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Wang CH, Lee AF, Chang WT, Huang CH, Tsai MS, Chou E, Lee CC, Chen SC, Chen WJ. Comparing Effectiveness of Initial Airway Interventions for Out-of-Hospital Cardiac Arrest: A Systematic Review and Network Meta-analysis of Clinical Controlled Trials. Ann Emerg Med 2020; 75:627-636. [DOI: 10.1016/j.annemergmed.2019.12.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/25/2019] [Accepted: 12/02/2019] [Indexed: 02/03/2023]
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Personalized physiology-guided resuscitation in highly monitored patients with cardiac arrest-the PERSEUS resuscitation protocol. Heart Fail Rev 2020; 24:473-480. [PMID: 30741366 DOI: 10.1007/s10741-019-09772-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Resuscitation guidelines remain uniform across all cardiac arrest patients, focusing on the delivery of chest compressions to a standardized rate and depth and algorithmic vasopressor dosing. However, individualizing resuscitation to the appropriate hemodynamic and ventilatory goals rather than a standard "one-size-fits-all" treatment seems a promising new therapeutic strategy. In this article, we present a new physiology-guided treatment strategy to titrate the resuscitation efforts to patient's physiologic response after cardiac arrest. This approach can be applied during resuscitation attempts in highly monitored patients, such as those in the operating room or the intensive care unit, and could serve as a method for improving tissue perfusion and oxygenation while decreasing post-resuscitation adverse effects.
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Präklinisches Atemwegsmanagement mit Larynxtubus oder Endotrachealtubus bei präklinischem Herz-Kreislauf-Stillstand. Med Klin Intensivmed Notfmed 2020; 115:213-221. [DOI: 10.1007/s00063-019-0588-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 03/10/2019] [Accepted: 04/17/2019] [Indexed: 10/26/2022]
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54
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Benoit JL, Wang HE. Intubation for Out-of-Hospital Cardiac Arrest: The Elephant Is in the Room. Ann Emerg Med 2020; 75:637-639. [PMID: 32160966 DOI: 10.1016/j.annemergmed.2020.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Justin L Benoit
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Henry E Wang
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, TX
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55
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Kim JW, Lee JW, Ryu S, Park JS, Yoo I, Cho YC, Ahn HJ. Changes in peak inspiratory flow rate and peak airway pressure with endotracheal tube size during chest compression. World J Emerg Med 2020; 11:97-101. [PMID: 32076475 DOI: 10.5847/wjem.j.1920-8642.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Adequate airway management plays an important role in high-quality cardiopulmonary resuscitation (CPR). Airway management is usually performed using an endotracheal tube (ETT) during CPR. However, no study has assessed the effect of ETT size on the flow rate and airway pressure during CPR. METHODS We measured changes in peak inspiratory flow rate (PIFR), peak airway pressure (Ppeak), and mean airway pressure (Pmean) according to changes in ETT size (internal diameter 6.0, 7.0, and 8.0 mm) and with or without CPR. A tidal volume of 500 mL was supplied at a rate of 10 times per minute using a mechanical ventilator. Chest compressions were maintained at a constant compression depth and speed using a mechanical chest compression device (LUCAS2, mode: active continuous, chest compression rate: 102±2/minute, chest compression depth 2-2.5 inches). RESULTS The median of several respiratory physiological parameters during CPR was significantly different according to the diameter of each ETT (6.0 vs. 8.0 mm): PIFR (32.1 L/min [30.5-35.3] vs. 28.9 L/min [27.5-30.8], P<0.001), Ppeak (48.84 cmH2O [27.46-52.11] vs. 27.45 cmH2O [22.53-52.57], P<0.001), and Pmean (18.34 cmH2O [14.61-21.66] vs.13.66 cmH2O [8.41-19.24], P<0.001). CONCLUSION The changes in PIFR, Ppeak, and Pmean were related to the internal diameter of ETT, and these values tended to decrease with an increase in ETT size. Higher airway pressures were measured in the CPR group than in the no CPR group.
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Affiliation(s)
- Jung Wan Kim
- Department of Emergency Medicine, Chungnam National University Hospital, Jung-gu, Daejeon, Republic of Korea
| | - Jin Woong Lee
- Department of Emergency Medicine, Chungnam National University Hospital, Jung-gu, Daejeon, Republic of Korea
| | - Seung Ryu
- Department of Emergency Medicine, Chungnam National University Hospital, Jung-gu, Daejeon, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, Jung-gu, Daejeon, Republic of Korea.,Department of Emergency Medicine, College of Medicine, Chungnam National University, Jung-gu, Daejeon, Republic of Korea
| | - InSool Yoo
- Department of Emergency Medicine, Chungnam National University Hospital, Jung-gu, Daejeon, Republic of Korea.,Department of Emergency Medicine, College of Medicine, Chungnam National University, Jung-gu, Daejeon, Republic of Korea
| | - Yong Chul Cho
- Department of Emergency Medicine, Chungnam National University Hospital, Jung-gu, Daejeon, Republic of Korea
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, Jung-gu, Daejeon, Republic of Korea
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56
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Breeman W, Van Vledder MG, Verhofstad MHJ, Visser A, Van Lieshout EMM. First attempt success of video versus direct laryngoscopy for endotracheal intubation by ambulance nurses: a prospective observational study. Eur J Trauma Emerg Surg 2020; 46:1039-1045. [PMID: 32072225 PMCID: PMC7593279 DOI: 10.1007/s00068-020-01326-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 02/06/2020] [Indexed: 11/30/2022]
Abstract
Purpose The aim of this study was to compare the rate of first attempt success of endotracheal intubation performed by ambulance nurses in patients with a Glasgow Coma Scale (GCS) of 3 using video laryngoscopy versus direct laryngoscopy. Methods A prospective cohort study was conducted in a single, independent ambulance service. Twenty of a total of 65 nurse-staffed ambulances were equipped with a video laryngoscope; a classic direct laryngoscope (Macintosh) was available on all 65 ambulances. The primary outcome was first attempt success of the intubation. Secondary outcomes were overall success, time needed for intubation, adverse events, technical or environmental issues encountered, and return of spontaneous circulation (ROSC). Ambulance nurses were asked if the intubation device had affected the outcome of the intubation. Results The first attempt success rate in the video laryngoscopy group [53 of 93 attempts (57%)] did not differ from that in the direct laryngoscopy group [61 of 126 (48%); p = 0.221]. However, the second attempt success rate was higher in the video laryngoscopy group [77/93 (83%) versus 80/126 (63%), p = 0.002]. The median time needed for the intubation (53 versus 56 s) was similar in both groups. Ambulance nurses more often expected a positive effect when performing endotracheal intubation with a video laryngoscope (n = 72, 81%) compared with a direct laryngoscope (n = 49, 52%; p < 0.001). Conclusion Although no significant effect on the first attempt success was found, video laryngoscopy did increase the overall success rate. Ambulance nurses had a more positive valuation of the video laryngoscope with respect to success chances.
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Affiliation(s)
- Wim Breeman
- AmbulanceZorg Rotterdam-Rijnmond, P.O. Box 4, 2990 AA, Barendrecht, The Netherlands.,Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Mark G Van Vledder
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Albert Visser
- AmbulanceZorg Rotterdam-Rijnmond, P.O. Box 4, 2990 AA, Barendrecht, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Wang HE, Benger JR. Endotracheal intubation during out-of-hospital cardiac arrest: New insights from recent clinical trials. J Am Coll Emerg Physicians Open 2020; 1:24-29. [PMID: 33000010 PMCID: PMC7493580 DOI: 10.1002/emp2.12003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 10/22/2019] [Accepted: 10/24/2019] [Indexed: 11/10/2022] Open
Abstract
Airway management is an important intervention during resuscitation of out-of-hospital cardiac arrest (OHCA). Endotracheal intubation is commonly used by emergency medical services paramedics in the advanced airway management of OHCA, but numerous studies question its safety and effectiveness. Furthermore, there is now increasing use of supraglottic airway devices. In this review, we provide an overview of 3 recent randomized clinical trials of advanced airway management (Pragmatic Airway Resuscitation Trial [PART], AIRWAYS-2, and Cardiac Arrest Airway Management [CAAM]) and highlight new information that is available to guide OHCA airway management practices.
