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Battaglini D, Schiavetti I, Ball L, Jakobsen JC, Lilja G, Friberg H, Wendel-Garcia PD, Young PJ, Eastwood G, Chew MS, Unden J, Thomas M, Joannidis M, Nichol A, Lundin A, Hollenberg J, Hammond N, Saxena M, Martin A, Solar M, Taccone FS, Dankiewicz J, Nielsen N, Morten Grejs A, Wise MP, Hängghi M, Smid O, Patroniti N, Robba C. Association between early airway intervention in the pre-hospital setting and outcomes in out of hospital cardiac arrest patients: A post-hoc analysis of the Target Temperature Management-2 (TTM2) trial. Resuscitation 2024; 203:110390. [PMID: 39244144 DOI: 10.1016/j.resuscitation.2024.110390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2024] [Revised: 09/01/2024] [Accepted: 09/02/2024] [Indexed: 09/09/2024]
Abstract
INTRODUCTION Airway management is a critical component of out-of-hospital cardiac arrest (OHCA) resuscitation. The primary aim of this study was to describe pre-hospital airway management in adult patients post-OHCA. Secondary aims were to investigate whether tracheal intubation (TI) versus use of supraglottic airway device (SGA) was associated with patients' outcomes, including ventilator-free days within 26 days of randomization, 6 months neurological outcome and mortality. METHODS Secondary analysis of the Target Temperature Management-2 (TTM2) trial conducted in 13 countries, including adult patients with OHCA and return of spontaneous circulation, with data available on pre-hospital airway management. A multivariate logistic regression model with backward stepwise selection was employed to assess whether TI versus SGA was associated with outcomes. RESULTS Of the 1900 TTM2 trial patients, 1702 patients (89.5%) were included, with a mean age of 64 years (Standard Deviation, SD = 13.53); 79.1% were males. Pre-hospital airway management was SGA in 484 (28.4%), and TI in 1218 (71.6%) patients. At hospital admission, 87.8% of patients with SGA and 98.5% with TI were mechanically ventilated (p < 0.001). In the multivariate analysis, TI in comparison with SGA was not independently associated with an increase in ventilator-free days within 26 days of randomization, improved neurological outcomes, or decreased mortality. The hazard ratio for mortality with TI vs. SGA was 1.06, 95%Confidence Interval (CI) 0.88-1.28, p = 0.54. CONCLUSIONS In the multicentre randomized TTM2-trial including patients with OHCA, most patients received prehospital endotracheal intubation to manage their airway. The choice of pre-hospital airway device was not independently associated with patient clinical outcomes. TRIAL REGISTRATION NUMBER NCT02908308.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical Science and Integrated Diagnostics (DISC), University of Genoa, Genova, Italy.
| | - Irene Schiavetti
- Department of Health Sciences, University of Genoa, Genova, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical Science and Integrated Diagnostics (DISC), University of Genoa, Genova, Italy
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark; Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Lund University, Lund, Sweden
| | - Pedro David Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Paul J Young
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington 6242, New Zealand; Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Glenn Eastwood
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne Australia; Department of Intensive Care, Austin Hospital, Heidelberg, Australia
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Johan Unden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden; Department of Operation and Intensive Care, Lund University, Hallands Hospital Halmstad, Halland, Sweden
| | - Matthew Thomas
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Alistar Nichol
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; University College Dublin-Clinical Research Centre at St Vincent's University Hospital, Dublin, Ireland
| | - Andreas Lundin
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 423 45 Gothenburg, Sweden
| | - Jacob Hollenberg
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - Naomi Hammond
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Manoj Saxena
- Critical Care Division and Department of Intensive Care Medicine, The George Institute for Global Health and St George Hospital Clinical School, University of New South Wales, Sydney, Australia
| | - Annborn Martin
- Department of Clinical Medicine, Anaesthesiology and Intensive Care, Lund University, Lund, Sweden
| | - Miroslav Solar
- Department of Internal Medicine, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic; Department of Internal Medicine-Cardioangiology, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Université Libre de Bruxelles, Hopital Universitaire de Bruxelles (HUB), Brussels, Belgium
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care and Clinical Sciences Helsingborg, Helsingborg Hospital, Lund University, Lund, Sweden
| | - Anders Morten Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Denmark, Department of Clinical Medicine, Aarhus University, Denmark
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Matthias Hängghi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital University of Bern, Bern, Switzerland
| | - Ondrej Smid
- 2nd Department of Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, 128 00 Prague 2, Czech Republic
| | - Nicolò Patroniti
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical Science and Integrated Diagnostics (DISC), University of Genoa, Genova, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical Science and Integrated Diagnostics (DISC), University of Genoa, Genova, Italy
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van Eijk JA, Doeleman LC, Loer SA, Koster RW, van Schuppen H, Schober P. Ventilation during cardiopulmonary resuscitation: A narrative review. Resuscitation 2024; 203:110366. [PMID: 39181499 DOI: 10.1016/j.resuscitation.2024.110366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 07/12/2024] [Accepted: 08/15/2024] [Indexed: 08/27/2024]
Abstract
Ventilation during cardiopulmonary resuscitation is vital to achieve optimal oxygenation but continues to be a subject of ongoing debate. This narrative review aims to provide an overview of various components and challenges of ventilation during cardiopulmonary resuscitation, highlighting key areas of uncertainty in the current understanding of ventilation management. It addresses the pulmonary pathophysiology during cardiac arrest, the importance of adequate alveolar ventilation, recommendations concerning the maintenance of airway patency, tidal volumes and ventilation rates in both synchronous and asynchronous ventilation. Additionally, it discusses ventilation adjuncts such as the impedance threshold device, the role of positive end-expiratory pressure ventilation, and passive oxygenation. Finally, this review offers directions for future research.
