along with the ITD would be the ultimate set-up.

  2. Minh Le Cong says:

    okay, I must admit when the resq trial came out I was a bit skeptical. Intuitively it seemed to be counter to other new developments in CPR such as making it simpler..push hard, fast and dont stop…etcetc.

    As a prehospital provider it still concerns me from a human factors viewpoint that adding more devices and increasing the complexity of CPR once again may simply discourage more bystanders to start. for trained providers…I dont mind relearning CPR if it has been proven to help outcomes. This interview has dispelled most of my skepticism and it was great to hear these two researchers talk through their rationale for their approach to the future of improved outcomes in CPR. The tailoring of resuscitation to a low flow state is of course logical and reducing reperfusion injury seems to be a novel and valuable goal.

    I had thought that prehospital ECMO was going to be the future of prehospital cardiac arrest management..what has been discussed here makes more sense physiologically and sounds doable with only a little more training.

    It is exciting to hear that resuscitation research is still active and trying to push the boundaries of useful reanimation!

  3. Rebecca says:

    I’m wondering about the utility of PEEP in cardiac arrest. I’ve heard several anti-PEEP (in cardiac arrest) arguments, but considering the goals of compression/decompression CPR with an ITD it seems that PEEP might help to further increase preload and forward flow.

    Also, it was unclear to me whether these strategies are being pursued for all cardiac arrest patients or only those in v-fib. We don’t see too many patients still in v-fib at the 15 minute mark, even with bystander CPR.

    • Rebecca, I believe right now it is being pursued only in pigs, but I believe these techniques will be for all initial rhythms if the animal data translates to humans.

  4. Dave Cummins says:

    Scott!!!!!!!! Curse you my friend! OK, ‘curse you’ was kind of strong, but holy cow, how could have you missed the boat on this one? The Res-Q-Pod and the CPR device that Dr Lurie sells is not only “not ready for prime time” but very likely might be an all-out sham. But in the interest of being fair, I will say that the evidence at this point is not sufficient to support or refute the use of these devices.
    I first became suspicious of the ResQPod when the AHA, out of nowhere, placed it on the 2005 update with a IIB recommendation and cited 6 studies in numerous journals as their evidence for consideration. Low and behold Dr Lurie was an author on all 6 articles and, come to find out, he invented the device. A few studies followed, some from Dr Lurie and a few from people doing research with him and they seemed to support the device. BUT, no other studies that were done completely independently of Dr Lurie have supported it’s use. AHA subsequently reduced the Impedance Threshold Device to a few-sentence blurb in the 2010 guidelines and downgraded it to IIB. No legitimate journals or societies have given Dr Lurie and the ResQPod the time of day since then.
    I recently heard Dr Lurie speak at a conference where he attempted to refute the most up to date and advance resuscitation literature that we have. We are finding out that endotracheal intubation in the routine cardiac arrest does not improve outcomes and may actually hurt in some circumstances. As we are discovering this is probably due to delays and interruptions of good quality chest compressions. Since the device he is selling requires intubation Dr Lurie claims that intubation is a must. I tend to agree with the International Liaison Committee on Resuscitation (ILCOR) who recommends continual uninterrupted compressions to maintain aortic blood flow pressures without the precipitous drop off that comes with even a few seconds of pause.
    I feel like I should be on a campaign to stop this madness from Dr Lurie and his sales campaign. How is it that no one calls this guy out for what he is: A SALESMAN! He is making a fortune on these products and is an amazing marketer, convincing people that he is promoting science rather than business. I make no claims against Dr Lurie’s knowledge, his skill as a physician or even his intentions. But I would argue that that little thing that separates us from our physician forefathers is evidence-based medicine. Research that is honest and open, well designed and verifiable evidence. We MUST have other independent study of these devices by numerous other people with larger numbers of patients before we jump on his bandwagon. Dr Lurie is a genius marketer and has been playing his hand like a pro. I just suspect that when the dust settles his devices will disappear off of the radar screen and so will Dr Lurie with his well-padded bank account.
    Please Dr Weingart, in the name of all that is holy and evidence-based, critique the literature on this and call this guy out in your next interview with him.

    • Dave,
      I’ve been waiting for a topic that can get people fired up. As out-of-hospital CPR trials go, the ResQ trial was quite big and got published in the Lancet, which at least the Brits would consider quite a legitimate journal. It was after that trial that I began to look at these devices seriously, b/c the literature up until that point had been equivocal. I hopefully am going to get Dr. Lurie and Dr. Yannopoulos to respond directly, but if not I will be back with more. Thanks again, my friend.

    • Minh Le Cong says:

      Yes Dave has echoed a lot of my initial skepticism. The literature suggests that both devices alone do not improve survival and the resq trial said that both devices together appeared to improve survival over and above standard CPR. this does seem illogical . Does one successful trial meet our resuscitation needs? Well CRASH 2, seemed to for TXA and trauma. Why? because the intervention is simple and costs about seventy dollars AU. Its true the same laws of economy do not apply to these two devicese and their application to prehospital CPR. Dave is right about the concern with promoting ETI for CPR. The theories behind it all sound logical but absolutely, we need more than one trial to justify expensive devices and retraining. very stimulating debate folks, thankyou!

    • I know Dr. Lurie, and he is a man of impeccable integrity who deeply cares about saving lives. He has devoted his life to researching cardiac arrest not in order to make money but in order to advance a field which had gone nowhere for years. He has helped to resuscitate resuscitation science from a dismal one to a hopeful one.

      If a device has a good rationale, he will study it. If this device turns out to actually work when rigorously studied, then someone has to actually manufacture and market it, or it will never be available. Dr. Lurie could easily have become rich just doing electrophysiology, but instead he took the initiative to advance ideas he both really believes in and about which he has done extensive, detailed research. Dr. Lurie is as unbiased as anyone who believes in his data can possibly be.

      I am dismayed to read such an uninformed, uncalled for attack on the character of a man whom Dr. Cummins knows absolutely nothing about. There are ways to express skepticism without attacking character. I suggest you learn them.

      Stephen Smith of Dr. Smith’s ECG Blog

    • For what it’s worth, the ITD does not actually require intubation. It can be used with a blind airway like the King, or even on a well-sealed BVM mask.