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Affiliation(s)
- Henry E. Wang
- Department of Emergency MedicineThe University of Texas Health Science Center at HoustonHoustonTexas
| | - Jonathan R. Benger
- Faculty of Health and Applied SciencesUniversity of the West of EnglandBristolUK
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Endotracheal Intubation Success Rate in an Urban, Supervised, Resident-Staffed Emergency Mobile System: An 11-Year Retrospective Cohort Study. J Clin Med 2020; 9:jcm9010238. [PMID: 31963162 PMCID: PMC7019886 DOI: 10.3390/jcm9010238] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/09/2020] [Accepted: 01/12/2020] [Indexed: 12/22/2022] Open
Abstract
Objectives: In the prehospital setting, endotracheal intubation (ETI) is sometimes required to secure a patient’s airways. Emergency ETI in the field can be particularly challenging, and success rates differ widely depending on the provider’s training, background, and experience. Our aim was to evaluate the ETI success rate in a resident-staffed and specialist-physician-supervised emergency prehospital system. Methods: This retrospective study was conducted on data extracted from the Geneva University Hospitals’ institutional database. In this city, the prehospital emergency response system has three levels of expertise: the first is an advanced life-support ambulance staffed by two paramedics, the second is a mobile unit staffed by an advanced paramedic and a resident physician, and the third is a senior emergency physician acting as a supervisor, who can be dispatched either as backup for the resident physician or when a regular Mobile Emergency and Resuscitation unit (Service Mobile d’Urgence et de Réanimation, SMUR) is not available. For this study, records of all adult patients taken care of by a second- and/or third-level prehospital medical team between 2008 and 2018 were screened for intubation attempts. The primary outcome was the success rate of the ETI attempts. The secondary outcomes were the number of ETI attempts, the rate of ETI success at the first attempt, and the rate of ETIs performed by a supervisor. Results: A total of 3275 patients were included in the study, 55.1% of whom were in cardiac arrest. The overall ETI success rate was 96.8%, with 74.4% success at the first attempt. Supervisors oversaw 1167 ETI procedures onsite (35.6%) and performed the ETI themselves in only 488 cases (14.9%). Conclusion: A resident-staffed and specialist-physician-supervised urban emergency prehospital system can reach ETI success rates similar to those reported for a specialist-staffed system.
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Girrbach F, Bercker S, Hinkelbein J. Alternative Hilfsmittel zum Atemwegsmanagement in der Notfallmedizin: Pro und Kontra. Notf Rett Med 2019. [DOI: 10.1007/s10049-019-00658-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kim JH, Ryoo HW, Kim JY, Ahn JY, Moon S, Lee DE, Mun YH. Application of a Dual-Dispatch System for Out-of-Hospital Cardiac Arrest Patients: Will More Hands Save More Lives? J Korean Med Sci 2019; 34:e141. [PMID: 31456379 PMCID: PMC6717243 DOI: 10.3346/jkms.2019.34.e141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/30/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Recovery after out-of-hospital cardiac arrest (OHCA) is difficult, and emergency medical services (EMS) systems apply various strategies to improve outcomes. Multi-dispatch is one means of providing high-quality cardiopulmonary resuscitation (CPR), but no definitive best-operation guidelines are available. We assessed the effects of a basic life support (BLS)-based dual-dispatch system for OHCA. METHODS This prospective observational study of 898 enrolled OHCA patients, conducted in Daegu, Korea from March 1, 2015 to June 30, 2016, involved patients > 18 years old with suspected cardiac etiology OHCA. In Daegu, EMS started a BLS-based dual-dispatch system in March 2015, for cases of cardiac arrest recognition by a dispatch center. We assessed the association between dual-dispatch and OHCA outcomes using multivariate logistic regressions. We also analyzed the effect of dual-dispatch according to the stratified on-scene time. RESULTS Of 898 OHCA patients (median, 69.0 years; 65.5% men), dual-dispatch was applied in 480 (53.5%) patients. There was no difference between the single-dispatch group (SDG) and the dual-dispatch group (DDG) in survival at discharge and neurological outcomes (survival discharge, P = 0.176; neurological outcomes, P = 0.345). In the case of less than 10 minutes of on-scene time, the adjusted odds ratio was 1.749 (95% confidence interval [CI], 0.490-6.246) for survival discharge and 6.058 (95% CI, 1.346-27.277) for favorable neurological outcomes in the DDG compared with the SDG. CONCLUSION Dual-dispatch was not associated with better OHCA outcomes for the entire study population, but showed favorable neurological outcomes when the on-scene time was less than 10 minutes.
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Affiliation(s)
- Jung Ho Kim
- Department of Emergency Medicine, Yeungnam University Hospital, Yeungnam University College of Medicine, Daegu, Korea
| | - Hyun Wook Ryoo
- Department of Emergency Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea.
| | - Jong Yeon Kim
- Department of Preventive Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Jae Yun Ahn
- Department of Emergency Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sungbae Moon
- Department of Emergency Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Dong Eun Lee
- Department of Emergency Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - You Ho Mun
- Department of Emergency Medicine, Yeungnam University Hospital, Yeungnam University College of Medicine, Daegu, Korea
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Kwanten LE, Madhivathanan P. Supraglottic airway devices: current and future uses. Br J Hosp Med (Lond) 2019; 79:31-35. [PMID: 29315046 DOI: 10.12968/hmed.2018.79.1.31] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Supraglottic airway devices have increasingly been used in anaesthesia since their invention in 1982. Now over half of general anaesthetic cases in the UK use them, and they have vital roles in difficult airway algorithms, pre-hospital use and emergency medicine. This article presents the current evidence regarding the complications of these devices, and compares these devices and endotracheal intubation. The technology of the newer generation devices has improved the safety profile, and they may be considered a better choice than endotracheal tubes in some cases. There may be a case for using these devices in a wider range of surgical and non-surgical cases.
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Affiliation(s)
- Lloyd E Kwanten
- Locum Consultant in Cardiothoracic Anaesthesia, Department of Perioperative Medicine, Barts Health NHS Trust, London EC1A 7BE
| | - Pradeep Madhivathanan
- Consultant in Cardiothoracic Anaesthesia and Critical Care Medicine, Department of Critical Care, Papworth Hospital NHS Foundation Trust, Cambridge
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Park JH, Song KJ, Shin SD, Ro YS, Hong KJ, Kong SY. Location of arrest and effect of prehospital advanced airway management after emergency medical service-witnessed out-of-hospital cardiac arrest: nationwide observational study. Emerg Med J 2019; 36:541-547. [PMID: 31326952 DOI: 10.1136/emermed-2018-207871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 06/12/2019] [Accepted: 07/02/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate the association of prehospital advanced airway management (AAM) on outcomes of emergency medical service (EMS)-witnessed out-of-hospital cardiac arrest (OHCA) according to the location of arrest. METHODS We evaluated a Korean national OHCA database from 2012 to 2016. Adults with EMS-witnessed, non-traumatic OHCA were included. Patients were categorised into four groups according to whether prehospital AAM was conducted (yes/no) and location of arrest ('at scene' or 'in the ambulance'). The primary outcome was discharge with good neurological recovery (cerebral performance category 1 or 2). Multivariable logistic regression analysis was conducted to evaluate the association between AAM and outcome according to the location of arrest. RESULTS Among 6620 cases, 1425 (21.5%) cases of arrest occurred 'at the scene', and 5195 (78.5%) cases of arrest occurred 'in an ambulance'. Prehospital AAM was performed in 272 (19.1%) OHCAs occurring 'at the scene' and 645 (12.4%) OHCAs occurring 'in an ambulance'. Patients with OHCA in the ambulance who had prehospital AAM showed the lowest good neurological recovery rate (6.0%) compared with OHCAs in the ambulance with no AAM (8.9%), OHCA at scene with AAM (10.7%) and OHCA at scene with no AAM (7.7%). For OHCAs occurring in the ambulance, the use of AAM had an adjusted OR of 0.67 (95% CI 0.45 to 0.98) for good neurological recovery. CONCLUSION Our data show no benefit of AAM in patients with EMS-witnessed OHCA. For patients with OHCA occurring in the ambulance, AAM was associated with worse clinical outcome.
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Affiliation(s)
- Jeong Ho Park
- Emergency Medicine, Seoul National University College of Medicine and Hospital, Seoul, The Republic of Korea
| | - Kyoung Jun Song
- Emergency Medicine, Seoul National University Boramae Medical Center, Seoul, The Republic of Korea
| | - Sang Do Shin
- Emergency Medicine, Seoul National University College of Medicine and Hospital, Seoul, The Republic of Korea
| | - Young Sun Ro
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, The Republic of Korea
| | - Ki Jeong Hong
- Emergency Medicine, Seoul National University College of Medicine and Hospital, Seoul, The Republic of Korea
| | - So Yeon Kong
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, The Republic of Korea
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Gamberini L, Baldazzi M, Coniglio C, Gordini G, Bardi T. Prehospital Airway Management in Severe Traumatic Brain Injury. Air Med J 2019; 38:366-373. [PMID: 31578976 DOI: 10.1016/j.amj.2019.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 05/12/2019] [Accepted: 06/13/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a leading cause of death and disability among trauma patients. The final outcome of TBI results from a complex interaction between primary and secondary mechanisms of injury that begin immediately after the traumatic event. The aim of this review was to evaluate the latest evidence regarding the impact of prehospital airway management and the outcome after traumatic brain injury. METHODS PubMed, Embase, and Cochrane searches were conducted using the MeSH database. Airway management, traumatic brain injury, pneumonia, and the subheadings of these Medical Subject Headings were combined. RESULTS The review is structured into 4 major topics: airway management devices, prehospital pharmacologic management, mortality and neurologic outcomes, and early respiratory infections. The available literature shows a shift toward a more comprehensive view of prehospital airway management, taking into account not only the location where airway management is attempted but also the drugs administered, the airway management devices used, and the skills of the main professional figures attending the scene. CONCLUSIONS Literature about this topic is still inconclusive; however, new evidence taking into consideration more complex aspects of airway management rather than orotracheal intubation per se shows improved outcomes with aggressive prehospital airway management.