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Affiliation(s)
- Jeroen A van Eijk
- Amsterdam UMC location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Public Health, Quality of Care, Amsterdam, the Netherlands.
| | - Lotte C Doeleman
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Public Health, Quality of Care, Amsterdam, the Netherlands
| | - Stephan A Loer
- Amsterdam UMC location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Public Health, Quality of Care, Amsterdam, the Netherlands
| | - Rudolph W Koster
- Amsterdam UMC location University of Amsterdam, Cardiology, Meibergdreef 9, Amsterdam, Netherlands
| | - Hans van Schuppen
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Public Health, Quality of Care, Amsterdam, the Netherlands
| | - Patrick Schober
- Amsterdam UMC location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Public Health, Quality of Care, Amsterdam, the Netherlands
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Chen JW, Chen CH, Wang HC, Chang HT, Yang SC, Cheng SH, Chen HC, Chen CH, Huang EPC, Sung CW. The association of time to key prehospital interventions recorded by EMT-worn video devices and sustained return of spontaneous circulation in out-of-hospital cardiac arrests. PREHOSP EMERG CARE 2024:1-13. [PMID: 39331817 DOI: 10.1080/10903127.2024.2410414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Revised: 09/08/2024] [Accepted: 09/23/2024] [Indexed: 09/29/2024]
Abstract
OBJECTIVES The quality of prehospital resuscitation provided by emergency medical technicians (EMTs) is essential to ensure better outcomes following out-of-hospital cardiac arrests (OHCA). We assessed the quality of prehospital resuscitation by recording time to key prehospital interventions using EMT-worn video devices and investigated its association with outcomes of patients with OHCA. METHODS This retrospective, cross-sectional study included cases of non-traumatic OHCA in adults treated by EMS in Hsinchu City, Taiwan, during 2022 and 2023. We used data from high-resolution, chest-mounted wearable cameras to define and measure six Quality Indices (QIs) for prehospital resuscitation interventions (i.e., time spent recognizing OHCA). To evaluate the association between QI performance and sustained return of spontaneous circulation (ROSC), we used multivariable logistic regression. RESULTS Of 745 patients eligible for this study, 187 (25.1%) achieved sustained ROSC. Six core QIs were analyzed: recognition of OHCA (median time: 9.0 seconds), time from recognizing OHCA to initiating cardiopulmonary resuscitation (CPR; 9.0 seconds), automated external defibrillator setup (34.0 seconds), time from recognizing OHCA to beginning ventilation (160.0 seconds), advanced airway management (300 seconds), and deploying a mechanical CPR device (50 seconds). The performance of the six QIs were not associated with sustained ROSC (Adjusted odds ratio [95% confidence interval]: 1.00 [0.99-1.00], 0.99 [0.98-1.00], 1.00 [1.00-1.01], 1.00 [1.00-1.00], 1.00 [1.00-1.00] and 0.99 [0.99-1.00], respectively). CONCLUSIONS This study describes the rate of sustained ROSC and time to key interventions captured by EMT-worn video devices in non-traumatic OHCA patients. Although we found no direct link between QI performance and improved OHCA outcomes, this study highlights the potential of video-assisted QIs to enhance the documentation and understanding of prehospital resuscitation processes. These findings suggest that further refinement and application of these QIs could support more effective resuscitation strategies and training programs.
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Affiliation(s)
- Jiun-Wei Chen
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu city, Taiwan
| | - Chi-Hsin Chen
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu city, Taiwan
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | | | | | | | | | | | | | - Edward Pei-Chuan Huang
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu city, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Wei Sung
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu city, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
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Baumkirchner JM, Havlicek M, Voelckel W, Trimmel H. Resuscitation of out-of-hospital cardiac arrest victims in Austria's largest helicopter emergency medical service: A retrospective cohort study. Resusc Plus 2024; 19:100678. [PMID: 38912530 PMCID: PMC11190555 DOI: 10.1016/j.resplu.2024.100678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/12/2024] [Accepted: 05/23/2024] [Indexed: 06/25/2024] Open
Abstract
Background Helicopter emergency medical services (HEMS) play a fundamental role in prehospital care. However, the impact of HEMS on survival of patients with out-of-hospital cardiac arrest (OHCA) is widely unknown. Therefore, the purpose of this study was to assess demographics, treatment, and outcome of patients with OHCA attended by physician-staffed helicopters. Methods Retrospective cohort study enrolling OHCA patients treated by HEMS during a ten-year period (2010-2019) in Austria. Patients were identified using electronic mission records of 13 HEMS bases run by the Austrian Automobile, Motorcycle and Touring Club (OEAMTC), and subsequently matched with the national register of deaths to determine 30-day and one-year survival rates. Results are reported according to the 2015 Utstein Style. Multivariable logistic regression analysis was used to identify factors associated with patient outcome. Results In total, 9344 presumed OHCA missions were identified. Cardiopulmonary resuscitation was attempted or continued by HEMS in 3889 cases. Approximately 32.2% of patients achieved return of spontaneous circulation (ROSC) and 22.5% sustained ROSC until arrival at the emergency department. Thirty-day and one-year survival rates were 14.0% and 12.4% respectively. HEMS response time, on-scene time, age, pathogenesis, arrest location, witness-status, first monitored rhythm, bystander automated external defibrillator (AED) use, airway type and administration of adrenaline were independent predictors of 30-day survival. Conclusions This study provides an extensive insight into the management of OHCA in an almost nationwide HEMS sample. Thirty-day and one-year survival rates are high, indicating high-quality care and systematic selection of patients with favorable prognosis.