    • R.J. Frascone says:

      Dave, I don’t even know where to start, but I’ll try to be brief. First your statement “the device [ITD] he is selling requires intubation Dr Lurie claims that intubation is a must.” This is absolutely incorrect. Use of an ITD with a facemask is strongly recommended (www.advancedcirculatory.com) and has been shown to be effective in cardiac arrest (Use of an inspiratory ITD on a facemask and ET tube to reduce intrathoracic pressures during the decompression phase of ACD-CPR. Plaisance et al. Crit Care Med 2005.) In the most recent, largest-ever, human trial of ACD-CPR with an ITD (ResQTRIAL), published in a reputable journal, The Lancet, the ITD was first placed on a facemask and ACD-CPR was begun upon arrival of the first responders, with the devices being placed on average, within 32 seconds. Both the ITD and ACD-CPR device should be considered primarily BLS devices, if they are to be maximally effective, and in fact, this study showed a 53% improvement in survival to hospital discharge with favorable neurologic outcome with ACD-CPR + ITD, with the survival benefit persisting to one year.

      Second, I would also challenge you on your statement that “endotracheal intubation in the routine cardiac arrest does not improve outcomes and may actually hurt in some circumstances”, especially in light of the recent data published on diminished survival and carotid blood flow during use of a supraglottic airway (SGA) in cardiac arrest (Chase et al, Segal et al, and Wang et al. Prehosp Emerg Care 2012). In addition, in one of the largest published databases on survival in cardiac arrest, the ROC PRIMED study (published in a reputable journal, Aufderheide et al. NEJM 2011), in fact, reported that in over 8700 patients, patient survival to hospital discharge with favorable neurologic outcome was 7.2% (81/1131) if patients received a facemask for airway management, 6.1% (26/935) if they received an ET tube for airway management, and 2.8% (26/935) if they received a supraglottic airway. SGAs have been popular because they don’t require interruptions in chest compressions, but medics can be trained to endotracheally intubate without stopping CPR. This is exactly what we are doing currently in a trial being conducted with my services with great success. I would argue that, in light of recent data, both for ET intubation and against SGAs, that ET intubation may still be the gold standard for airway management.

      Third, I take exception to your statement that “no other studies that were done completely independently of Dr Lurie have supported it’s [ITD} use.” There are over 40 animal and clinical studies that support the ITD’s use, 11 that I’m aware of that do not have Keith Lurie’s name on them and that are published in reputable journals (Langhelle Resuscitation 2002, Bahlmann Resuscitation 2003, Thayne Resuscitation 2005, Cabrini Crit Care Med 2008, Hinchey Ann Emerg Med 2010, Thigpen Respir Care 2010, Thigpen Circulation 2010, Dailey Circulation 2010, Saussey Circulation 2010, Burnett Circulation 2011, Chase Prehosp Emerg Care 2012). These studies include experience with an ITD in over 1500 human subjects and dozens of animal subjects.

      Finally, it’s regrettable that you have chosen, with seeming great pride, to attack the motivations of the devices’ inventor so personally and with misleading and inaccurate statements. Have you read the science on ACD-CPR with an ITD (not a single negative or neutral study), and it’s use with vasodilators and pauses in cardiac arrest? When you insult the ethics of Dr. Lurie, you insult the ethics of all of the researchers with whom he has collaborated, many of whom are the finest researchers in the resuscitation field in the world. I have worked personally with him for 20 years and have seen this science live in animal models numerous times in the lab. I don’t know anyone smarter, more dedicated to his patients and to research, or the betterment of the science of resuscitation in this space. He is painfully ethical, as you would find if you ever had the privilege to collaborate with him on a project. Dr. Lurie is not becoming rich with these devices, but when did it become a crime to be a capitalist? I submit that the profit motive is one of the great drivers in advancement of medical technology. Who else is motivated to try and make things better than someone with a good idea? Combine the profit motive with great intellect, and you have a powerful, productive system that drives medical advancement and benefits everybody.

      • Minh Le Cong says:

        Dr Frascone, thankyou for further information. May I ask if you can inform us of how your EMS providers are trying to perform ETI without chest compression interruption? I suspect it is with video laryngoscopy, correct? This is the only way I would know currently of achieving this..apart from surgical airway…the other option though is the Fastrach or AirQ ILMA placement then blind tube through them…is that the option yu have chosen?
        I find it interesting that the face mask ventilation produced the best overall survival outcome in the study you cited. This is in line with data out of Korean EMS recently…finding SGA devices were worse than face mask and ETI use for prehospital arrest patients.

        • R.J. Frascone says:

          Minh, you are correct. It is a videolaryngoscope trial. We are comparing the Storz CMAC and the King Vision scopes in a single crossover design. We are 6 months into the one year study. To your second comment, we have published an abstract which demonstrated decreased cerebral perfusion in a porcine model, in marginal pressure states, with SGA’s vs ETI. A colleague and co-author of the ResQ Trial, Dr. Brian Mahoney, Hennepin County Medical Center, has IRB approval and is about to begin a study in the ED looking at the same thing in humans. Should be interesting. RJ

          • Minh Le Cong says:

            RJ, that sounds freakin awesome. Am I correct that your EMS providers in the trial are getting to play with either the CMAC or the King Vision…in the field? Can I come work with them..fantastic trial..one of the first I know of comparing those devices in a prehospital setting. I was trying to get a proposal going for a similar aeromedical study comparing The King Vision with DL..but it fell through..so great to hear your study is underway..I really look forward to hearing the results and reading the paper!

            • Jeff Morgan says:

              ETI is posh possible without stopping compressions. It is a matter of practice and training. Not everytime but often. It is the time to raise the bar…

      • Minh Le Cong says:

        Dr Frascone, I looked up some of your references you cited in your response.
        I assume when you are referring to prehospital ETI and improved outcomes with the Wang 2012 article you mean this conference abstract?
        http://emspatientperspective.com/2012/03/16/a-positive-wang-intubation-study/
        Thankyou as I was not aware of that one and look forward to reading the full published article when it comes out.

        My take on all the literature and discussion is that the jury is still out on this idea of what is the best prehospital airway management in out of hospital cardiac arrest patients.

        retrospective reviews such as this ( and the others mentioned in the reference article list at the bottom of the webpage) http://lenus.ie/hse/handle/10147/207235

        Do indicate possible harmful relationship.
        To me reading literature out of Japan and the US, the hypoxia related cause of arrest prehospital group benefit the most from early control of the airway and ventilation. Doing ETI early in that group makes sense to me. For VF and VT related arrest, I am undecided at this point. Work from researchers like Wang and yourself will hopefully shed greater light on this area for all of us!

        My concern is that from a human factors issue, if providers are led to believe that ETI success is crucial to outcomes in OHCA then fixation errors can occur and a lot of otherwise very useful interventions can get delayed or ill performed. Wang’s work and my own experience is that teaching providers to reach and maintain a certain level of ETI prehospital success is very challenging….regardless of professional background. Its fine to get the ETI in first pass but how many attempts is worthwhile before you give up in OHCA? That is why I am undecided right now. great discussion and appreciate your thoughts and commentary on this.