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Affiliation(s)
- Lorenzo Gamberini
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy.
| | - Marzia Baldazzi
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Coniglio
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Giovanni Gordini
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Tommaso Bardi
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
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Bayesian Analysis of the Pragmatic Airway Resuscitation Trial. Ann Emerg Med 2019; 74:809-817. [PMID: 31272823 DOI: 10.1016/j.annemergmed.2019.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/29/2019] [Accepted: 05/02/2019] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE Intubation and laryngeal tube insertion are common airway management strategies in out-of-hospital cardiac arrest. Bayesian analysis offers an alternate statistical approach to assess the results of a trial. We use Bayesian analysis to compare the effectiveness of initial laryngeal tube versus initial intubation strategies on outcomes after out-of-hospital cardiac arrest in the Pragmatic Airway Resuscitation Trial. METHODS We performed a post hoc Bayesian analysis of the Pragmatic Airway Resuscitation Trial. We defined prior distributions representing neutral or skeptical estimates of laryngeal tube benefit. Using Bayesian log binomial models, we fit models for 72-hour survival, hospital survival, and hospital survival with favorable neurologic status. We estimated the posterior probability (the probability of observing an effect difference between treatment groups) of the benefit of laryngeal tube over intubation on out-of-hospital cardiac arrest outcomes. RESULTS The parent trial enrolled 3,004 patients (1,505 laryngeal tube, 1,499 intubation). Under a neutral prior distribution (relative risk 1.0), laryngeal tube was better than intubation (72-hour survival risk difference 1.8% [95% credible interval {CrI} -0.9% to 4.5%], posterior probability 91%; hospital survival 1.4% [95% CrI -0.4% to 3.4%], posterior probability 93%; and hospital survival with favorable neurologic status 0.7% [95% CrI -0.5% to 2.1%], posterior probability 86%). Under a skeptical prior distribution (relative risk 0.83 to 0.92), laryngeal tube was also better than intubation (72-hour survival risk difference 1.7% [95% CrI -0.9% to 4.3%], posterior probability 89%; hospital survival 1.3% [95% CrI -0.5% to 3.3%], posterior probability 91%; and hospital survival with favorable neurologic status 0.6% [95% CrI -0.5% to 2.0%], posterior probability 82%). CONCLUSION Under various prior assumptions, post hoc Bayesian analysis of the Pragmatic Airway Resuscitation Trial confirmed better out-of-hospital cardiac arrest outcomes with a strategy of initial laryngeal tube than initial intubation.
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Goto T, Goto Y, Hagiwara Y, Okamoto H, Watase H, Hasegawa K. Advancing emergency airway management practice and research. Acute Med Surg 2019; 6:336-351. [PMID: 31592072 PMCID: PMC6773646 DOI: 10.1002/ams2.428] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 04/11/2019] [Indexed: 12/11/2022] Open
Abstract
Emergency airway management is one of the vital resuscitative procedures undertaken in the emergency department (ED). Despite its clinical and research importance in the care of critically ill and injured patients, earlier studies have documented suboptimal intubation performance and high adverse event rates with a wide variation across the EDs. The optimal emergency airway management strategies remain to be established and their dissemination to the entire nation is a challenging task. This article reviews the current published works on emergency airway management with a focus on the use of airway management algorithms as well as the importance of first‐pass success and systematic use of rescue intubation strategies. Additionally, the review summarizes the current evidence for each of the important airway management processes, such as assessment of the difficult airway, preparation (e.g., positioning and oxygenation), intubation methods (e.g., rapid sequence intubation), medications (e.g., premedications, sedatives, and neuromuscular blockades), devices (e.g., direct and video laryngoscopy and supraglottic devises), and rescue intubation strategies (e.g., airway adjuncts and rescue intubators), as well as the airway management in distinct patient populations (i.e., trauma, cardiac arrest, and pediatric patients). Well‐designed, rigorously conducted, multicenter studies that prospectively and comprehensively characterize emergency airway management should provide clinicians with important opportunities for improving the quality and safety of airway management practice. Such data will not only advance research into the determination of optimal airway management strategies but also facilitate the development of clinical guidelines, which will, in turn, improve the outcomes of critically ill and injured patients in the ED.
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Affiliation(s)
- Tadahiro Goto
- Graduate School of Medical Sciences University of Fukui Fukui Japan
| | - Yukari Goto
- Department of Emergency and Critical Care Nagoya University Hospital Nagoya Aichi Japan
| | - Yusuke Hagiwara
- Department of Pediatric Emergency and Critical Care Medicine Tokyo Metropolitan Children's Medical Centre Fuchu Tokyo Japan
| | - Hiroshi Okamoto
- Department of Critical Care Medicine St. Luke's International Hospital Tokyo Japan
| | - Hiroko Watase
- Department of Surgery University of Washington Seattle Washington
| | - Kohei Hasegawa
- Department of Emergency Medicine Massachusetts General Hospital Harvard Medical School Boston Massachusetts
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Fouche PF, Stein C, Jennings PA, Boyle M, Bernard S, Smith K. Review article: Emergency endotracheal intubation in non-traumatic brain pathologies: A systematic review and meta-analysis. Emerg Med Australas 2019; 31:533-541. [PMID: 31041848 DOI: 10.1111/1742-6723.13304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 12/30/2022]
Abstract
Endotracheal intubation is an advanced airway procedure performed in the ED and the out-of-hospital setting for acquired brain injuries that include non-traumatic brain pathologies such as stroke, encephalopathies, seizures and toxidromes. Controlled trial evidence supports intubation in traumatic brain injuries, but it is not clear that this evidence can be applied to non-traumatic brain pathologies. We sought to analyse the impact of emergency intubation on survival in non-traumatic brain pathologies and also to quantify the prevalence of intubation in these pathologies. We conducted a systematic literature search of Medline, Embase and the Cochrane Library. Eligibility, data extraction and assessment of risk of bias were assessed independently by two reviewers. A bias-adjusted meta-analysis using a quality-effects model pooled prevalence of intubation in non-traumatic brain pathologies. Forty-six studies were included in this systematic review. No studies were suitable for meta-analysis the primary outcome of survival. Thirty-nine studies reported the prevalence of intubation in non-traumatic brain pathologies and a meta-analysis showed that emergency intubation was used in 12% (95% CI 0-33) of pathologies. Endotracheal intubation was used commonly in haemorrhagic stroke 79% (95% CI 47-100) and to a lesser extent for seizures 18% (95% CI 10-27) and toxidromes 25% (95% CI 6-48). This systematic review shows that there is no high-quality clinical evidence to support or refute emergency intubation in non-traumatic brain pathologies. Our analysis shows that intubation is commonly used in non-traumatic brain pathologies, and the need for rigorous evidence is apparent.
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Affiliation(s)
- Pieter F Fouche
- Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia
| | - Christopher Stein
- Department of Emergency Medical Care, University of Johannesburg, Johannesburg, South Africa
| | | | - Malcolm Boyle
- School of Medicine, Griffith University, Griffith, Queensland, Australia
| | - Stephen Bernard
- Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
| | - Karen Smith
- Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
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Benoit JL, McMullan JT, Wang HE, Xie C, Xu P, Hart KW, Stolz U, Lindsell CJ. Timing of Advanced Airway Placement after Witnessed Out-of-Hospital Cardiac Arrest. PREHOSP EMERG CARE 2019; 23:838-846. [DOI: 10.1080/10903127.2019.1595236] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Burjek NE, Burns KM, Jagannathan N. Aligning airway management strategy with resuscitation priorities for out-of-hospital cardiac arrest. J Thorac Dis 2019; 11:364-368. [PMID: 30962975 DOI: 10.21037/jtd.2018.12.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Nicholas E Burjek
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Katharine M Burns
- Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Narasimhan Jagannathan
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Ruetzler K, Leung S, Chmiela M, Rivas E, Szarpak L, Khanna S, Mao G, Drake RL, Sessler DI, Turan A. Regurgitation and pulmonary aspiration during cardio-pulmonary resuscitation (CPR) with a laryngeal tube: A pilot crossover human cadaver study. PLoS One 2019; 14:e0212704. [PMID: 30811470 PMCID: PMC6392290 DOI: 10.1371/journal.pone.0212704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/07/2019] [Indexed: 11/18/2022] Open
Abstract
Background High-quality chest compressions are imperative for Cardio-Pulmonary-Resuscitation (CPR). International CPR guidelines advocate, that chest compressions should not be interrupted for ventilation once a patient’s trachea is intubated or a supraglottic-airway-device positioned. Supraglottic-airway-devices offer limited protection against pulmonary aspiration. Simultaneous chest compressions and positive pressure ventilation both increase intrathoracic pressure and potentially enhances the risk of pulmonary aspiration. The hypothesis was, that regurgitation and pulmonary aspiration is more common during continuous versus interrupted chest compressions in human cadavers ventilated with a laryngeal tube airway. Methods Twenty suitable cadavers were included, and were positioned supine, the stomach was emptied, 500 ml of methylene-blue-solution instilled and laryngeal tube inserted. Cadavers were randomly assigned to: 1) continuous chest compressions; or, 2) interrupted chest compressions for ventilation breaths. After 14 minutes of the initial designated CPR strategy, pulmonary aspiration was assessed with a flexible bronchoscope. The methylene-blue-solution was replaced by 500 ml barium-sulfate radiopaque suspension. 14 minutes of CPR with the second designated ventilation strategy was performed. Pulmonary aspiration was then assessed with a conventional chest X-ray. Results Two cadavers were excluded for technical reasons, leaving 18 cadavers for statistical analysis. Pulmonary aspiration was observed in 9 (50%) cadavers with continuous chest compressions, and 7 (39%) with interrupted chest compressions (P = 0.75). Conclusion Our pilot study indicate, that incidence of pulmonary aspiration is generally high in patients undergoing CPR when a laryngeal tube is used for ventilation. Our study was not powered to identify potentially important differences in regurgitation or aspiration between ongoing vs. interrupted chest compression. Our results nonetheless suggest that interrupted chest compressions might better protect against pulmonary aspiration when a laryngeal tube is used for ventilation.