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Affiliation(s)
- Julian M. Baumkirchner
- Medical University of Vienna, Vienna, Austria
- Department of Surgery, Zuger Kantonsspital, Baar, Switzerland
| | | | - Wolfgang Voelckel
- Departement of Anaesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria
- University of Stavanger, Network for Medical Science, Stavanger, Norway
- Christophorus Air Rescue, OEAMTC, Vienna, Austria
| | - Helmut Trimmel
- Christophorus Air Rescue, OEAMTC, Vienna, Austria
- Department of Anaesthesiology, Emergency Medicine and Intensive Care, County Hospital Wiener Neustadt, Wiener Neustadt, Austria
- Karl Landsteiner Institute for Emergency Medicine, Wiener Neustadt, Austria
- Danube Private University, Krems, Austria
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Shin J, Lee HJ, Jin KN, Shin JH, You KM, Lee SGW, Jung JH, Song KJ, Pak J, Park TY, Park CJ, Bae GT. Automatic Mechanical Ventilation vs Manual Bag Ventilation During CPR: A Pilot Randomized Controlled Trial. Chest 2024; 166:311-320. [PMID: 38373673 DOI: 10.1016/j.chest.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND There is insufficient evidence supporting the theory that mechanical ventilation can replace the manual ventilation method during CPR. RESEARCH QUESTION Is using automatic mechanical ventilation (MV) feasible and comparable to the manual ventilation method during CPR? STUDY DESIGN AND METHODS This pilot randomized controlled trial compared MV and manual bag ventilation (BV) during CPR after out-of-hospital cardiac arrest (OHCA). Patients with medical OHCA arriving at the ED were randomly assigned to two groups: an MV group using a mechanical ventilator and a BV group using a bag valve mask. Primary outcome was any return of spontaneous circulation (ROSC). Secondary outcomes were changes of arterial blood gas analysis results during CPR. Tidal volume, minute volume, and peak airway pressure were also analyzed. RESULTS A total of 60 patients were enrolled, and 30 patients were randomly assigned to each group. There were no statistically significant differences in basic characteristics of OHCA patients between the two groups. The rate of any return of spontaneous circulation was 56.7% in the MV group and 43.3% in the BV group, indicating no significant (P = .439) difference between the two groups. There were also no statistically significant differences in changes of PH, Pco2, Po2, bicarbonate, or lactate levels during CPR between the two groups (P values = .798, 0.249, .515, .876, and .878, respectively). Significantly lower tidal volume (P < .001) and minute volume (P = .009) were observed in the MV group. INTERPRETATION In this pilot trial, the use of MV instead of BV during CPR was feasible and could serve as a viable alternative. A multicenter randomized controlled trial is needed to create sufficient evidence for ventilation guidelines during CPR. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT05550454; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Jonghwan Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, South Korea; Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Hui Jai Lee
- Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea.
| | - Kwang Nam Jin
- Department of Radiology, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Jung Ho Shin
- Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Kyoung Min You
- Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Stephen Gyung Won Lee
- Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Jin Hee Jung
- Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Kyoung Jun Song
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, South Korea; Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Jieun Pak
- Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Tae Yun Park
- Department of Internal Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Chang Je Park
- Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Gi Tak Bae
- Department of Nursing, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
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Wang HE, Yu MI, Crowe RP, Nassal MMJ, Gage C, Hyer JM, Powell J, Ulintz A, Sharkey-Toppen T, Wei L, Moeller K, Panchal AR. Longitudinal Changes in Emergency Medical Services Advanced Airway Management. JAMA Netw Open 2024; 7:e2427763. [PMID: 39172452 PMCID: PMC11342135 DOI: 10.1001/jamanetworkopen.2024.27763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 06/18/2024] [Indexed: 08/23/2024] Open
Abstract
Importance Identifying longitudinal changes in advanced airway management by emergency medical services (EMS) is crucial for understanding practice patterns and optimizing care. Objective To examine the longitudinal trends in endotracheal intubation (ETI) and supraglottic airway (SGA) utilization in a national EMS cohort. Design, Setting, and Participants This retrospective cross-sectional study analyzed 2011 to 2022 data from the ESO Data Collaborative, a national database of US prehospital electronic health records. The study included all 911 EMS events in which advanced airway management was attempted. Data were analyzed from November 2022 to January 2024. Exposures Advanced airway management attempts, including ETI, SGA, and surgical airways. Main Outcomes and Measures The annual percentage of ETI and SGA attempts, stratified by underlying condition (cardiac arrest, nonarrest medical, nonarrest trauma, pediatrics). Results Among 47.5 million EMS activations, 444 041 (mean [SD] age, 60.6 [19.8] years; 273 296 [61.5%] men) involved advanced airway management, including 305 584 (68.8%) that used ETI and 200 437 (45.1%) that used SGA. The overall incidence was 9.3 per 1000 EMS events. In the cardiac arrest cohort from 2011 to 2022, EMS events with ETI attempts decreased from 2470 of 2831 (87.3%) to 40 083 of 72 793 (55.1%) and those with SGA attempts increased from 711 of 2831 (25.1%) to 44 386 of 72 793 (61.0%). In the pediatric subset, there were similarly large decreases in ETI attempts, from 117 of 182 EMS events (97.3%) to 1573 of 2307 EMS events (68.2%), and increases in SGA attempts, from 11 of 182 EMS events (6.6%) to 1058 of 2307 EMS events (45.9%). In the nonarrest medical and nonarrest trauma cohorts, ETI attempts decreased and SGA attempts increased but to a much lower extent. Conclusions and Relevance In this national cross-sectional study of EMS care episodes, there were marked shifts in advanced airway management practices, with the increased use of SGA and decreased use of ETI. These observations highlight current trends in EMS airway management practices.
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Affiliation(s)
- Henry E. Wang
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - Mengda Ivy Yu
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus
| | | | | | - Christopher Gage
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - J. Madison Hyer
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus
| | - Jonathan Powell
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - Alexander Ulintz
- Department of Emergency Medicine, The Ohio State University, Columbus
| | | | - Lai Wei
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus
| | - Kim Moeller
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - Ashish R. Panchal
- Department of Emergency Medicine, The Ohio State University, Columbus
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Freund Y. Rethinking the paradigm of Glasgow Coma Scale directed intubation in poisoned comatose patients: insights from the NICO randomized controlled trial. Eur J Emerg Med 2024; 31:163-164. [PMID: 38661501 DOI: 10.1097/mej.0000000000001135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Affiliation(s)
- Yonathan Freund
- Sorbonne Université, FHU IMProving Emergency Care IMPEC and Emergency Department, Hopital Pitié-Salpêtrière, APHP.SU, Paris, France
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Xu X, Ma H, Zhang Y, Liu W, Jung B, Li X, Shen L. Efficacy of bougie first approach for endotracheal intubation with video laryngoscopy during continuous chest compression: a randomized crossover manikin trial. BMC Anesthesiol 2024; 24:181. [PMID: 38773386 PMCID: PMC11106944 DOI: 10.1186/s12871-024-02560-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 05/14/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND Endotracheal intubation is challenging during cardiopulmonary resuscitation, and video laryngoscopy has showed benefits for this procedure. The aim of this study was to compare the effectiveness of various intubation approaches, including the bougie first, preloaded bougie, endotracheal tube (ETT) with stylet, and ETT without stylet, on first-attempt success using video laryngoscopy during chest compression. METHODS This was a randomized crossover trial conducted in a general tertiary teaching hospital. We included anesthesia residents in postgraduate year one to three who passed the screening test. Each resident performed intubation with video laryngoscopy using the four approaches in a randomized sequence on an adult manikin during continuous chest compression. The primary outcome was the first-attempt success defined as starting ventilation within a one minute. RESULTS A total of 260 endotracheal intubations conducted by 65 residents were randomized and analyzed with 65 procedures in each group. First-attempt success occurred in 64 (98.5%), 57 (87.7%), 56 (86.2%), and 46 (70.8%) intubations in the bougie-first, preloaded bougie, ETT with stylet, and ETT without stylet approaches, respectively. The bougie-first approach had a significantly higher possibility of first-attempt success than the preloaded bougie approach [risk ratio (RR) 8.00, 95% confidence interval (CI) 1.03 to 62.16, P = 0.047], the ETT with stylet approach (RR 9.00, 95% CI 1.17 to 69.02, P = 0.035), and the ETT without stylet approach (RR 19.00, 95% CI 2.62 to 137.79, P = 0.004) in the generalized estimating equation logistic model accounting for clustering of intubations operated by the same resident. In addition, the bougie first approach did not result in prolonged intubation or increased self-reported difficulty among the study participants. CONCLUSIONS The bougie first approach with video laryngoscopy had the highest possibility of first-attempt success during chest compression. These results helped inform the intubation approach during CPR. However, further studies in an actual clinical environment are warranted to validate these findings. TRIAL REGISTRATION Clinicaltrials.gov; identifier: NCT05689125; date: January 18, 2023.