        • A lot of the prehospital ETI research in cardiac arrest should find a negative survival benefit due to the ridiculously low compression fraction for the entire code! Research in areas with good compression fractions has had favorable outcomes.

  5. One of my questions with the ROC-PRIMED trial was that it appeared to show that the ITD was no better or no worse than the sham. It seemed that their study was attempting to do too much at once (differing styles of CPR, ITD, and a targeted ventilation rate). One could argue that any benefits seen by the ITD were due to a lower, more controlled ventilation rate thanks to the blinky-light on the ITD.

    I know another detractor is the cost of the ITD device, which given no large survival benefit seen will certainly slow its adoption. It would be interesting to hear their ideas on this and any comments!

    • Oops, should have read the supplement to hear their comments on the trial! :-)

      Their comments to my first point: they acknowledge the deficiencies but state they intended to include some of the tests together due to the fact that they were intended to be tested together. Although I’m not exactly satisfied that the trial proved they were mutually exclusive in their benefit from the controlled ventilation rate. However, they state there are more trials coming out which will show benefit.

  6. Patrick Wanner says:

    Very interesting podcast, I especially found the part on ischemia/reperfusion injury refreshing. Another, perhaps better researched, agent one could consider in the immediate post-ROSC period is sevorflurane. These patients will typically spend a while in the ED, where depending on your setup, maintaining anesthesia with sevo wouldn’t be too complicated (compared to the ICU). However, where I practice in Europe, we tend to maintain with fentanyl/midazolam or propofol/remifentanil, although we have sevo at our disposal in the trauma bay… Here’s an interesting reference though:

    Meybohm P, Gruenewald M, Albrecht M, Zacharowski KD, Lucius R, Zitta K, Koch A, Tran N, Scholz J, Bein B. Hypothermia and postconditioning after cardiopulmonary resuscitation reduce cardiac dysfunction by modulating inflammation, apoptosis and remodeling. PLoS One. 2009;4:e7588. doi: 10.1371/journal.pone.0007588. [PMC free article] [PubMed] [Cross Ref]

    As usual with all these pre-/postconditioning studies, what remains to be elucidated is whether these improvements in myocardial function and inflammation profile will translate to actually better outcomes.

  7. keith lurie says:

    In 1987 I had a pt who was resuscitated with a toilet plunger on his chest. Little did I know I would be responding by blog to an audio interview I had with Dr. Yannopoulos 25 years later. Since 1987 we have learned a lot about the physiology of CPR, how to optimize the chest as a bellows to move more blood to the heart and brain, lower ICP, and have finally begun to improve outcomes after cardiac arrest. It has captured the imagination of many and it is fascinating! In our interview we tried to share what we think is exciting about the future in resuscitation and what we know today. We have discovered lots of aspects of CPR that need improvement, including the following errors which are literally deadly, when they are made in isolation or simultaneously: excessive ventilation rates, excessive compression rates, incomplete chest wall recoil, pauses in CPR, too much epinephrine, shock before CPR, and supraglottic airways that can be inflated too much to compress the carotid arteries and prevent venous blood flow out of the brain. We also know there are no silver bullets. What is critical is that we provide better perfusion more rapidly and protect the body after prolonged ischemia from reperfusion injury. This can be accomplished by some of the advances we discussed on the pod cast. A system of care is needed just like any other complex disease state. Therapeutic hypothermia is wonderful but the pt needs to be alive and hemodynamically stable to get this therapy. The work we discussed with sodium nitroprusside and intentional pauses in the first 1-3 minutes of CPR to prevent reperfusion injury after prolonged ischemia is extremely promising.

    With regard to the ITD and ACD CPR, there have also been some important advances. We are not a liberty to discuss publically some important new findings from the NIH ROC PRIMED study on the ITD. Suffice it to say that when CPR is performed at the correct compression rate the ITD functions as intended and benefits were observed: as Dr. Idris pointed out last year at the AHA Scientific Sessions in November 2011, CPR rates in the ROC PRIMED study varied from 50-240 compressions per minute. That is a big problem: too fast and too slow is deadly and no ITD can help in that setting. That makes the interpretation of any new intervention, including the ITD and Analyze Early-Analyze late difficult. Stay tuned.

    I read with disappointment the comments of Dr. Cummins. I do not know him but I would encourage him to review the science behind the ITD and ACD+ITD. In the pig laboratory it is striking. Blood flow to the heart and brain are quadrupled compared with standard CPR. Independent labs have also reported this. I started Advanced Circulatory Systems with great reluctance 15 years ago after no other company wanted to pursue what appears to be life-saving technology. Contrary to Dr. Cummins comments, I have not made a dime with this technology and quite the contrary but I am very pleased to report meeting multiple survivors who were treated with this technology, including our U of MN cardiac EP fellow from 2007. He had a cardiac arrest running around one of the lakes in Minneapolis. He now practices in Tennessee and has done great. Another is a Professor from the U of WI who told EMS personnel to stop doing CPR when he was being treated with ACD+ITD CPR: he went unconscious again as he was still in VF. Both of these pts and many more are completely intact and function like you and I do, every day trying to make a difference. Dr. Cummins should visit us in Minnesota and speak with some who have nothing to do with our company or research who have seen firsthand in pigs and people that it is possible to save more lives based upon sound physiology. Dr. Aufderheide, who was the first or co-author of many clinical papers on the ITD, has nothing to do with the company that makes these devices. I would encourage you to contact him at the Medical College of Wisconsin. He will provide an unbiased opinion: he was first author of both the NIH ROC study and the ResQTrial. He is a physician-scientist.

    So for those who are new to the challenges of trying to changes outcomes after cardiac arrest, I would encourage you to read some of the science. There will always be nay saying and politics but physiology is like physics and some principles are sound. That was the focus of our pod cast.

    I am more than willing to share what we have learned about the physiology of CPR; we should be putting our energy into making our EMS systems better and our in-hospital care better rather than writing disparaging remarks on a blog. The world is not flat. The science of CPR is in a very dynamic space and what you heard on the pod cast is just the tip of the iceberg of some of the exciting advances that we and others are studying and applying in patients. I challenge all who read this blog to learn what the outcomes after cardiac arrest are in your EMS systems and hospitals and make them even better next year.

    • Dr. Lurie, thank you for taking the time to write this comment; I think all of the readers will take these words to heart.

