Resuscitation dogmalysis

Here are the references to ‘Resuscitation Dogmalysis’ (more to follow)

Dogma: “Adult patients are best intubated in the sniffing position”

Lysis: They’re not. Humans – adult or child or infant or newborn – are best intubated with the external auditory meatus aligned horizontally to the suprasternal notch. In your ‘standard’ 70 kg adult that might be sniffing with one pillow, but make that assumption and direct laryngoscopy, and bag-mask ventilation for that matter, will be more difficult than it needs to be.

See Levitan’s explanation and references from the AirwayCam site

Dogma: “He doesn’t need intubating, he’s got a gag reflex”

Lysis: Gag reflex was absent in 37% of healthy subjects;12 patients with a gag reflex were significantly obtunded Lancet, 1(8271), 565.

Videofluoroscopy of neurological patients: No association between an absent gag reflex and aspiration
Clin Otolaryngol Allied Sci. 1993 Aug;18(4):303-7

Dogma: “You can’t / shouldn’t do surgical airways in kids”

Lysis: Clinical experience is so rare animal model studies are the best we have to go on, and needle crikes have a high failure rate (40%) and high incidence of perforation of posterior wall (42%). Note in infants the cricothyroid membrance is often too small for a tube so a tracheotomy may need to be done with cutting of the anterior part of a tracheal ring to make space. It will bleed and losing control of the trachea is possible, which should be prevented by gaining purchase on the trachea using sutures or a surgical towel clip. After short training 97% success was achieved in one study using a surgical, as opposed to needle, technique.

See Transtracheal airways in kids

Dogma: “In maternal cardiac arrest, the baby must be delivered within 5 minutes”

Lysis: Earlier is better, but later is still appropriate, in fact most of the reported survivors were delivered after this timeframe: median delivery time in neonatal survivors 10 mins (range 1-47) , maternal survivors 9 mins (range 1-37).

See Perimortem Caesarean Delivery: Late is Better than Not

Dogma: “Acidosis causes cardiovascular depression”

Lysis: Myocardial contractility is affected by intracellular acidosis. Extracellular acidosis (which is measured on a blood gas) may have some protective effects by increasing intracellular sodium ions and intracellular calcium. The overall effect of a low serum pH may depend on the relative balance of these protective ion movements and intracellular acidosis. One should certainly not assume a low pH is a cause of shock, but rather the cause of the shock may also be causing a low pH.

J Physiol. Nov 1989; 418: 163–187

Dogma: “Vasoactives have to be infused through a central line”

Lysis: They are risky if they extravasate, but studies from ICU and retrieval settings show it can be done safely. Central route is preferable, but this should not delay haemodynamic resuscitation. You can start the norepinephrine peripherally though a good proximal line, with someone regularly checking it, and then put in the central line in less hurried circumstances.

ICU setting, and what to do if they extravasate from EMCrit
Retrieval setting

Dogma: “In COPD, if you intubate you’ll never get them off the ventilator”

Lysis: Breen’s study – A total of 74 patients were admitted to the ICU with acute respiratory failure due to COPD during the study period. Mean forced expiratory volume in 1 second (FEV1) was 0.74 (0.34) l. Eighty five per cent of the group underwent invasive mechanical ventilation for a median of 2 days (range 1–17). The median duration of stay in the ICU was 3 days (range 2–17). Survival to hospital discharge was 79.7%

Thorax. Jan 2002; 57(1): 29–33

Wildman study – of the 832 patients recruited, 517 (62%) survived to 180 days. Of the survivors, 421 (81%) responded to a questionnaire. Of the respondents, 73% considered their quality of life to be the same as or better than it had been in the stable period before they were admitted, and 96% would choose similar treatment again

Thorax. 2009 Feb;64(2):128-32

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