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Affiliation(s)
- Xiaohan Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College , Beijing, 100730, China
| | - Haobo Ma
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Yuelun Zhang
- Center for Prevention and Early Intervention, National Infrastructures for Translational Medicine, Institute of Clinical Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100730, China
| | - Wei Liu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College , Beijing, 100730, China
| | - Boris Jung
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
- Intensive Care Unit, Lapeyronie Teaching Hospital, Montpellier University, Montpellier, France
- Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, USA
| | - Xu Li
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College , Beijing, 100730, China.
| | - Le Shen
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College , Beijing, 100730, China.
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Koga Y, Fujita M, Yagi T, Todani M, Nakahara T, Kaneda K, Tsuruta R. Association of Advanced Airway Management in Preference to Intravenous Adrenaline on Neurological Outcomes Following Out-of-Hospital Cardiac Arrest. Cureus 2024; 16:e59926. [PMID: 38854252 PMCID: PMC11161664 DOI: 10.7759/cureus.59926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2024] [Indexed: 06/11/2024] Open
Abstract
AIM To examine the preference for advanced airway management (AAM) or intravenous adrenaline administration (IVAd) provided by emergency medical services (EMS) for out-of-hospital cardiac arrest (OHCA) with shockable or nonshockable rhythms. METHODS We conducted a retrospective analysis of a nationwide cohort of OHCA patients in Japan. Adult patients with witnessed collapse who were provided AAM and/or IVAd by EMS between June 2014 and December 2019 were divided into the AAM preferred group and IVAd preferred group, according to the initial advanced EMS intervention. The rates of favorable neurological outcomes (cerebral performance category 1 or 2 after 30 days) were compared between groups of patients with initial shockable or nonshockable rhythms. RESULTS We analyzed 1365 and 9733 patients with initial shockable and nonshockable rhythms, respectively. Of these patients, 1033 (75.7%) with shockable and 7844 (80.6%) with nonshockable rhythms, respectively, were assigned to the AAM preferred group. Favorable neurological outcomes were significantly more frequent in the AAM preferred group than in the IVAd preferred group in patients with a shockable rhythm (13.6% vs 9.3%, respectively; P = 0.039), but not in those with a nonshockable rhythm (1.0% vs 0.8%, respectively; P = 0.509). Preferred AAM was independently associated with a higher probability of favorable neurological outcomes in patients with a shockable rhythm (adjusted odds ratio 1.66, 95% confidence interval 1.08-2.53, P = 0.020), but not in patients with a nonshockable rhythm. CONCLUSIONS AAM provided by EMS in preference to IVAd was associated with the favorable neurological outcomes of OHCA patients with shockable rhythms.
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Affiliation(s)
- Yasutaka Koga
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, JPN
| | - Motoki Fujita
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, JPN
| | - Takeshi Yagi
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, JPN
| | - Masaki Todani
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, JPN
| | - Takashi Nakahara
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, JPN
| | - Kotaro Kaneda
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, JPN
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, JPN
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10
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Okubo M, Komukai S, Izawa J, Kiyohara K, Matsuyama T, Iwami T, Kitamura T. Sequence of Epinephrine and Advanced Airway Placement After Out-of-Hospital Cardiac Arrest. JAMA Netw Open 2024; 7:e2356863. [PMID: 38372996 PMCID: PMC10877448 DOI: 10.1001/jamanetworkopen.2023.56863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/28/2023] [Indexed: 02/20/2024] Open
Abstract
Importance While epinephrine and advanced airway management (AAM) (supraglottic airway insertion and endotracheal intubation) are commonly used for out-of-hospital cardiac arrest (OHCA), the optimal sequence of these interventions remains unclear. Objective To evaluate the association of the sequence of epinephrine administration and AAM with patient outcomes after OHCA. Design, Setting, and Participants This cohort study analyzed the nationwide, population-based OHCA registry in Japan and included adults (aged ≥18 years) with OHCA for whom emergency medical services personnel administered epinephrine and/or placed an advanced airway between January 1, 2014, and December 31, 2019. The data analysis was performed between October 1, 2022, and May 12, 2023. Exposure The sequence of intravenous epinephrine administration and AAM. Main Outcomes and Measures The primary outcome was 1-month survival. Secondary outcomes were 1-month survival with favorable functional status and prehospital return of spontaneous circulation. To control imbalances in measured patient demographics, cardiac arrest characteristics, and bystander and prehospital interventions, propensity scores and inverse probability of treatment weighting (IPTW) were performed for shockable and nonshockable initial rhythm subcohorts. Results Of 259 237 eligible patients (median [IQR] age, 79 [69-86] years), 152 289 (58.7%) were male. A total of 21 592 patients (8.3%) had an initial shockable rhythm, and 237 645 (91.7%) had an initial nonshockable rhythm. Using IPTW, all covariates between the epinephrine-first and AAM-first groups were well balanced, with all standardized mean differences less than 0.100. After IPTW, the epinephrine-first group had a higher likelihood of 1-month survival for both shockable (odds ratio [OR], 1.19; 95% CI, 1.09-1.30) and nonshockable (OR, 1.28; 95% CI, 1.19-1.37) rhythms compared with the AAM-first group. For the secondary outcomes, the epinephrine-first group experienced an increased likelihood of favorable functional status and prehospital return of spontaneous circulation for both shockable and nonshockable rhythms compared with the AAM-first group. Conclusions and Relevance These findings suggest that for patients with OHCA, administration of epinephrine before placement of an advanced airway may be the optimal treatment sequence for improved patient outcomes.