    • Minh Le Cong says:

      thankyou Dr Lurie for both your interview and the response here. I enjoyed hearing you and Dr Yannapolous share your thoughts and research anecdotes. When I started using ketamine sedation in patients with agitated schizophrenia for aeromedical retrieval four years ago, there were similar nay sayers…there still are but thats what research is for. I understand the committment it takes to prove something is safe, effective yet totally contrary to established beliefs. Its good to hear someone speak with conviction on something they believe will help patients and advance our understanding. I look forward to reading and hearing more of your resuscitation research in the years to come!

    • Dave Cummins says:

      Indeed, as Dr Smith stated, I made some hasty comments that attack character rather just sticking to my main point. Dr Lurie, you took the high road and are a gentleman. My apologies.
      I will reiterate my intended message like this: Although Dr Weingart has no obligation to restrict any type of speaker on his program and made a very clear statement of conflict of interest (and has no obligation to do that either) the fact remains that Dr Lurie is the inventor of these two devices and has some personal interest in seeing that they succeed. With proper disclosures these talks SHOULD happen, but they should be taken into the context for which they are delivered. If you have a speaker from XX pharmaceutical company talk to your group or hospital about the latest anticoagulant you very clearly understand the nature of your talk and wouldn’t expect to see that pharmaceutical rep speaking at a major conference outside of the vendor room.
      I will also say, regardless of any financial implications of the sale of a device, we have also found that many of the “latest/greatest” devices and treatments for cardiac arrest such as amiodarone, high-dose epi, bi-phasic defibrillation, vasopressin, etcetera have not lived up to the hype and initial buzz generated by the people promoting them.
      My earlier message, although impulsively written and nearly unprofessional, remains the same. We must have better evidence from human trials done by people with absolutely no connection Dr Lurie or his company that show these devices work (or probably work) before we promote them. Dr Smith’s blog and Dr Weingart’s blog are both powerful media by which to disseminate information on our specialty. Again, you have no obligation to anyone on who to have speak or how they speak. But suffice it to say there are many medical schools and residency programs that would not let Dr Lurie speak to promote his products due to the clear and obvious conflicts of interest.
      Dr Lurie, my apologies again for attacking your character.

      • Dave, well done; thank you for that. I honestly don’t know the proper course for physician innovators. Folks like Dan Cook, inventor of the AirQ ILA and Dr. Lurie are espousing products that they have devoted a good deal of their lives to and truly believe are going to save lives. Yet you are correct, we must always consider all biases when evaluating the literature. Problem is, independent researchers rarely want to do large scale, funded studies on ideas and techniques that they themselves did not invent or conceptualize. After ResQ what will happen next? Best we can hope for is a group like ANZICS or the Europeans to do an independent trial. But if the Europeans go at it, they will probably make it an equipoise enrollment and the results will be equivocal b/c they won’t enroll patients in which the docs felt the pt would benefit. Perhaps Ben Bobrow will do a large scale EMS trial in Arizona as before and after and we can get some corroboration that way.

        • For one who has just discovered this blog and podcast series – it almost takes more time to read the comments than to hear the extensive podcast on the Future of CPR.

          My Thoughts: SUPERB job in ALL ways by Scott Weingart who has brought together two cutting edge state-of-the-art researcher clinicians in the field. NO WHERE ELSE would one have opportunity to hear this great discussion. As one with 30 years experience in academics – I am as sensitive to potential “promotion” as anyone – but I did NOT in any way, shape or form get that from the truly fascinating presentations by Dr. Lurie and Yanapolous. As Scott emphasized multiple times – This is NOT YET READY FOR PRIME TIME. Instead – it is a look at a bunch of fascinating potential interventions for the future.

          Rather than with drugs alone – the future seems to lie with enhanced methods of CPR. Although I have my own reservations as to relative benefit/harm of resuscitating victims of OHCA who have been down without bystander CPR for that 5-to-10 minute period (in how many in whom ROSC is obtained will we be able to also restore intact neurologic function?) – the point of this wonderful and fascinating podcast is that there MAY be a number of important interventions that may form the Future of CPR – and at least offer HOPE for meaningful salvage of some percentage of these victims who would otherwise be dead.

          THANK YOU Scott (and Drs. Lurie and Yanapolous) for this great podcast presentation! – Ken Grauer, MD

  8. Jeremy Mackinnon says:

    Dr Lurie

    I may not have close to the amount of letters behind my name as the usual poster on this site, but first and foremost I would like to thank you for your effort in to the science of resuscitation. Well I never had the chance to use the ACD device I have used the ITD on a number of out of hospital cardiac arrests before the take over of our health system and the protocols we must follow changed to a provincal standard. Every patient I had the oppertunty to use the ITD on combined with uninturupted CPR and King Airway Device had remarkable changes from our past patients. In one year I had more patients wth ROSC then in the 10years of my career total. Through research that you and others provide and blogs that Consimate(sp?) professionals like Scott and Stephen provide it makes me excited about medicine, its future and bringing upstairs hospital care outside.

    Respectfully
    Jeremy M

  9. Brian D. Mahoney says:

    I have known and worked with Dr. Lurie for twenty years. I could not be more startled nor baffled by anyone questioning his ethics.

    But that is not what I wanted to contribute to here. I read with interest the comments above of Minh Le Cong about endotracheal intubation without stopping chest compressions. Allow me to describe how it is done in my system – Hennepin County (Minneapolis). Typically 3 of my colleague first responders arrive in about 3.5 minutes and initiate continuous hands only CPR, place the King Airway #4 inflated with 60 cc (reduced from 80 after the findings in our animal lab published by Segal showing supraglottic airways compressing the carotid in the pig model), place the ResQPOD on the King which guides ventilations at 10 a minute, place the AED and shock if indicated at the two minute mark. My paramedics arrive about 3 minutes after the first responders. The paramedics bring the LUCAS 2 device and it is placed with as little interruption in the continuous chest compressions as possible. After the next two minute assessment the paramedic was permittted/and now encouraged to replace the King with an endotracheal tube. This is placed using a standard Miller or Mac blade (I cannot yet afford one of the video options listed by Minh Le Cong). The paramedic is not allowed to turn off the LUCAS 2 during this attempt at endotracheal intubation. The paramedic is instructed to replace the King if they are unable to endotracheally intubate without turning off the LUCAS 2. In a brief quality assurance review of 36 cases of endotracheal intubation under the circumstances described above, the paramedics reported that in 35/36 cases they were able to intubate without turning off the LUCAS 2, and that the intubation was as easy or at least no harder than any other intubation they had done. So far two of them have told me that they had one of the first responders stabilize the cricoid cartilage due to motion. In one case the paramedic said he had stopped the LUCAS 2 briefly and then restarted it immediately after intubation. I have recently reminded all the paramedics that they must not turn off the LUCAS 2 to accomplish intubation. Endotracheal intubation must be accomplished with continous chest compressions or return to the King until we have further information on potential problems of supraglottic balloon inflation on carotid blood flow in humans.