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Affiliation(s)
- Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
- * E-mail:
| | - Steve Leung
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Mark Chmiela
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Eva Rivas
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
- Department of Anesthesiology, Hospital Clinic, Barcelona, Spain
| | - Lukasz Szarpak
- Department of Emergency Medicine, University of Warszaw, Warszaw, Poland
| | - Sandeep Khanna
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Guangmei Mao
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
- Department of Quantitative Health Sciences, Cleveland Clinic, Ohio, United States of America
| | - Richard L. Drake
- Department of Anatomy, Lerner College of Medicine at Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Daniel I. Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
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Liu YC, Qi YM, Zhang H, Walline J, Zhu HD. A survey of ventilation strategies during cardiopulmonary resuscitation. World J Emerg Med 2019; 10:222-227. [PMID: 31534596 DOI: 10.5847/wjem.j.1920-8642.2019.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Many controversies still exist regarding ventilator parameters during cardiopulmonary resuscitation (CPR). This study aimed to investigate the CPR ventilation strategies currently being used among physicians in Chinese tertiary hospitals. METHODS A survey was conducted among the cardiac arrest team physicians of 500 tertiary hospitals in China in August, 2018. Surveyed data included physician and hospital information, and preferred ventilation strategy during CPR. RESULTS A total of 438 (88%) hospitals completed the survey, including hospitals from all 31 mainland Chinese provinces. About 41.1% of respondents chose delayed or no ventilation during CPR, with delayed ventilations all starting within 12 minutes. Of all the respondents who provided ventilation, 83.0% chose to strictly follow the 30:2 strategy, while 17.0% chose ventilations concurrently with uninterrupted compressions. Only 38.3% respondents chose to intubate after initiating CPR, while 61.7% chose to intubate immediately when resuscitation began. During bag-valve-mask ventilation, only 51.4% of respondents delivered a frequency of 10 breaths per minute. In terms of ventilator settings, the majority of respondents chose volume control (VC) mode (75.2%), tidal volume of 6-7 mL/kg (72.1%), PEEP of 0-5 cmH2O (69.9%), and an FiO2 of 100% (66.9%). However, 62.0% of respondents had mistriggers after setting the ventilator, and 51.8% had high pressure alarms. CONCLUSION There is a great amount of variability in CPR ventilation strategies among cardiac arrest team physicians in Chinese tertiary hospitals. Guidelines are needed with specific recommendations on ventilation during CPR.
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Affiliation(s)
- Ye-Cheng Liu
- Department of Emergency Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Yan-Meng Qi
- Department of Emergency Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Hui Zhang
- Department of Emergency Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Joseph Walline
- Accident and Emergency Medicine Academic Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Hua-Dong Zhu
- Department of Emergency Medicine, Peking Union Medical College Hospital, Beijing, China
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Lemaitre EL, Tritsch L, Noll E, Diemunsch P, Meyer N. Effectiveness of Intubating Laryngeal Mask Airway in managing out-of-hospital cardiac arrest by non-physicians. Resuscitation 2018; 136:61-69. [PMID: 30572066 DOI: 10.1016/j.resuscitation.2018.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/31/2018] [Accepted: 12/10/2018] [Indexed: 11/30/2022]
Abstract
AIM OF THE STUDY The role of supraglottic devices in airway management in out-of-hospital cardiac arrest (OHCA) remains controversial. The aim of this study was to evaluate the feasibility and effectiveness of intubation through the Intubating Laryngeal Mask Airway (ILMA) when used by prehospital emergency nurses in the setting of OHCA. METHODS We conducted a prospective, observational trial during 12 years by the Fire Department and prehospital emergency service of the health district of Strasbourg, France. The primary outcome was the success rate of ventilation after intubation through the ILMA, while the secondary outcomes were the success rate of ventilation after insertion of the ILMA and complications related to ILMA placement and intubation. Factors associated with successful intubation were also studied. RESULTS During the study period, 1464 ILMA placements were attempted by emergency nurses during OHCA. Ventilation was possible in 1250 patients (85.38%) after ILMA placement and in 1078 patients (73.63%) after intubation. Regurgitation of gastric contents occurred in 237 (16.18%) patients, mostly during basic life support. Two factors were predictive of a successful tracheal intubation: the performance of the Chandy maneuver OR = 2.91 (CI: 2.07-3.97) and the number of attempts at intubation OR = 1.95 (CI: 1.43-2.61). Conversely, the number of attempts at ILMA insertion was predictive of an intubation failure OR = 0.11 (CI: 0.07-0.17). CONCLUSION The success rate of intubation through the ILMA was high. After ILMA placement, ventilation was possible in 1250 patients (85.38%) and in 1078 patients (73.63%) after intubation.
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Affiliation(s)
- Elena-Laura Lemaitre
- Emergency Department, Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France; Department of Anaesthesiology, Critical Care and Prehospital Emergency Medicine, Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France.
| | | | - Eric Noll
- Department of Anaesthesiology, Critical Care and Prehospital Emergency Medicine, Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France
| | - Pierre Diemunsch
- Department of Anaesthesiology, Critical Care and Prehospital Emergency Medicine, Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France
| | - Nicolas Meyer
- Laboratory of Biostatistics, Faculty of Medicine, Strasbourg, France; ICUBE UMR 7357, University of Strasbourg, Strasbourg, France; Public Health Department, Département de Santé Publique, GMRC, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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Möglicher Einfluss von mechanischen Thoraxkompressionssystemen und supraglottischen Atemwegs
hilfen auf das Outcome nach einem Kreislaufstillstand. Notf Rett Med 2018. [DOI: 10.1007/s10049-018-0490-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Schauer SG, Naylor JF, Maddry JK, Beaumont DM, Cunningham CW, Blackburn MB, April MD. Prehospital Airway Management in Iraq and Afghanistan: A Descriptive Analysis. South Med J 2018; 111:707-713. [DOI: 10.14423/smj.0000000000000906] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Bielski A, Rivas E, Ruetzler K, Smereka J, Puslecki M, Dabrowski M, Ladny JR, Frass M, Robak O, Evrin T, Szarpak L. Comparison of blind intubation via supraglottic airway devices versus standard intubation during different airway emergency scenarios in inexperienced hand: Randomized, crossover manikin trial. Medicine (Baltimore) 2018; 97:e12593. [PMID: 30290627 PMCID: PMC6200544 DOI: 10.1097/md.0000000000012593] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Securing the airway and enabling adequate oxygenation and ventilation is essential during cardiopulmonary resuscitation (CPR). The aim of the study was to evaluate the success rate of blind intubation via the I-Gel and the Air-Q compared with direct laryngoscopy guided endotracheal intubation by inexperienced physician and to measure time to successful intubation. METHODS The study was designed as a randomized, cross-over simulation study. A total of 134 physicians, from specialties other than Anesthesia or Emergency Medicine, who considered themselves skilled in endotracheal intubation but who have never used any kind of supraglottic airway device performed blind intubation via the I-Gel and Air-Q and direct laryngoscopy guided endotracheal intubation in 3 randomized scenarios: normal airway without chest compression during intubation attempt; normal airway with continuous chest compression during intubation attempt; difficult airway with continuous chest compression. RESULTS Scenario A: Success rate with initial intubation attempt was 72% for endotracheal intubation, 75% in Air-Q, and 81% in I-Gel. Time to endotracheal intubation and ease of intubation was comparable with all 3 airway devices used. Scenario B: Success rate with the initial intubation attempt was 42% for endotracheal intubation, compared with 75% in Air-Q and 80% in I-Gel. Time for endotracheal intubation was significantly prolonged in endotracheal intubation (42 seconds, 35-49), compared with Air-Q (21 seconds, 18-32) and I-Gel (19 seconds, 17-27). Scenario C: The success rate with the initial intubation attempt was 23% in endotracheal intubation, compared with 65% in Air-Q and 74% in I-Gel. Time to intubation was comparable with both supraglottic airway devices (20 vs 22 seconds) but was significantly shorter compared with endotracheal intubation (50 seconds, P < .001). CONCLUSIONS Less to moderately experienced providers are able to perform endotracheal intubation in easy airways but fail during ongoing chest compressions and simulated difficult airway. Consequently, less to moderately experienced providers should refrain from endotracheal intubation during ongoing chest compressions during CPR and in expected difficult airways. Supraglottic airway devices are reliable alternatives and blind intubation through these devices is a valuable airway management strategy.