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Affiliation(s)
- Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Junichi Izawa
- Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Okinawa, Japan
| | - Kosuke Kiyohara
- Department of Food Science, Otsuma Women’s University, Tokyo, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Taku Iwami
- Department of Preventive Services, Kyoto University, Kyoto, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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11
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Forestell B, Ramsden S, Sharif S, Centofanti J, Al Lawati K, Fernando SM, Welsford M, Nichol G, Nolan JP, Rochwerg B. Supraglottic Airway Versus Tracheal Intubation for Airway Management in Out-of-Hospital Cardiac Arrest: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Controlled Trials. Crit Care Med 2024; 52:e89-e99. [PMID: 37962112 DOI: 10.1097/ccm.0000000000006112] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
OBJECTIVES Given the uncertainty regarding the optimal approach for airway management for adult patients with out-of-hospital cardiac arrest (OHCA), we conducted a systematic review and meta-analysis to compare the use of supraglottic airways (SGAs) with tracheal intubation for initial airway management in OHCA. DATA SOURCES We searched MEDLINE, PubMed, Embase, Cochrane Library, as well as unpublished sources, from inception to February 7, 2023. STUDY SELECTION We included randomized controlled trials (RCTs) of adult OHCA patients randomized to SGA compared with tracheal intubation for initial prehospital airway management. DATA EXTRACTION Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model. We used the modified Cochrane risk of bias 2 tool and assessed certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We preregistered the protocol on PROSPERO (CRD42022342935). DATA SYNTHESIS We included four RCTs ( n = 13,412 patients). Compared with tracheal intubation , SGA use probably increases return of spontaneous circulation (ROSC) (relative risk [RR] 1.09; 95% CI, 1.02-1.15; moderate certainty) and leads to a faster time to airway placement (mean difference 2.5 min less; 95% CI, 1.6-3.4 min less; high certainty). SGA use may have no effect on survival at longest follow-up (RR 1.06; 95% CI, 0.84-1.34; low certainty), has an uncertain effect on survival with good functional outcome (RR 1.11; 95% CI, 0.82-1.50; very low certainty), and may have no effect on risk of aspiration (RR 1.04; 95% CI, 0.94 to 1.16; low certainty). CONCLUSIONS In adult patients with OHCA, compared with tracheal intubation, the use of SGA for initial airway management probably leads to more ROSC, and faster time to airway placement, but may have no effect on longer-term survival outcomes or aspiration events.
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Affiliation(s)
- Ben Forestell
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sophie Ramsden
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sameer Sharif
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Division of Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada
- Departments of Emergency Medicine and Medicine, Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, WA
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
- Department of Anesthesia and Intensive Care Medicine, Royal United Hospital, Bath, United Kingdom
| | - John Centofanti
- Division of Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Kumait Al Lawati
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Division of Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shannon M Fernando
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada
| | - Michelle Welsford
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Graham Nichol
- Departments of Emergency Medicine and Medicine, Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, WA
| | - Jerry P Nolan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
- Department of Anesthesia and Intensive Care Medicine, Royal United Hospital, Bath, United Kingdom
| | - Bram Rochwerg
- Division of Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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12
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Katabami K, Kimura T, Hirata T, Tamakoshi A. Association Between Advanced Airway Management With Adrenaline Injection and Prognosis in Adult Patients With Asystole Asphyxia Out-of-hospital Cardiac Arrest. J Epidemiol 2024; 34:31-37. [PMID: 36709978 PMCID: PMC10701249 DOI: 10.2188/jea.je20220240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/26/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The neurological prognosis of asphyxia is poor and the effect of advanced airway management (AAM) in the prehospital setting remains unclear. This study aimed to evaluate the association between AAM with adrenaline injection and prognosis in adult patients with asystole asphyxia out-of-hospital cardiac arrest (OHCA). METHODS This study assessed all-Japan Utstein cohort registry data between January 1, 2013 and December 31, 2019. We used propensity score matching analyses before logistic regression analysis to evaluate the effect of AAM on favorable neurological outcome. RESULTS There were 879,057 OHCA cases, including 70,299 cases of asphyxia OHCAs. We extracted the data of 13,642 cases provided with adrenaline injection by emergency medical service. We divided 7,945 asphyxia OHCA cases in asystole into 5,592 and 2,353 with and without AAM, respectively. After 1:1 propensity score matching, 2,338 asphyxia OHCA cases with AAM were matched with 2,338 cases without AAM. Favorable neurological outcome was not significantly different between the AAM and no AAM groups (adjusted odds ratio [OR] 1.1; 95% confidence interval [CI], 0.5-2.5). However, the return of spontaneous circulation (ROSC) (adjusted OR 1.7; 95% CI, 1.5-1.9) and 1-month survival (adjusted OR 1.5; 95% CI, 1.1-1.9) were improved in the AAM group. CONCLUSION AAM with adrenaline injection for patients with asphyxia OHCA in asystole was associated with improved ROSC and 1-month survival rate but showed no differences in neurologically favorable outcome. Further prospective studies may comprehensively evaluate the effect of AAM for patients with asphyxia.