  10. Brian and others–Who would be the best person in the resuscitation community to talk about these new potential problems with SGAs in cardiac arrest. I want to get someone on the show ASAP b/c this is an incredibly important shift in the new paradigm many of us have adopted over the past couple of years.

    • Minh Le Cong says:

      good call. My gut hunch based on anaesthetic literature and practice is that LMA type designs should not present this problem of occluding the carotid arteries. The King LT and similar designs with big balloons may present an issue theoretically in humans. Frankly its something I had never thought of worrying about but its good to raise and discuss it if there has been some animal data to suggest an issue.

    • Brian D. Mahoney says:

      I could speak to it if you would like.
      Keith Lurie would be excellent of course.
      Do you have a phone number I could call you at to discuss this?
      My office phone is 612-873-5689

  11. Minh Le Cong says:

    thanks Brian, thats very helpful! Sounds like you dont need a video laryngoscope to do this. This is an area of resuscitation practice that can do with some tidying up. Traditionally we thought ETI was crucial because everyone dies without an airway, right? I still remember back in my hospital residency days, having an arguement with the anaesthesiology crew who turned up to a cardiac arrest, they wanted to tube before I could deliver a shock for VF..and they had stopped CPR to do the tube! This whole idea of stopping CPR to get the tube in needs to be settled once and for all and it seems you great folk at Hennepin are gathering data to do just that! Stabilising the cricoid cartilage makes perfect sense. LUCAS sounds awesome they way you are using it…pity the data does not give us a clear answer for it though over standard CPR care. My only question is that if your King airway is working fine with good Capnography trace, is it really that advantageous to try to replace it with ETI in the field? Are you that worried about carotid flow in a porcine arrest model with SGA devices?

    • We don’t interrupt compressions to intubate in my neck of the woods and we also don’t use VL either. Pretty similar setup to what Brian described, except our firefighters handle CPR. We also see a lot of KingLT placement first-line, but it isn’t required.

    • Rebecca says:

      I’ll second Christopher’s experiences. In all of the cardiac arrests I’ve had as a paramedic where I have been in charge of the airway, I have only had to hold compressions to intubate twice. Both of these situations were in patients with difficult anatomy and poor visualization.
      I usually instruct the firefighter/EMT to continue CPR and I have another EMT assisting me. I insert the laryngescope, suction if necessary, usually get good visualization of the cords (often with the help of external laryngeal manipulation) and am able to pass the ETT without ever having to stop compressions. If the patient is positioned well and CPR is being done correctly on a firm surface, there is really very minimal movement of the airway.
      The hardest part about this procedure is usually convincing the person perfoming compressions that I really don’t need them to stop.
      If I am not getting good visualization of the cords due to movement from compressions, I wait until the laryngescope is in the patient’s mouth, the ETT is in my other hand, and my partner/assistant has their hand on the patient’s larynx. After about 5 seconds of “hands off” time, I either know that I am not going to be able to visualize the cords, or I have the tube in place. Either way CPR can be resumed immediately.

      • I will add a few comments to these excellent tips. When I teach my residents to intubate during compressions, we always use a bougie b/c once that has passed the cords, the compressions have no effect on the ability to subsequently railroad the tube. Bougies just slip in easier with no hang-up from stylet bends and you are putting a much smaller object through the moving cords.

        Further, I have started using a trick I picked up on the Society of Airway Management forums, though I am blanking as to the author. The trick is, once you have inserted the laryngscope 1-2″ into the mouth and are about to begin advancing further to find epiglottis, insert the bougie into the mouth and advance it to the right 3rd molars.

        Then when you are ready to lift the jaw, you only have to move the bougie an 1″ further to intubate the cords, rather than trying to maintain visualization while someone hands you the bougie. This works with styletted ET tubes as well.

      • Matthieu Gensburger says:

        I totally second that. In cardiac arrest patient, I always try direct laryngoscopy first with ongoing chest compressions (manual or LUCAS), using a standard Macintosh blade, external manipulation if needed and no cricoid pressure, then try to pass a styleted ET tube. So far I only once had to stop the compressions for a few second, just for the time to pass the tube through the cords. Laryngeal motion is minimal during properly performed compressions. Would intubation fail, I would then grab a ILMA.

        I have always wondered where the (mis)beliefs surrounding tracheal intubation during ongoing CPR come from, and it puzzles me that an airway guru and out-of-the-box thinker like Dr Le Cong actually never tried ;)

    • Brian D. Mahoney says:

      Before I write any more I want to be sure that any readers know that I am one of the principal investigators in the ResQTrial published in the Lancet January, 2011. I have no financial conflicts at all.

      Great question on why take out a perfectly good functioning KingLT? These are my ideas behind that. I welcome all of your suggestions to improve on this approach.
      1. I believe that the endotracheal balloon does a better job isolating the trachea against aspiration than the KingLT balloon. I don’t know this – just believe it.
      2. I believe that there are many animal and human studies convincing me that the ResQPOD contributes to patient survival and neurologic quality of survival. I believe that the balloon on the endotracheal tube will do a better job allowing the ResQPOD to do its work of preventing unneccesary air from being drawn down the trachea during elastic recoil of the chest. This preserves some negative intrathoracic pressure to draw additional blood flow back into the chest. This additional blood returned to the chest is available for the next chest compression to push it forward to heart and head. I believe that the balloon on an ETT will do a better job sealing the airway than the balloon on the KingLT facilitating the function of the ResQPOD.
      3. The balloon on the KingLT #4 inflated to 60 cc held in your hand is squishy soft. But I don’t know how much pressure it may be exerting on the carotids from the inside of a human glottis. I don’t think it is much considering how soft it is in my hands but I am worried. In our animal lab Nicholas Segal researched this question in a pig model of cardiac arrest. This research was presented at NAEMSP in Tucson in January, 2011. The King, Combitube and LMA were all studied. The data is complex, and fascinating. It is in a pig model. We have IRB approval to study this in human CPR but have run into a glitch with the ultrasound device that was to measure carotid flow for us. I am not criticizing any of these airways – I think they can be lifesavers. However I would suggest you inflate one to whatever manufacturer’s recommendation you use and hold the balloon in your hand. Then ask yourself do you think this balloon might compress a weakly pulsating carotid from the inside. For this reason we have chosen to use 60 cc of air in the KingLT #4.