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Affiliation(s)
| | - Eva Rivas
- Department of Anesthesiology, Hospital Clinic, IDIBAPS (Institut d’Investigacions Biomèdiques August Pi i Sunyer), University of Barcelona, Barcelona, Spain
- Department of OUTCOMES RESEARCH, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kurt Ruetzler
- Department of OUTCOMES RESEARCH, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jacek Smereka
- Department of Emergency Medical Service, Wroclaw Medical University, Wroclaw
| | - Mateusz Puslecki
- Department of Rescue Medical Service, Poznan University of Medical Sciences, Poznan
| | - Marek Dabrowski
- Department of Rescue Medical Service, Poznan University of Medical Sciences, Poznan
| | - Jerzy R. Ladny
- Department of Emergency Medicine and Disaster, Medical University Bialystok, Bialystok
| | - Michael Frass
- Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Oliver Robak
- Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Togay Evrin
- Department of Emergency Medicine, UFuK University Medical Faculty, Dr Ridvan Ege Education and Research Hospital, Ankara, Turkey
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White L, Melhuish T, Holyoak R, Ryan T, Kempton H, Vlok R. Advanced airway management in out of hospital cardiac arrest: A systematic review and meta-analysis. Am J Emerg Med 2018; 36:2298-2306. [PMID: 30293843 DOI: 10.1016/j.ajem.2018.09.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 09/16/2018] [Accepted: 09/25/2018] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES To assess the difference in survival and neurological outcomes between endotracheal tube (ETT) intubation and supraglottic airway (SGA) devices used during out-of-hospital cardiac arrest (OHCA). METHODS A systematic search of five databases was performed by two independent reviewers until September 2018. Included studies reported on (1) OHCA or cardiopulmonary resuscitation, and (2) endotracheal intubation versus supraglottic airway device intubation. Exclusion criteria (1) stimulation studies, (2) selectively included/excluded patients, (3) in-hospital cardiac arrest. Odds Ratios (OR) with random effect modelling was used. Primary outcomes: (1) return of spontaneous circulation (ROSC), (2) survival to hospital admission, (3) survival to hospital discharge, (4) discharge with a neurologically intact state. RESULTS Twenty-nine studies (n = 539,146) showed that overall, ETT use resulted in a heterogeneous, but significant increase in ROSC (OR = 1.44; 95%CI = 1.27 to 1.63; I2 = 91%; p < 0.00001) and survival to admission (OR = 1.36; 95%CI = 1.12 to 1.66; I2 = 91%; p = 0.002). There was no significant difference in survival to discharge or neurological outcome (p > 0.0125). On sensitivity analysis of RCTs, there was no significant difference in ROSC, survival to admission, survival to discharge or neurological outcome (p > 0.0125). On analysis of automated chest compression, without heterogeneity, ETT provided a significant increase in ROSC (OR = 1.55; 95%CI = 1.20 to 2.00; I2 = 0%; p = 0.0009) and survival to admission (OR = 2.16; 95%CI = 1.54 to 3.02; I2 = 0%; p < 0.00001). CONCLUSIONS The overall heterogeneous benefit in survival with ETT was not replicated in the low risk RCTs, with no significant difference in survival or neurological outcome. In the presence of automated chest compressions, ETT intubation may result in survival benefits.
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Affiliation(s)
- Leigh White
- School of Medicine, University of Queensland, Brisbane, QLD, Australia; Department of Anaesthesia and Perioperative Medicine, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia.
| | - Thomas Melhuish
- Intensive Care Service, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Rhys Holyoak
- Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia
| | - Thomas Ryan
- Department of Orthopaedics, John Hunter Hospital, Newcastle, NSW, Australia; Sydney Clinical School, University of Notre Dame, Sydney, NSW, Australia
| | - Hannah Kempton
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Department of Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| | - Ruan Vlok
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Sydney Clinical School, University of Notre Dame, Sydney, NSW, Australia; Wagga Wagga Rural Referral Hospital, Wagga Wagga, NSW, Australia
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Abstract
PURPOSE OF REVIEW Historically, most evidence supporting emergency airway management strategies have been limited to small series, retrospective analyses and extrapolation from other settings (i.e. the operating room). Over the past year, several large, randomized clinical trials have offered new findings to inform emergency airway management techniques. RECENT FINDINGS One large, randomized clinical trial, found improved first attempt success rates with bougie facilitated intubation compared with traditional intubation. Two randomized clinical trials suggested better outcomes in adult out-of-hospital cardiac arrest (OHCA) with supraglottic airways (SGA) than intubation. A randomized clinical trial in OHCA patients could not identify outcome differences between endotracheal intubation (ETI) and bag-valve mask (BVM) ventilation but suggested higher rates of aspiration with BVM. SUMMARY These studies offer new findings to inform the practice of emergency airway management. Bougie use should be considered as a first-line approach in emergency intubation. SGA-based strategies should be considered as a first-line approach in the management of OHCA.
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Kim SY, Park SO, Kim JW, Sung J, Lee KR, Lee YH, Hong DY, Baek KJ. How much experience do rescuers require to achieve successful tracheal intubation during cardiopulmonary resuscitation? Resuscitation 2018; 133:187-192. [PMID: 30172693 DOI: 10.1016/j.resuscitation.2018.08.032] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/08/2018] [Accepted: 08/28/2018] [Indexed: 01/07/2023]
Abstract
AIM The cardiopulmonary resuscitation (CPR) guidelines recommend that endotracheal intubation (ETI) should be performed only by highly skilled rescuers. However, the definition of 'highly skilled' is unclear. This study evaluated how much experience with ETI is required for rescuers to perform successful ETI quickly without complications including serious chest compression interruption (interruption time <10 s) or oesophageal intubation during CPR. METHODS This was a clinical observation study using review of CPR video clips in an urban emergency department (ED) over 2 years. Accumulated ETI experience and performance of ETI were analysed. Main outcomes were 1) 'qualified ETI': successful ETI within 60 s without complications and 2) 'highly qualified ETI': successful ETI within 30 s without complications. RESULTS We analysed 110 ETIs using direct laryngoscopy during CPR. The success rate improved and the time to successful ETI decreased with increasing experience; however, the total interruption time of chest compression did not decrease. A 90% success rate for qualified ETI required 137 experiences of ETIs (1218 days of training). A 90% success rate for highly qualified ETI required at least 243 experiences of ETIs (1973 days of training). CONCLUSIONS Accumulated experience can improve the ETI success rate and time to successful ETI during CPR. Because ETI must be performed quickly without serious interruption of chest compression during CPR, becoming proficient at ETI requires more experience than that required for non-arrest patients. In our analysis, more than 240 experiences were required to achieve a 90% success rate of highly qualified ETI.
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Affiliation(s)
- Sin Young Kim
- Department of Emergency Medicine, School of Medicine, Konkuk University, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Sang O Park
- Department of Emergency Medicine, School of Medicine, Konkuk University, Konkuk University Medical Center, Seoul, Republic of Korea.
| | - Jong Won Kim
- Department of Emergency Medicine, School of Medicine, Konkuk University, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Juno Sung
- Department of Biology, University of Iowa, Iowa City, IA, USA
| | - Kyeong Ryong Lee
- Department of Emergency Medicine, School of Medicine, Konkuk University, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Young Hwan Lee
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Dae Young Hong
- Department of Emergency Medicine, School of Medicine, Konkuk University, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Kwang Je Baek
- Department of Emergency Medicine, School of Medicine, Konkuk University, Konkuk University Medical Center, Seoul, Republic of Korea
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Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JCJ, Aufderheide TP, Gray RE, Gray PC, Verkest M, Owens PC, Brienza AM, Sternig KJ, May SJ, Sopko GR, Weisfeldt ML, Nichol G. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA 2018; 320:769-778. [PMID: 30167699 PMCID: PMC6583103 DOI: 10.1001/jama.2018.7044] [Citation(s) in RCA: 239] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
IMPORTANCE Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital cardiac arrest (OHCA). The optimal method for OHCA advanced airway management is unknown. OBJECTIVE To compare the effectiveness of a strategy of initial LT insertion vs initial ETI in adults with OHCA. DESIGN, SETTING, AND PARTICIPANTS Multicenter pragmatic cluster-crossover clinical trial involving EMS agencies from the Resuscitation Outcomes Consortium. The trial included 3004 adults with OHCA and anticipated need for advanced airway management who were enrolled from December 1, 2015, to November 4, 2017. The final date of follow-up was November 10, 2017. INTERVENTIONS Twenty-seven EMS agencies were randomized in 13 clusters to initial airway management strategy with LT (n = 1505 patients) or ETI (n = 1499 patients), with crossover to the alternate strategy at 3- to 5-month intervals. MAIN OUTCOMES AND MEASURES The primary outcome was 72-hour survival. Secondary outcomes included return of spontaneous circulation, survival to hospital discharge, favorable neurological status at hospital discharge (Modified Rankin Scale score ≤3), and key adverse events. RESULTS Among 3004 enrolled patients (median [interquartile range] age, 64 [53-76] years, 1829 [60.9%] men), 3000 were included in the primary analysis. Rates of initial airway success were 90.3% with LT and 51.6% with ETI. Seventy-two hour survival was 18.3% in the LT group vs 15.4% in the ETI group (adjusted difference, 2.9% [95% CI, 0.2%-5.6%]; P = .04). Secondary outcomes in the LT group vs ETI group were return of spontaneous circulation (27.9% vs 24.3%; adjusted difference, 3.6% [95% CI, 0.3%-6.8%]; P = .03); hospital survival (10.8% vs 8.1%; adjusted difference, 2.7% [95% CI, 0.6%-4.8%]; P = .01); and favorable neurological status at discharge (7.1% vs 5.0%; adjusted difference, 2.1% [95% CI, 0.3%-3.8%]; P = .02). There were no significant differences in oropharyngeal or hypopharyngeal injury (0.2% vs 0.3%), airway swelling (1.1% vs 1.0%), or pneumonia or pneumonitis (26.1% vs 22.3%). CONCLUSIONS AND RELEVANCE Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with a strategy of initial ETI. These findings suggest that LT insertion may be considered as an initial airway management strategy in patients with OHCA, but limitations of the pragmatic design, practice setting, and ETI performance characteristics suggest that further research is warranted. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02419573.