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Affiliation(s)
- Kenichi Katabami
- Department of Public Health, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takashi Kimura
- Department of Public Health, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takumi Hirata
- Department of Public Health, Hokkaido University Faculty of Medicine, Sapporo, Japan
- Institute for Clinical and Translational Science, Nara Medical University Hospital, Nara, Japan
| | - Akiko Tamakoshi
- Department of Public Health, Hokkaido University Faculty of Medicine, Sapporo, Japan
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13
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Neamjun S, Phinyo P, Wittayachamnankul B, Wongtanasarasin W. Early endotracheal intubation is not associated with the rate of return of spontaneous circulation following cardiac arrest at the emergency department: an exploratory analysis. World J Emerg Med 2024; 15:297-300. [PMID: 39050216 PMCID: PMC11265638 DOI: 10.5847/wjem.j.1920-8642.2024.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/18/2024] [Indexed: 07/27/2024] Open
Affiliation(s)
- Siwat Neamjun
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Phichayut Phinyo
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Borwon Wittayachamnankul
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Wachira Wongtanasarasin
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento 95817, USA
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14
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Jarvis JL, Panchal AR, Lyng JW, Bosson N, Donofrio-Odmann JJ, Braude DA, Browne LR, Arinder M, Bolleter S, Gross T, Levy M, Lindbeck G, Maloney LM, Mattera CJ, Wang CT, Crowe RP, Gage CB, Lang ES, Sholl JM. Evidence-Based Guideline for Prehospital Airway Management. PREHOSP EMERG CARE 2023; 28:545-557. [PMID: 38133523 DOI: 10.1080/10903127.2023.2281363] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 11/05/2023] [Indexed: 12/23/2023]
Abstract
Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel made specific recommendations on the different PICO (population, intervention, comparison, outcome) questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations. The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.
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Affiliation(s)
- Jeffrey L Jarvis
- Office of the Medical Director, Metropolitan Area EMS Authority, Fort Worth, Texas
| | - Ashish R Panchal
- National Registry of Emergency Medical Technicians, Columbus, Ohio
| | - John W Lyng
- Emergency Medicine, North Memorial Health Hospital Level 1 trauma center, Minneapolis, Minnesota
| | - Nichole Bosson
- EMS, Los Angeles County Department of Health Services, Los Angeles, California
| | | | - Darren A Braude
- Department of Emergency Medicine, The University of New Mexico, Albuquerque, New Mexico
| | - Lorin R Browne
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Arinder
- EMS, Global Medical Response Inc., Greenwood Village, Colorado
| | - Scott Bolleter
- EMS, Healthcare Innovation & Sciences Centre, Spring Branch, Texas
| | - Toni Gross
- Department of Emergency Medicine, LCMC Health, New Orleans, Louisiana
| | | | - George Lindbeck
- National Registry of Emergency Medical Technicians, Columbus, Ohio
| | - Lauren M Maloney
- Department of Emergency Medicine, Stony Brook Medicine, Stony Brook, New York
| | | | - Cheng-Teng Wang
- Department of Emergency Medicine, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | | | - Christopher B Gage
- Research, National Registry of Emergency Medical Technicians, Columbus, Ohio
| | - Eddy S Lang
- Department of Emergency Medicine, Alberta Health Services, Edmonton, Canada
| | - J Matthew Sholl
- National Registry of Emergency Medical Technicians, Columbus, Ohio
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15
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Wang HE. Prehospital Airway Management - the Continued Search for Evidence. PREHOSP EMERG CARE 2023; 28:558-560. [PMID: 38133521 DOI: 10.1080/10903127.2023.2281361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Henry E Wang
- Department Emergency Medicine, The Ohio State University, Columbus, Ohio
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16
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Idris AH, Aramendi Ecenarro E, Leroux B, Jaureguibeitia X, Yang BY, Shaver S, Chang MP, Rea T, Kudenchuk P, Christenson J, Vaillancourt C, Callaway C, Salcido D, Carson J, Blackwood J, Wang HE. Bag-Valve-Mask Ventilation and Survival From Out-of-Hospital Cardiac Arrest: A Multicenter Study. Circulation 2023; 148:1847-1856. [PMID: 37952192 PMCID: PMC10840971 DOI: 10.1161/circulationaha.123.065561] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/28/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Few studies have measured ventilation during early cardiopulmonary resuscitation (CPR) before advanced airway placement. Resuscitation guidelines recommend pauses after every 30 chest compressions to deliver ventilations. The effectiveness of bag-valve-mask ventilation delivered during the pause in chest compressions is unknown. We sought to determine: (1) the incidence of lung inflation with bag-valve-mask ventilation during 30:2 CPR; and (2) the association of ventilation with outcomes after out-of-hospital cardiac arrest. METHODS We studied patients with out-of-hospital cardiac arrest from 6 sites of the Resuscitation Outcomes Consortium CCC study (Trial of Continuous Compressions versus Standard CPR in Patients with Out-of-Hospital Cardiac Arrest). We analyzed patients assigned to the 30:2 CPR arm with ≥2 minutes of thoracic bioimpedance signal recorded with a cardiac defibrillator/monitor. Detectable ventilation waveforms were defined as having a bioimpedance amplitude ≥0.5 Ω (corresponding to ≥250 mL VT) and a duration ≥1 s. We defined a chest compression pause as a 3- to 15-s break in chest compressions. We compared the incidence of ventilation and outcomes in 2 groups: patients with ventilation waveforms in <50% of pauses (group 1) versus those with waveforms in ≥50% of pauses (group 2). RESULTS Among 1976 patients, the mean age was 65 years; 66% were male. From the start of chest compressions until advanced airway placement, mean±SD duration of 30:2 CPR was 9.8±4.9 minutes. During this period, we identified 26 861 pauses in chest compressions; 60% of patients had ventilation waveforms in <50% of pauses (group 1, n=1177), and 40% had waveforms in ≥50% of pauses (group 2, n=799). Group 1 had a median of 12 pauses and 2 ventilations per patient versus group 2, which had 12 pauses and 12 ventilations per patient. Group 2 had higher rates of prehospital return of spontaneous circulation (40.7% versus 25.2%; P<0.0001), survival to hospital discharge (13.5% versus 4.1%; P<0.0001), and survival with favorable neurological outcome (10.6% versus 2.4%; P<0.0001). These associations persisted after adjustment for confounders. CONCLUSIONS In this study, lung inflation occurred infrequently with bag-valve-mask ventilation during 30:2 CPR. Lung inflation in ≥50% of pauses was associated with improved return of spontaneous circulation, survival, and survival with favorable neurological outcome.