      So with these considerations in mind I have the first responders start with the KingLT placing the ResQPOD on it. At about minute 6-7 into the arrest with the LUCAS 2 providing nonstop chest compressions, the paramedics are encouraged to remove the KingLT just after the last 2 minute rhythm check. Compressions are restarted and are not to be stopped during attempted endotracheal intubation. If intubation is successful it is confirmed with endtidal CO2, Wee aspiration, and auscultation for breath sounds. The ResQPOD is placed on the ETT. If intubation cannot be achieved the KingLT and ResQPOD are replaced into the airway.

      Charlie Lick of Allina in Minnesota has some data showing marked improvement in survival and neurologic quality of survival since adding LUCAS to High Performance CPR principals. We have only had LUCAS 2 since May 3, 2011. We looked at our numbers at 6 months and there was a favorable trend. We will look again at one year. The paramedics and emergency medicine residents have a favorable impression – we shall wait to see what the data shows. One advantage of the LUCAS 2 is that it allows the paramedics and firefighters to do quality CPR safely in a moving ambulance. As we all know standing CPR in a moving ambulance is poor quality and dangerous for the standing provider as well as the seated provider they may fly into. I can tell you that my paramedics and firefighters appreciate this aspect of LUCAS 2. This has also allowed us to consider a system wide collaborative effort with all the PCI centers to bring them younger, witnessed VF/VT/AED shockable rhythms to the cath lab with ongoing CPR. We hope to roll this out in the near term.

      One of the comments was on bougie. Yes I agree completely. They make difficult intubations doable and blind intubations no longer blind since you can use the tactile feedback of the tracheal rings and the carina endpoint to help assure you are in the trachea as you confirm with end tidal CO2, Wee aspiration, and auscultation of breath sounds. We use them routinely.

      • Our area adopted the “work them where you find them until ROSC or you call it” model. I’m very interested to hear about your results with on-going mechanical CPR and caths, as this could potentially alter our CPR strategy.

      • Jakob Mathiszig-Lee says:

        Is the Lucas radioleucent? The London air ambulance physician response unit has a zoll autopulse which they occasionally take people to the cath lab on as the output is so good but apparently the band makes primary PCI a nightmare. My understanding is zoll are working on a new band to mitigate this.

        • Zoll has video of a cath being performed with the AutoPulse going and it didn’t appear to cause much problems for that interventionalist. It does appear to inhibit some of the view, but no more than manual CPR would.

          The LUCAS-1 and LUCAS-2 present a challenge in height restrictions, otherwise their suction-cup end does not obscure the view any more than manual CPR does. Physio also has videos of caths being performed with the LUCAS device operating.

          • Matthieu Gensburger says:

            PCI is possible with the Lucas going on (see ref. below), but I’ve been told only oblique views are possible (although the paper did not mention it).

            Larsen, A. I., Hjørnevik, Å. S., Ellingsen, C. L., & Nilsen, D. W. T. (2007). Cardiac arrest with continuous mechanical chest compression during percutaneous coronary intervention?A report on the use of the LUCAS device.
            Resuscitation, 75(3), 454–459.

        • Physio-Control does offer a carbon fiber back plate for LUCAS that is completely radiolucent for use in the cath lab. Because the LUCAS electronics are in the hood of the device, not the backboard, it lends itself very well for imaging in most projections; the Straight Cranial, Straight Caudal, Straight Lateral, LOA/ROA Cranial, and LOA/ROA Caudal projections.

          LUCAS is widely used in cath labs in Europe and is the most published mechanical chest compression device on the market for this purpose. There are several life-saving cases presented (e.g. a recent press-release from St Georges hospital in London http://www.stgeorges.nhs.uk/press291.asp) as well as several scientific publications (e.g., Azadi “Use of the LUCAS mechanical CPR device in the cardiac catheterization laboratory,” Invasive Cardiology 2012;24:79-83), which laid the groundwork for an AHA class IIa recommendation to use mechanical CPR during PCI/cardiac arrest.

          One of our LUCAS cath lab users has provided a practical tip regarding the clearance; try lowering the table and then from an LAO cranial move to a LAO caudal or vice versa. Same thing from the RAO. Once past the LUCAS, the detector can be moved into a straight Caudal or straight Cranial position if that is desired. This should work fine in Siemens, Phillips, Toshiba, and GE cath labs.

      • Minh Le Cong says:

        Thanks Brian. What you describe makes sense and is a very reasonable approach. You asked for suggestions to improve it. here is one. use a portable ventilator to control IPPV. This way you can ensure precise delivery of minute volume, PEEP and even FiO2. Most importantly you can control the ventilation rate. As Christopher has alluded to, its my opinion that the ResQ pod device may exert its benefit in controlling provider delivered hand ventilation rates. Extrapolation from prehospital TBI and ETI research would suggest that possibly some of the demonstrated harmful association between prehospital ETI may be due to suboptimal ventilation once the trachea and lungs are isolated with an ETT. This would seem in keeping with the overall concept of using machines to do a lot of the work in resuscitation…like what you are doing with LUCAs 2 device and seeing beneficial trends. I would go as far as suggesting hooking up the King LT to a portable ventilator right from the get go if it is positioned well and you are getting decent capnography trace. This would free up the prehospital providers to getting other things done like trying out some of those novel pharmacologic interventions you , Keith and Demetris mentioned. And this is getting onto some of the real logistical issues of providing ACLS and indeed prehospital critical care in the ambulance or by a roadside. Its difficult to get a lot of this stuff started and going well when its only a couple of providers doing it. I think its great if you can get two crews to attend to the one patient to start some of this prehospital critical care ASAP. So it has always been a matter of prioritisation for providers when initiating prehospital ACLS. Traditionally the mantra was ABC, then its become CAB..its difficult to keep up! But with machines we as prehospital providers can get things setup quickly like compressions, then focus on other things like the airway, then with a portable ventilator going you have essentially secured ABC. Now some might be rolling their eyes at the thought of forking out money for an expensive portable ventilator..not a problem. There are affordable gas driven ventilators that work fine in this situation…not hard to learn how to drive them,my Norwegian buddies on http://www.scancrit.com wrote an article on one such device
        http://www.scancrit.com/2012/01/10/small-ventilator/

        To me its seems the natural progression of the prehospital critical care you guys are already doing in Hennepin county.

      • Minh Le Cong says:

        One other suggestion to improve. Replace the King LT with the Fastrach ILMA. One device does both jobs as SGA as well as intubating device. Learning curve for Fastrach ILMA in the published literature is about 15-20 successful intubations. For successful ventilation its even less, about 5 attempts to get useful proficiency. AS long as you teach the anatomy and mechanics of the design of the ILMA to novices, they can insert and successfully ventilate with a high rate of success. Last simulation session I ran for one of the air retrieval crews, I taught a novice ( one of our pilots) in 5 minutes how to insert and successfully ventilate the mannikin. About the compression of the carotids with LMA devices in particular the Fastrach ILMA, I could only find this single case report, reporting a benefit in the event of concern of carotid artery compromise
        http://medind.nic.in/iad/t08/i6/iadt08i6p858.pdf
        My gut feeling is that it is not going turn out to be an issue, even with the King LT but will watch out for your research publication with keen interest. Let us know!