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Affiliation(s)
- Henry E. Wang
- Department of Emergency Medicine, University of Texas Health Science Center at Houston
- Department of Emergency Medicine, University of Alabama at Birmingham
| | - Robert H. Schmicker
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle
| | - Mohamud R. Daya
- Department of Emergency Medicine, Oregon Health and Science University, Portland
| | | | - Ahamed H. Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Jestin N. Carlson
- Department of Emergency Medicine, Saint Vincent Hospital, Allegheny Health Network, Erie, Pennsylvania
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Heather Herren
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle
| | - Matthew Hansen
- Department of Emergency Medicine, Oregon Health and Science University, Portland
| | - Neal J. Richmond
- MedStar Mobile Healthcare, Fort Worth, Texas
- currently with Department of Emergency Medicine, John Peter Smith Health Network, Fort Worth, Texas
| | | | - Tom P. Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee
| | - Randal E. Gray
- Department of Emergency Medicine, University of Alabama at Birmingham
| | - Pamela C. Gray
- Department of Emergency Medicine, University of Alabama at Birmingham
| | | | - Pamela C. Owens
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | | | | | - Susanne J. May
- Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle
| | - George R. Sopko
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Myron L. Weisfeldt
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Graham Nichol
- Departments of Emergency Medicine and Medicine, Harborview Center for Prehospital Emergency Care, University of Washington, Seattle
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Newell C, Grier S, Soar J. Airway and ventilation management during cardiopulmonary resuscitation and after successful resuscitation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:190. [PMID: 30111343 PMCID: PMC6092791 DOI: 10.1186/s13054-018-2121-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 07/04/2018] [Indexed: 12/28/2022]
Abstract
After cardiac arrest a combination of basic and advanced airway and ventilation techniques are used during cardiopulmonary resuscitation (CPR) and after a return of spontaneous circulation (ROSC). The optimal combination of airway techniques, oxygenation and ventilation is uncertain. Current guidelines are based predominantly on evidence from observational studies and expert consensus; recent and ongoing randomised controlled trials should provide further information. This narrative review describes the current evidence, including the relative roles of basic and advanced (supraglottic airways and tracheal intubation) airways, oxygenation and ventilation targets during CPR and after ROSC in adults. Current evidence supports a stepwise approach to airway management based on patient factors, rescuer skills and the stage of resuscitation. During CPR, rescuers should provide the maximum feasible inspired oxygen and use waveform capnography once an advanced airway is in place. After ROSC, rescuers should titrate inspired oxygen and ventilation to achieve normal oxygen and carbon dioxide targets.
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Affiliation(s)
- Christopher Newell
- Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - Scott Grier
- Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - Jasmeet Soar
- Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK.
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80
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Aleksandrowicz D, Gaszyński T. Tracheal intubation in a simulated cervical spine immobilisation: The Macintosh laryngoscope versus supraglottic airway devices - A manikin study. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2018. [DOI: 10.1016/j.tacc.2018.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Abstract
Cardiac arrest is a leading cause of death in the United States, with a hospital discharge rate of approximately 10%. International resuscitation guidelines offer standardized cardiac arrest management approaches, but beyond the guidelines, are promising innovations to improve resuscitative care. Although clinical data do not yet support the routine use of mechanical chest compressions, corticosteroids, thrombolytics, and adjunctive ventilation devices during arrest, these therapies may have an important role in select patients. Extracorporeal membrane oxygenation during cardiopulmonary resuscitation is a promising advancement and may have survival benefit in select patients. The evidence for standard therapies and these innovations is discussed.
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Affiliation(s)
- Bram J Geller
- Department of Cardiovascular Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, South Pavilion 11th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Benjamin S Abella
- Department of Emergency Medicine, University of Pennsylvania, 3400 Spruce Street Ground Ravdin, Philadelphia, PA 19104, USA
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82
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Nadolny K, Szarpak L, Gotlib J, Panczyk M, Sterlinski M, Ladny JR, Smereka J, Galazkowski R. An analysis of the relationship between the applied medical rescue actions and the return of spontaneous circulation in adults with out-of-hospital sudden cardiac arrest. Medicine (Baltimore) 2018; 97:e11607. [PMID: 30045296 PMCID: PMC6078650 DOI: 10.1097/md.0000000000011607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 06/28/2018] [Indexed: 12/11/2022] Open
Abstract
Sudden cardiac arrest (SCA) is a significant medical and social issue, the main cause of death in Europe and the United States.The aim of the research was to evaluate the effectiveness of emergency medical procedures applied by emergency medical teams in prehospital care in the context of return of spontaneous circulation (ROSC).The case-control study was based on the medical documentation of the Rescue Service in Katowice (responsible for monitoring 2.7 million inhabitants of the region) referring to 2016. The research involved exclusively adults (ie, individuals older than 18 years) with out-of-hospital cardiac arrest (OHCA). After considering the above inclusion criteria, there were 1603 dispatch order forms (0.64% of all dispatch orders) involved in further research.On the basis of the emergency medical procedure forms, the actions of emergency medical teams were verified as medical procedures (endotracheal intubation, the use of suction pumps, defibrillation, the use of alternatives providing airway patency and ROSC was determined.The analysis covered 1603 cases of OHCA. SCA turned out more frequent in men than in women (P = .000). Most often, SCA occurred in domestic conditions during the day and was witnessed by a third person. In 59.9% of the cases, actions were taken by witnesses, which increased the probability of ROSC. Patients were usually intubated (51.4%). Respirators were used less frequently (20.2%). Ventricular fibrillation (VF) was reported only in 22.0% of the cases. The ROSC rate was higher in the group of patients with diagnosed VF than in those with nonshockable rhythms (VF, 55.43% vs asystole, 24.05%; P = .000).Successful resuscitation depends on the quality of emergency medical procedures performed at the place of incident. The highest probability of ROSC is related with defibrillation (in the cases of VF or ventricular tachycardia with no pulse), intubation, the application of a respirator, and performing mechanical ventilation, as well as with a shorter time from dispatch to arrival.
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Affiliation(s)
- Klaudiusz Nadolny
- Department of Emergency Medicine and Disasters, Medical University of Bialystok, Bialystok
| | - Lukasz Szarpak
- Department of Emergency Medicine, Lazarski University, Warsaw
| | - Joanna Gotlib
- Division of Teaching and Outcomes of Education, Faculty of Health Sciences, Medical University of Warsaw
| | - Mariusz Panczyk
- Division of Teaching and Outcomes of Education, Faculty of Health Sciences, Medical University of Warsaw
| | - Maciej Sterlinski
- Department of Arrhythmia, The Cardinal Stefan Wyszynski Institute of Cardiology
| | - Jerzy Robert Ladny
- Department of Emergency Medicine and Disasters, Medical University of Bialystok, Bialystok
| | - Jacek Smereka
- Department of Emergency Medical Service, Wroclaw Medical University
| | - Robert Galazkowski
- Department of Emergency Medical Service, Medical University of Warsaw, Warsaw, Poland
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Abstract
PURPOSE OF REVIEW To evaluate the past and present literature on ventilation during out of hospital cardiac arrest, highlighting research that has informed current guidelines. RECENT FINDINGS Previous studies have studied what are optimal compression-to-ventilation ratios, ventilation rates, and methods of ventilation. Continuous chest compression cardiopulmonary resuscitation (CPR) has not shown to provide a significant survival benefit over the traditional 30 : 2 CPR. The optimal ventilation rate is recommended at 8 to 10 breaths per minute. Methods such as capnography and thoracic impedance are being used to evaluate ventilation in research studies. SUMMARY Future out of hospital cardiac arrest studies are still exploring how to optimize the delivery of ventilation during the initial stages of resuscitation. More prospective studies focusing on ventilation are needed to inform guidelines.