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Affiliation(s)
- Ahamed H Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas (A.H.I, B.Y.Y., S.S., M.P.C.)
| | | | - Brian Leroux
- Department of Biostatistics (B.L., J.C.), University of Washington, Seattle
| | - Xabier Jaureguibeitia
- Department of Communications Engineering, University of the Basque Country, Bilbao, Spain (E.A.E., X.J.)
| | - Betty Y Yang
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas (A.H.I, B.Y.Y., S.S., M.P.C.)
| | - Sarah Shaver
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas (A.H.I, B.Y.Y., S.S., M.P.C.)
| | - Mary P Chang
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas (A.H.I, B.Y.Y., S.S., M.P.C.)
| | - Tom Rea
- Department of Medicine (Emergency Medicine) (T.R.), University of Washington, Seattle
| | - Peter Kudenchuk
- Department of Medicine (Cardiology) (P.K.), University of Washington, Seattle
| | - Jim Christenson
- Department of Biostatistics (B.L., J.C.), University of Washington, Seattle
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada (J.C.)
| | | | - Clifton Callaway
- Department of Emergency Medicine, University of Pittsburgh, PA (C.C., D.S.)
| | - David Salcido
- Department of Emergency Medicine, University of Pittsburgh, PA (C.C., D.S.)
| | | | - Jennifer Blackwood
- Public Health-Seattle & King County, Emergency Medical Services Division, Seattle, WA (J.B.)
| | - Henry E Wang
- Department of Emergency Medicine, The Ohio State University, Columbus (H.E.W.)
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17
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Perlman R, Tsai K, Lo J. Trauma Anesthesiology Perioperative Management Update. Adv Anesth 2023; 41:143-162. [PMID: 38251615 DOI: 10.1016/j.aan.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Anesthesia for patients with life-threatening injuries is an essential part of post-accident care. Unfortunately, there is variability in trauma anesthesia care and numerous nonstandardized methods of working with patients remain. Uncertainty exists as to when and how best to intubate trauma patients, the use of vasopressors, and the appropriate management of severe traumatic brain injury. Some physicians recommend prehospital rapid sequence intubation, whereas others use bag-mask ventilation at lower pressures with no cricoid pressure and early transport to a trauma center. Overall, the absence of uniformity in trauma anesthesia care underlines the need for continued study and dialogue to define best practices and optimize patient outcomes.
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Affiliation(s)
- Ryan Perlman
- Trauma Anesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8211, Los Angeles, CA 90048, USA.
| | - Kevin Tsai
- Department of Anaesthesia, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8211, Los Angeles, CA 90048, USA
| | - Jessie Lo
- Trauma Education Program, Department of Anaesthesia, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8211, Los Angeles, CA 90048, USA
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18
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Ahn S, Jin BY, Cho H, Moon S, Cho YD, Park JH. Association of prehospital advanced airway and epinephrine with survival in patients with out-of-hospital cardiac arrest. Sci Rep 2023; 13:17836. [PMID: 37857787 PMCID: PMC10587122 DOI: 10.1038/s41598-023-44991-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 10/14/2023] [Indexed: 10/21/2023] Open
Abstract
Survival benefits of prehospital advanced airway and epinephrine in out-of-hospital cardiac arrest (OHCA) patients are controversial, but few studies evaluated this together. This study evaluated association of prehospital advanced airway and epinephrine with survival outcomes in OHCA patients. This was observational study using a prospective multicentre KoCARC registry. Adult OHCA patients between October 2015 and December 2021 were included. The variables of interest were prehospital managements, which was classified into basic life support (BLS)-only, BLS + advanced airway, and BLS + advanced airway + epinephrine. In total, 8217 patients were included in analysis. Survival to discharge and good neurological outcomes were lowest in the BLS + advanced airway + epinephrine group (22.1% in BLS-only vs 13.2% in BLS + advanced airway vs 7.5% in BLS + advanced airway + epinephrine, P < 0.001 and 17.1% in BLS-only vs 9.2% in BLS + advanced airway vs 4.3% in BLS + advanced airway + epinephrine, P < 0.001, respectively). BLS + advanced airway + epinephrine group was less likely to survive to discharge and have good neurological outcomes (aOR 0.39, 95% CI 0.28-0.55, P < 0.001 and aOR 0.33, 95% CI 0.21-0.51, P < 0.001, respectively) than BLS-only group after adjusting for potential confounders. In prehospital settings with intermediate EMS providers and prehospital advanced airway insertion is performed followed by epinephrine administration, prehospital management with BLS + advanced airway + epinephrine in OHCA patients was associated with lower survival to discharge rate compared to BLS-only.
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Affiliation(s)
- Sejoong Ahn
- Department of Emergency Medicine, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Republic of Korea
| | - Bo-Yeong Jin
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hanjin Cho
- Department of Emergency Medicine, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Republic of Korea
| | - Sungwoo Moon
- Department of Emergency Medicine, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Republic of Korea
| | - Young-Duck Cho
- Department of Emergency Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Jong-Hak Park
- Department of Emergency Medicine, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Republic of Korea.
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19
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Budde AM, Tung A. Airway management during resuscitation. Int Anesthesiol Clin 2023; 61:9-14. [PMID: 37678199 DOI: 10.1097/aia.0000000000000410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Anna M Budde
- Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Avery Tung
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
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20
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Palisch AC. Airway Management of the Cardiac Arrest Victim. Emerg Med Clin North Am 2023; 41:543-558. [PMID: 37391249 DOI: 10.1016/j.emc.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
Appropriate airway management is critical to successful cardiac arrest resuscitation. However, the timing and method of airway management during cardiac arrest have traditionally been guided by expert and consensus opinion informed by observational data. In the last 5 years, recent studies, including several randomized controlled trials (RCTs), have provided additional clarity to help guide airway management. This article will review both current data and guidelines for airway management in cardiac arrest, a stepwise approach to airway management, the utility of various airway adjuncts, and best practices for oxygenation and ventilation in the peri-arrest period.
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Affiliation(s)
- Anthony Chase Palisch
- Department of Emergency Medicine, Vanderbilt University, 1211 Medical Center Drive, Nashville, TN 37232, USA.