  12. Minh Le Cong says:

    fantastic tips. You can tell I have never tried to tube someone during compressions. Its just not what we do down under…or at least at the places where I worked. Routinely, we would stop compressions to get the tube in. I have thought if i had to then I would Fastrach ILMA them..all blind technique…I got no. problem with that. But DL during compressions..you have convinced me to tell the compressor to keep going and ignore what I am doing in the mouth!

    • You can usually time it to pass the cords during your rhythm check if its bouncing around too much, but often a little bit of ELM will put it into view without problem.

      • Ray Gadd says:

        I have recently changed by technique in Cardiac arrest with all the literature re: never stopping CPR and do the bougie/ETT with good success the bougie makes it easy to hit the target.
        That with an N of 2 so far.

  13. Wonderful podcasts.

    I think we may be rapidly approaching the point where any new intra- or post-arrest therapies need to be assessed, at least as one cohort if not as the sole test arm, in patients who also receive appropriate therapeutic hypothermia. The outcomes that the best centers are seeing in the chilled patients, both quantitatively (in numbers saved) and qualitatively (in prolonged downtimes, comorbidities, and often extensive periods of low- or no-flow), suggests that these patients are experiencing a fundamentally different post-arrest physiological course. Since so many of the problems we’re facing are, as discussed in the podcast, really linked to the post-ROSC cascade of failure from this “ultimate shock state” — perhaps influenced in part by our care, such as reperfusion injury and drugs like epinephrine — and hypothermia seems tailored to mitigate this process, in every trial where we see benefits in some intermediate endpoint (more ROSC, better cardiocerebral perfusion, etc) but not improvements in neurologically-intact discharge, I always end up wondering, “but what if they were cooled?” To what extent can hypothermia “bridge the gap” for these patients, possibly extending more temporary benefits all the way out to long-term physiologic normality?

    Not that every hospital in the world is practicing therapeutic hypothermia, of course, but that’s an issue of implementation, logistics, finances, etc. to be fought in the trenches. Nevertheless, it’s clear that that’s the direction we’re headed, so when we’re looking to the future it seems like omitting this piece may be omitting something critical.

    • Brandon, Yes I agree with you in spirit. But remember in the control groups of the best hypothermia studies, Vfib OOHCA patients still had a 25% neurologically intact survival rate. So for the most part making the post-arrest course include hypothermia will increase the study’s power, but not necessarily sway the results so long as both groups either got it or did not get it. But then you can argue the smaller points that a patient who has been cooled has a fundamentally different physiology and that is why I agree, once hypothermia has become a true rather than stated standard of care, all of these studies should include it.

      • I think we’re on the same page. Just to illustrate the point, though, let’s take the example of epi. I’ve come full circle on this, because in the past I was extremely underwhelmed at the apparent immortality of a drug that has repeatedly failed to demonstrate any improvements in neurologically-intact survival to discharge. Unquestionably it got us more ROSC, but so what if they all died later anyway? But now, with the improvements in post-ROSC care, mostly hypothermia (and perhaps things like early PCI, or even neat stuff like ECMO), we’re doing better and better at managing these sick resuscitated patients and coaxing them back towards life. Yet to give the ICU a chance to work their magic, we need to buy enough time to turn the short-term problem of cardiac arrest into a medium-term problem of post-arrest care, and this is where something like epi might finally come into its own. Drs. Yannopoulos and Lurie talked about the synergistic effects of active decompression and the ITD, where the former alone may do very little, and likewise I think it’s been a standard fixture in the resuscitation literature for the past couple decades to discover therapies that improve ROSC but accomplish nothing further. Adding in the post-arrest care to keep carrying the ball downfield might create the value in treatments that otherwise had not just little, but none (and yes, without longterm survival, I see absolutely no value in more ROSC). Hopefully that makes some sense.

        • I understand where you are coming from, but it is a numbers game. If epi would have shown a 5% increase in neurologically intact survivors of vfib with hypothermia, then it still should have shown 2.5% increase without unless there is a specific effect epi has only on hypothermia patients. However if that 2.5% wound up being an insig. p-value then hypothermia perhaps would have turned a negative study positive.

          • I suppose my fantasy is that with the right synergy the improvement in numbers would be much better than that, but you’re right overall, of course.

            Incidentally, the Beth Israel Deaconess in Boston is reporting a retrospective survey of in-hospital arrests where, after supposedly normalizing all the other variables, they’ve shown a significant correlation between time to epi administration and outcomes — all the way out through discharge. Not a perfect endpoint, and obviously not directly portable to out-of-hospital settings, but still seems groundbreaking; I believe it’s under review at the NEJM now.

  14. Greg Kelly says:

    I thought the podcast was one of the best and found Dr Lurie’s knowledge and enthusiasm to be really stimulating and exciting.

    However enthusiasm and desire to do the best for our patients can lead us to down the wrong path and that’s the reason why we need to have good quality RCTs with as much blinding as possible. Having read the trial there are two concerns.

    The first is that the trial sponsor had more than the usual amount of input, in the paper’s own words “The sponsor (Advanced Circulatory Systems) helped investigators to obtain government funding, design the study, interpret the data, write the report and decide to submit the report for publication.”

    The second is that some patients (those that had airway problems including leak and failure to place an advanced airway and those with non-cardiac arrest) were excluded from the final analysis. This was a pre-planned exclusion but it still seems like a non intention to treat analysis (especially the airway patients). There is no breakdown of the “airway” exclusions alone in the paper or appendix but when all of the excluded patients were analysed the outcome difference was no longer significant (just).

    I await further studies with great interest!

    • Greg, I hear what you are saying, but if the exclusions are planned before the study’s start then they can only affect the external generalizability and do not affect the internal validity of a study. Intention to treat only comes into play on patients who met inclusion, but for whatever reason did not achieve the treatment of their group. still, i hear what you are saying.

  15. The Future of Cardiopulmonary Resuscitation (CPR) http://t.co/Rg7gTYM3

  16. insert the bougie before you get to the vallecula by @emcrit http://t.co/NLlwmWjj

  17. Thanks for tbe podcast, I have learned so much, it has really halped make me a better paramedic.

    With the King LTSD, you can also perform a tube exchange with a bougie, which would theoretically cause no disruption of compressions, and give you a cuffed tube in the trachea. For those of you who have first response units using this device, it could be an option for you.