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Wang HE, Donnelly JP, Barton D, Jarvis JL. Assessing Advanced Airway Management Performance in a National Cohort of Emergency Medical Services Agencies. Ann Emerg Med 2018; 71:597-607.e3. [DOI: 10.1016/j.annemergmed.2017.12.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/22/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
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Bernhard M, Behrens NH, Wnent J, Seewald S, Brenner S, Jantzen T, Bohn A, Gräsner JT, Fischer M. Out-of-hospital airway management during manual compression or automated chest compression devices. Anaesthesist 2018; 67:109-117. [DOI: 10.1007/s00101-017-0401-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 11/25/2017] [Accepted: 11/30/2017] [Indexed: 11/28/2022]
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86
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An assessment of ventilation and perfusion markers in out-of-hospital cardiac arrest patients receiving mechanical CPR with endotracheal or supraglottic airways. Resuscitation 2018; 122:61-64. [DOI: 10.1016/j.resuscitation.2017.11.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 11/08/2017] [Accepted: 11/22/2017] [Indexed: 10/18/2022]
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87
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Team-focused Cardiopulmonary Resuscitation: Prehospital Principles Adapted for Emergency Department Cardiac Arrest Resuscitation. J Emerg Med 2018; 54:54-63. [DOI: 10.1016/j.jemermed.2017.08.065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 07/31/2017] [Accepted: 08/11/2017] [Indexed: 11/22/2022]
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Garg R, Ahmed SM, Kapoor MC, Rao SSCC, Mishra BB, Kalandoor MV, Singh B, Divatia JV. Comprehensive cardiopulmonary life support (CCLS) for cardiopulmonary resuscitation by trained paramedics and medics inside the hospital. Indian J Anaesth 2017; 61:883-894. [PMID: 29217853 PMCID: PMC5703001 DOI: 10.4103/ija.ija_664_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The cardiopulmonary resuscitation (CPR) guideline of comprehensive cardiopulmonary life support (CCLS) for management of the patient with cardiopulmonary arrest in adults provides an algorithmic step-wise approach for optimal outcome of the patient inside the hospital by trained medics and paramedics. This guideline has been developed considering the infrastructure of healthcare delivery system in India. This is based on evidence in the international and national literature. In the absence of data from the Indian population, the extrapolation has been made from international data, discussed with Indian experts and modified accordingly to ensure their applicability in India. The CCLS guideline emphasise the need to recognise patients at risk for cardiac arrest and their timely management before a cardiac arrest occurs. The basic components of CPR include chest compressions for blood circulation; airway maintenance to ensure airway patency; lung ventilation to enable oxygenation and defibrillation to convert a pathologic 'shockable' cardiac rhythm to one capable to maintaining effective blood circulation. CCLS emphasises incorporation of airway management, drugs, and identification of the cause of arrest and its correction, while chest compression and ventilation are ongoing. It also emphasises the value of organised team approach and optimal post-resuscitation care.
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Affiliation(s)
- Rakesh Garg
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Syed Moied Ahmed
- Department of Anaesthesiology and Critical Care, J N Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
- Address for correspondence: Dr. Syed Moied Ahmed, Department of Anaesthesiology and Critical Care, J N Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India. E-mail:
| | | | - SSC Chakra Rao
- Department of Anaesthesiology, Care Emergency Hospital, Kakinada, Andhra Pradesh, India
| | - Bibhuti Bhusan Mishra
- Department of Anaesthesiology, Indian College of Anaesthesiologists, Bhubaneswar, Odisha, India
| | | | - Baljit Singh
- Department of Anaesthesiology and Intensive Care, GB Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Jigeeshu Vasishtha Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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89
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Fouche PF, Stein C, Simpson P, Carlson JN, Doi SA. Nonphysician Out-of-Hospital Rapid Sequence Intubation Success and Adverse Events: A Systematic Review and Meta-Analysis. Ann Emerg Med 2017; 70:449-459.e20. [DOI: 10.1016/j.annemergmed.2017.03.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 03/12/2017] [Accepted: 03/16/2017] [Indexed: 12/20/2022]
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90
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Chiang WC, Hsieh MJ, Chu HL, Chen AY, Wen SY, Yang WS, Chien YC, Wang YC, Lee BC, Wang HC, Huang EPC, Yang CW, Sun JT, Chong KM, Lin HY, Hsu SH, Chen SY, Ma MHM. The Effect of Successful Intubation on Patient Outcomes After Out-of-Hospital Cardiac Arrest in Taipei. Ann Emerg Med 2017; 71:387-396.e2. [PMID: 28967516 DOI: 10.1016/j.annemergmed.2017.08.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 07/24/2017] [Accepted: 08/01/2017] [Indexed: 12/15/2022]
Abstract
STUDY OBJECTIVE The effect of out-of-hospital intubation in patients with out-of-hospital cardiac arrest remains controversial. The Taipei City paramedics are the earliest authorized to perform out-of-hospital intubation among Asian areas. This study evaluates the association between successful intubation and out-of-hospital cardiac arrest survival in Taipei. METHODS We analyzed 6 years of Utstein-based registry data from nontrauma adult patients with out-of-hospital cardiac arrest who underwent out-of-hospital airway management including intubation, laryngeal mask airway, or bag-valve-mask ventilation. The primary analysis was intubation success on patient outcomes. The primary outcome was survival to discharge and the secondary outcomes included sustained return of spontaneous circulation and favorable neurologic survival. Sensitivity analysis was performed with intubation attempts rather than intubation success. Subgroup analysis of advanced life support-serviced districts was also performed. RESULTS A total of 10,853 cases from 2008 to 2013 were analyzed. Among out-of-hospital cardiac arrest patients receiving airway management, successful intubation, laryngeal mask airway, and bag-valve-mask ventilation was reported in 1,541, 3,099, and 6,213 cases, respectively. Compared with bag-valve-mask device use, successful out-of-hospital intubation was associated with improved chances of sustained return of spontaneous circulation (adjusted odds ratio [aOR] 1.91; 95% confidence interval [CI] 1.66 to 2.19), survival to discharge (aOR 1.98; 95% CI 1.57 to 2.49), and favorable neurologic outcome (aOR 1.44; 95% CI 1.03 to 2.03). The results were comparable in sensitivity and subgroup analyses. CONCLUSION In nontrauma adult out-of-hospital cardiac arrest in Taipei, successful out-of-hospital intubation was associated with improved odds of sustained return of spontaneous circulation, survival to discharge, and favorable neurologic outcome.
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Affiliation(s)
- Wen-Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin County, Taiwan.
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsin-Lan Chu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Albert Y Chen
- Civil Engineering, National Taiwan University, Taipei, Taiwan
| | - Shin-Yi Wen
- Civil Engineering, National Taiwan University, Taipei, Taiwan
| | - Wen-Shuo Yang
- Emergency Medical Services (Ambulance) Division, Taipei City Fire Department, Taipei, Taiwan
| | - Yu-Chun Chien
- Emergency Medical Services (Ambulance) Division, Taipei City Fire Department, Taipei, Taiwan; School of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Yao-Cheng Wang
- Emergency Medical Services (Ambulance) Division, Taipei City Fire Department, Taipei, Taiwan
| | - Bin-Chou Lee
- Taipei City Hospital, Chung-Shaw Branch, Taipei, Taiwan
| | - Huei-Chih Wang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Chih-Wei Yang
- Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan
| | - Jen-Tang Sun
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Kah-Meng Chong
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hao-Yang Lin
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Hsien Hsu
- Department of Emergency Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu City, Taiwan
| | - Shey-Ying Chen
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin County, Taiwan.
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91
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Ohashi-Fukuda N, Fukuda T, Yahagi N. Effect of pre-hospital advanced airway management for out-of-hospital cardiac arrest caused by respiratory disease: a propensity score-matched study. Anaesth Intensive Care 2017; 45:375-383. [PMID: 28486897 DOI: 10.1177/0310057x1704500314] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Optimal pre-hospital care for out-of-hospital cardiac arrest (OHCA) caused by respiratory disease may differ from that for OHCA associated with other aetiologies, especially with respect to respiratory management. We aimed to investigate whether pre-hospital advanced airway management (AAM) was associated with favourable outcomes after OHCA caused by intrinsic respiratory disease. This nationwide, population-based, propensity score-matched study of adult patients in Japan with OHCA due to respiratory disease from 1 January 2005 to 31 December 2012 compared patients with and without pre-hospital AAM. The primary outcome was neurologically favourable survival at one month after the OHCA. Of 49,534 eligible patients, 20,458 received pre-hospital AAM and 29,076 did not. In a propensity score-matched cohort (18,483 versus 18,483 patients), the odds of neurologically favourable survival were significantly lower for patients receiving pre-hospital AAM (0.6% versus 1.5%; odds ratio [OR] 0.42 [95% confidence interval {CI} 0.34 to 0.52]). The results from multivariable logistic regression analysis also showed that pre-hospital AAM was significantly associated with a decreased chance of neurologically favourable survival (adjusted OR 0.43 [95% CI 0.35 to 0.52]). Similar findings were observed for one-month survival and pre-hospital return of spontaneous circulation. In subgroup analyses, pre-hospital AAM was associated with poor neurological outcomes, regardless of the type of airway device used (laryngeal mask airway, adjusted OR 0.35 [95% CI 0.19 to 0.57]; oesophageal obturator airway, adjusted OR 0.44 [95% CI 0.35 to 0.55]; and endotracheal tube, adjusted OR 0.47 [95% CI 0.30 to 0.69]). In conclusion, pre-hospital AAM was associated with poor neurological outcome among patients with OHCA caused by intrinsic respiratory disease.