    Bougies…..what CAN’T they do?

    • Dan, Have you successfully done this maneuver? Many of us have tried and found it to be difficult or impossible despite the theoretical potential. The port is ill-suited to this purpose though I am quite fond of the device.

    • Minh Le Cong says:

      I find this discussion of exchanging a perfectly working King LT for a cuffed ETI to be fascinating. I confess I have never used a King LT. LMA type devices I have used a lot. It is not easy to pass a bougie into the trachea blindly via a LMA type device. It is reported though and done under fibreoptic guidance in one report I read via a LMA Supreme. I have never been successful blind bougie insertion with standard LMAs and must admit I would not pass a bougie via the ILMA for fear of injuring the larynx or trachea.

      Looking at the King LT design, I cannot see how it would be any easier. Indeed it looks harder. But if Dan you have had successful real cases then would love to hear about them.

      It concerns me though that in prehospital settings, providers would consider taking out a functioning advanced airway to try to replace it with another piece of cuffed plastic. It makes more sense to use the one device to ventilate then if you want try to intubate without having to displace the device already in position.

  18. I have only done it in the sim lab and manikins, not on a real patient. In that area, it has worked pretty well, although I most likely would not be using it in practice. In my area, only ALS providers would be performing ETI or placing the King, (no EMT-I/AEMT support, only basic) so since I or my partner would have been the ones placing the airway, as Dr. Le Cong said, it doesn’t make sense. If I got a patent airway, I’d be very happy with it. Just putting it out there to see what feedback there is for the idea, since it is out there.

    Anecdotally, I have noticed that some ED’s are very reticent about using the King with mechanical ventilation, although the manufacturer says it can be done. I had one case where a very difficult airway was secured in the field with a King, on arrival at the ED, it was removed and ETI was attempted, with predictable results. Maybe this technique would have been preferable. Once again, anecdotal and certainly not anything near scientific.

    Thanks again for the chance to learn…I’m always looking for opportunities to learn more as a prehospital provider, and I’m definitely getting it here. Going back to read now…

  19. Minh Le Cong says:

    Thanks Dan. Just given me a great idea for my next prehospital podcast. Mechanical ventilation using extraglottic airways..the experience of the Royal Flying doctor service of Australia. It can be done! My take is that you need a really good reason to remove a functioning extraglottic airway , prehospital or ED. Its reasonable to have one or two ETI attempts if yu really want because at least you know yu can reinsert the extraglottic and be back to square one. But remember Cliff Reids words in our interview. Your penis length or female equivalent will remain the same regardless of who secures the airway. The other thing to consider is performing a surgical airway under extraglottic support. That is very sensible particularly as Levitan states if they are going to end up with a surgical airway in ICU anyway.

    • Jimmy D says:

      One observation, one concern.

      Observation—During my recent trip to the University of Massachusetts to regain my ACLS-Instructor rating, I was required to teach the practical portion of an ACLS class to a group of 20 senior medical students. Each one of them were able to intubate the resuscitation mannequin during continuous chest compressions while using the McGrath MAC video laryngoscope, whereas, without this device, they were almost completely unable to manage the mannequin’s airway, save for the students who elected to pursue Anesthesia (1) and Emergency Medicine (2). Videolaryngoscopy–it’s here and it’s better. Videolaryngoscopy (with a MAC shaped blade) makes intubation during chest compressions possible for care providers on multiple levels. Of course this should be studied in simulation.

      Concern—Excessive ventilation has been determined to be detrimental in resuscitation, a point I take to heart and am mindful of. Appropriately applied ventilation is of great concern to me, and I am concerned that the proper methods and tools are getting lost in the shuffle here.

  20. Miz Black Crow says:

    Not to add another voice to a clearly-controversial topic…

    …but I notice that nobody, including Scott, has mentioned the fact that the FDNY ran a trial with the ResQPod, used in all out-of-hospital cardiac arrests that were attended by FDNY Paramedics. (I know. I was there.)

    The following is an excerpt from a SEMSCO bulletin dated May of 2010:

    ” Starting 1/5/2010, NYC used the ResQPOD on 744 cardiac arrests and managed 541 arrests without the device during a 90 day period. Sustained ROSC (Return Of Spontaneous Circulation) was 18.28% in the ResQPOD group versus 25.14% without the ResQPOD for an effect (if you’re a stats geek) of -6.6%. Comparing all arrests to the same period in 2009 (one year earlier), there was a net decrease in ROSC of 1.98%. When the ITDs were removed from service, ROSC increased to pre-ResQPOD levels. FDNY docs are crunching the numbers by type of arrest, bystander versus no bystander CPR, and checking for statistical significance before they make definitive pronouncements. One thing is certain: in a City that sees over 1,200 cardiac arrests every 90 days and has the capability to carefully study every event, trends will become obvious[.] ”

    The ResQPod was pulled from the service in a hurry–well before the intended expiration of the trial, which I believe was supposed to last 1 year–when that information came out. Since I haven’t seen a study published involving our data, and not much explanation has filtered down to the street level, I can’t give the best analysis of why it didn’t work–whether it was misuse, provider miseducation, faulty devices, or poor device design / concept. But it didn’t work. Personally, I was unable to achieve ROSC with any patient during the trial, but my personal results are (by definition) anecdotal anyway.

    I also understand that ROSC rates, not survival-to-discharge or neurologic deficits, were the end-point of the study, and that what is good for ROSC may be bad for long-term-survival (as some people argue with epinephrine); I can’t see something that’s bad for ROSC being good for the patient in general, but I make no judgments one way or another. In the end, however, one of the (the?) largest EMS organizations in the US has decided it doesn’t work in the out-of-hospital setting, at least not for us.

    As for intubation during compressions, I’ve never seen the harm in it except in truly difficult airways, and usually get success with it. Since our alternative is, for now, the CombiTube (with its massive latex balloon), and my understanding is that that much intraesophageal pressure may decrease cerebral blood flow, I make every attempt to intubate rather than provide a glottic device, and usually have no difficulty with ETI during CPR. Laryngeal manipulation and a Mac blade (that I tend to use like a Miller and directly manipulate the epiglottis rather than the vallecula) work just fine for me.

    • Yep,

      I’ve been waiting for a while now for the publication of the NYC study. As I think you elude to, raw stats in this form of study are useless, the propensity analysis will be interesting, though it has been 2 years now, so one wonders if it was a non-sig and unlikely to be published result.

      Can I gently request that all comments are posted with real rather than nicknames–much thanks.

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