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Affiliation(s)
- N Ohashi-Fukuda
- PhD Student, Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - T Fukuda
- Specialist Emergency Physician and Critical Care Specialist, Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan, Research Fellow, Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - N Yahagi
- Emeritus Professor, Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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92
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Carlson JN, Wang HE. Paramedic Intubation: Does Practice Make Perfect? Ann Emerg Med 2017; 70:391-393. [DOI: 10.1016/j.annemergmed.2017.03.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 03/13/2017] [Indexed: 10/19/2022]
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93
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Soar J, Nolan J, Böttiger B, Perkins G, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars M, Smith G, Sunde K, Deakin C. Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“). Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0330-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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94
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A pilot, prospective, randomized trial of video versus direct laryngoscopy for paramedic endotracheal intubation. Resuscitation 2017; 114:121-126. [DOI: 10.1016/j.resuscitation.2017.03.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 03/14/2017] [Accepted: 03/15/2017] [Indexed: 12/13/2022]
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95
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Dyson K, Bray JE, Smith K, Bernard S, Straney L, Nair R, Finn J. Paramedic Intubation Experience Is Associated With Successful Tube Placement but Not Cardiac Arrest Survival. Ann Emerg Med 2017; 70:382-390.e1. [PMID: 28347556 DOI: 10.1016/j.annemergmed.2017.02.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/02/2017] [Accepted: 01/31/2017] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE Paramedic experience with intubation may be an important factor in skill performance and patient outcomes. Our objective is to examine the association between previous intubation experience and successful intubation. In a subcohort of out-of-hospital cardiac arrest cases, we also measure the association between patient survival and previous paramedic intubation experience. METHODS We analyzed data from Ambulance Victoria electronic patient care records and the Victorian Ambulance Cardiac Arrest Registry for January 1, 2008, to September 26, 2014. For each patient case, we defined intubation experience as the number of intubations attempted by each paramedic in the previous 3 years. Using logistic regression, we estimated the association between intubation experience and (1) successful intubation and (2) first-pass success. In the out-of-hospital cardiac arrest cohort, we determined the association between previous intubation experience and patient survival. RESULTS During the 6.7-year study period, 769 paramedics attempted intubation in 14,857 patients. Paramedics typically performed 3 intubations per year (interquartile range 1 to 6). Most intubations were successful (95%), including 80% on the first attempt. Previous intubation experience was associated with intubation success (odds ratio 1.04; 95% confidence interval 1.03 to 1.05) and intubation first-pass success (odds ratio 1.02; 95% confidence interval 1.01 to 1.03). In the out-of-hospital cardiac arrest subcohort (n=9,751), paramedic intubation experience was not associated with patient survival. CONCLUSION Paramedics in this Australian cohort performed few intubations. Previous experience was associated with successful intubation. Among out-of-hospital cardiac arrest patients for whom intubation was attempted, previous paramedic intubation experience was not associated with patient survival.
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Affiliation(s)
- Kylie Dyson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Ambulance Victoria, Victoria, Australia.
| | - Janet E Bray
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Alfred Hospital, Melbourne, Victoria, Australia; School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Ambulance Victoria, Victoria, Australia; Discipline of Emergency Medicine, University of Western Australia, Perth, Australia
| | - Stephen Bernard
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Ambulance Victoria, Victoria, Australia; Alfred Hospital, Melbourne, Victoria, Australia
| | - Lahn Straney
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Judith Finn
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Discipline of Emergency Medicine, University of Western Australia, Perth, Australia; School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
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96
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Chalkias A, Pavlopoulos F, Koutsovasilis A, d'Aloja E, Xanthos T. Airway pressure and outcome of out-of-hospital cardiac arrest: A prospective observational study. Resuscitation 2017; 110:101-106. [DOI: 10.1016/j.resuscitation.2016.10.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/22/2016] [Accepted: 10/30/2016] [Indexed: 11/29/2022]
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97
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Kim YY, Kang GH, Kim WH, Choi HY, Jang YS, Lee YJ, Kim JG, Kim H, Kim GY. Comparison of blind intubation through supraglottic devices and direct laryngoscopy by novices: a simulation manikin study. Clin Exp Emerg Med 2016; 3:75-80. [PMID: 27752621 PMCID: PMC5051610 DOI: 10.15441/ceem.15.069] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 03/27/2016] [Accepted: 03/31/2016] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This study aimed to compare intubation performance between blind intubation through supraglottic airway devices and direct laryngoscopy by novices under manikin simulation. We hypothesized that the intubation time by novices using supraglottic airway devices was superior to that with the Macintosh laryngoscope (MCL). METHODS A prospective, randomized crossover study was conducted with 95 participants, to evaluate i-gel, air-Q, LMA Fastrach, and MCL devices. Primary outcomes were the intubation time and the success rate for intubation. RESULTS The i-gel showed the shortest insertion and tube passing time among the four devices; the i-gel and air-Q also showed the shortest total intubation time (all P<0.0083; i-gel vs. air-Q, P=0.03). The i-gel and MCL showed the highest cumulative success rate (all P<0.0083; i-gel vs. MCL, P=0.12). CONCLUSION Blind intubation through the i-gel showed almost equal intubation performance compared to direct laryngoscopy.
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Affiliation(s)
- Young Yong Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Gu Hyun Kang
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Won Hee Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hyun Young Choi
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Yong Soo Jang
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Young Jae Lee
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jae Guk Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hyeongtae Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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98
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Kasinski M, Madziala M, Iskrzycki L, Gawlowski P. Are firefighters able to perform blind endotracheal intubation via LMA Fastrach? An experimental study. Am J Emerg Med 2016; 34:2458-2459. [PMID: 27743626 DOI: 10.1016/j.ajem.2016.09.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 09/20/2016] [Indexed: 11/28/2022] Open
Affiliation(s)
| | - Marcin Madziala
- Department of Emergency Medicine, Medical University of Warsaw Warsaw, Poland.
| | - Lukasz Iskrzycki
- Department of Emergency Medical Service Wroclaw Medical University, Wroclaw, Poland
| | - Pawel Gawlowski
- Department of Emergency Medical Service Wroclaw Medical University, Wroclaw, Poland
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99
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Soar J, Nolan JP, Böttiger BW, Perkins GD, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars MB, Smith GB, Sunde K, Deakin CD. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation 2016; 95:100-47. [PMID: 26477701 DOI: 10.1016/j.resuscitation.2015.07.016] [Citation(s) in RCA: 920] [Impact Index Per Article: 115.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Germany
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Pierre Carli
- SAMU de Paris, Department of Anaesthesiology and Intensive Care, Necker University Hospital, Paris, France
| | - Tommaso Pellis
- Anaesthesia, Intensive Care and Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | - Markus B Skrifvars
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Gary B Smith
- Centre of Postgraduate Medical Research & Education, Bournemouth University, Bournemouth, UK
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK
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100
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Rehn M, Hyldmo PK, Magnusson V, Kurola J, Kongstad P, Rognås L, Juvet LK, Sandberg M. Scandinavian SSAI clinical practice guideline on pre-hospital airway management. Acta Anaesthesiol Scand 2016; 60:852-64. [PMID: 27255435 PMCID: PMC5089575 DOI: 10.1111/aas.12746] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/13/2016] [Accepted: 04/24/2016] [Indexed: 12/17/2022]
Abstract
Background The Scandinavian society of anaesthesiology and intensive care medicine task force on pre‐hospital airway management was asked to formulate recommendations following standards for trustworthy clinical practice guidelines. Methods The literature was systematically reviewed and the grading of recommendations assessment, development and evaluation (GRADE) system was applied to move from evidence to recommendations. Results We recommend that all emergency medical service (EMS) providers consider to: apply basic airway manoeuvres and airway adjuncts (good practice recommendation); turn unconscious non‐trauma patients into the recovery position when advanced airway management is unavailable (good practice recommendation); turn unconscious trauma patients to the lateral trauma position while maintaining spinal alignment when advanced airway management is unavailable [strong recommendation, low quality of evidence (QoE)]. We suggest that intermediately trained providers use a supraglottic airway device (SAD) or basic airway manoeuvres on patients in cardiac arrest (weak recommendation, low QoE). We recommend that advanced trained providers consider using an SAD in selected indications or as a rescue device after failed endotracheal intubation (ETI) (good practice recommendation). We recommend that ETI should only be performed by advanced trained providers (strong recommendation, low QoE). We suggest that videolaryngoscopy is considered for ETI when direct laryngoscopy fails or is expected to be difficult (weak recommendation, low QoE). We suggest that advanced trained providers apply cricothyroidotomy in ‘cannot intubate, cannot ventilate’ situations (weak recommendation, low QoE). Conclusion This guideline for pre‐hospital airway management includes a combination of techniques applied in a stepwise fashion appropriate to patient clinical status and provider training.
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Affiliation(s)
- M. Rehn
- The Norwegian Air Ambulance Foundation Drøbak Norway
- London's Air Ambulance Barts Health Trust London UK
- Field of Pre‐hospital Critical Care University of Stavanger Stavanger Norway
| | - P. K. Hyldmo
- The Norwegian Air Ambulance Foundation Drøbak Norway
- Department of Anaesthesiology and Intensive Care Sørlandet Hospital Kristiansand Norway
| | - V. Magnusson
- Department of Anaesthesia and Intensive Care Medicine Landspitali University Hospital Reykjavik Iceland
| | - J. Kurola
- Centre for Pre‐hospital Emergency Care Kuopio University Hospital Kuopio Finland
| | - P. Kongstad
- Department of Pre‐hospital Care and Disaster Medicine Region of Skåne Lund Sweden
| | - L. Rognås
- Pre‐hospital Critical Care Service Aarhus University Hospital Aarhus Denmark
- The Danish Air Ambulance Aarhus Denmark
| | - L. K. Juvet
- Norwegian Institute of Public Health Oslo Norway
- University College of Southeast Norway Notodden Norway
| | - M. Sandberg
- Air Ambulance Department Oslo University Hospital Oslo Norway
- University of Oslo Oslo Norway
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