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21
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Balakrishnan R, Andrea L, Moskowitz A. Closing the evidence gap for in-hospital cardiac arrest: a focus on advanced airway management. J Thorac Dis 2023; 15:4033-4039. [PMID: 37559600 PMCID: PMC10407530 DOI: 10.21037/jtd-23-145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/09/2023] [Indexed: 08/11/2023]
Affiliation(s)
| | - Luke Andrea
- Division of Critical Care Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Ari Moskowitz
- Division of Critical Care Medicine, Montefiore Medical Center, Bronx, NY, USA
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22
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Yumoto T, Hongo T, Hifumi T, Inoue A, Sakamoto T, Kuroda Y, Yorifuji T, Nakao A, Naito H. Association between prehospital advanced life support by emergency medical services personnel and neurological outcomes among adult out-of-hospital cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation: A secondary analysis of the SAVE-J II study. J Am Coll Emerg Physicians Open 2023; 4:e12948. [PMID: 37064164 PMCID: PMC10090941 DOI: 10.1002/emp2.12948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 04/18/2023] Open
Abstract
Study Objective Early deployment of extracorporeal cardiopulmonary resuscitation (ECPR) is critical in treating refractory out-of-hospital cardiac arrest (OHCA) patients who are potential candidates for ECPR. The effect of prehospital advanced life support (ALS), including epinephrine administration or advanced airway, compared with no ALS in this setting remains unclear. This study's objective was to determine the association between any prehospital ALS care and outcomes of patients who received ECPR with emergency medical services-treated OHCA. Methods This was a secondary analysis of data from the Study of Advanced Cardiac Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan (SAVE-J) II study. Patients were separated into 2 groups-those who received prehospital ALS (ALS group) and those did not receive prehospital ALS (no ALS group). Multiple logistic regression analysis was used to investigate the association between prehospital ALS and favorable neurological outcomes (defined as Cerebral Performance Category scores 1-2) at hospital discharge. Results A total of 1289 patients were included, with 644 patients in the ALS group and 645 patients in the no ALS group. There were fewer favorable neurological outcomes at hospital discharge in the ALS group compared with the no ALS group (10.4 vs 19.8%, p <0.001). A multiple logistic regression analysis revealed that any prehospital ALS care (adjusted odds ratios 0.47; 95% confidence interval 0.34-0.66; p <0.001) was associated with unfavorable neurological outcomes at hospital discharge. Conclusion Prehospital ALS was associated with worse neurological outcomes at hospital discharge in patients treated with ECPR for OHCA. Further prospective studies are required to determine the clinical implications of these findings.
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Affiliation(s)
- Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical SciencesOkayama UniversityOkayama Kita‐kuOkayamaJapan
| | - Takashi Hongo
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical SciencesOkayama UniversityOkayama Kita‐kuOkayamaJapan
| | - Toru Hifumi
- Department of Emergency and Critical Care MedicineSt. Luke's International HospitalChuo‐kuTokyoJapan
| | - Akihiko Inoue
- Department of Emergency, Disaster and Critical Care MedicineHyogo Emergency Medical CenterChuo‐kuKobeJapan
| | - Tetsuya Sakamoto
- Department of Emergency MedicineTeikyo University School of MedicineItabashi‐KuTokyoJapan
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care MedicineKagawa University HospitalMiki‐cho, Kita‐gunKagawaJapan
| | - Takashi Yorifuji
- Department of Epidemiology, Faculty of Medicine, Dentistry, and Pharmaceutical SciencesOkayama UniversityOkayama Kita‐kuOkayamaJapan
| | - Atsunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical SciencesOkayama UniversityOkayama Kita‐kuOkayamaJapan
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical SciencesOkayama UniversityOkayama Kita‐kuOkayamaJapan
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23
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Bloom JE, Partovi A, Bernard S, Okyere D, Heritier S, Mahony E, Eliakundu AL, Dawson LP, Voskoboinik A, Anderson D, Ball J, Chan W, Kaye DM, Nehme Z, Stub D. Use of a novel smartphone-based application tool for enrolment and randomisation in pre-hospital clinical trials. Resuscitation 2023; 187:109787. [PMID: 37028747 DOI: 10.1016/j.resuscitation.2023.109787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/11/2023] [Accepted: 03/25/2023] [Indexed: 04/08/2023]
Abstract
The effective recruitment and randomisation of patients in pre-hospital clinical trials presents unique challenges. Owing to the time critical nature of many pre-hospital emergencies and limited resourcing, the use of traditional methods of randomisation that may include centralised telephone or web-based systems are often not practicable or feasible. Previous technological limitations have necessitated that pre-hospital trialists strike a compromise between implementing pragmatic, deliverable study designs, and robust enrolment and randomisation methodologies. In this commentary piece, we present a novel smartphone-based solution that has the potential to align pre-hospital clinical trial recruitment processes to that of best-in-practice in-hospital and ambulatory care setting studies. Running title: Smartphone application based randomisation in pre-hospital clinical trials.
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Affiliation(s)
- Jason E Bloom
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia; School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia; Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | | | - Stephen Bernard
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Daniel Okyere
- Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Stephane Heritier
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Emily Mahony
- Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Amminadab L Eliakundu
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Luke P Dawson
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Aleksandr Voskoboinik
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - David Anderson
- Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia; Department of Paramedicine, Monash University, McMahons Road, Frankston, VIC 3199, Australia
| | - Jocasta Ball
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Ziad Nehme
- Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia; Department of Paramedicine, Monash University, McMahons Road, Frankston, VIC 3199, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia; Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia.
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Bartos JA, Clare Agdamag A, Kalra R, Nutting L, Frascone RJ, Burnett A, Vuljaj N, Lick C, Tanghe P, Quinn R, Simpson N, Peterson B, Haley K, Sipprell K, Yannopoulos D. Supraglottic Airway Devices are Associated with Asphyxial Physiology After Prolonged CPR in Patients with Refractory Out-of-Hospital Cardiac Arrest Presenting for Extracorporeal Cardiopulmonary Resuscitation. Resuscitation 2023; 186:109769. [PMID: 36933882 DOI: 10.1016/j.resuscitation.2023.109769] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Multiple randomized clinical trials have compared specific airway management strategies during ACLS with conflicting results. However, patients with refractory cardiac arrest died in almost all cases without the availability of extracorporeal cardiopulmonary resuscitation (ECPR). Our aim was to determine if endotracheal intubation (ETI) was associated with improved outcomes compared to supraglottic airways (SGA) in patients with refractory cardiac arrest presenting for ECPR. METHODS We retrospectively studied 420 consecutive adult patients with refractory out-of-hospital cardiac arrest due to shockable presenting rhythms presenting to the University of Minnesota ECPR program. We compared outcomes between patients receiving ETI (n=179) and SGA (n=204). The primary outcome was the pre-cannulation arterial PaO2 upon arrival to the ECMO cannulation center. Secondary outcomes included neurologically favorable survival to hospital discharge and eligibility for VA-ECMO based upon resuscitation continuation criteria applied upon arrival to the ECMO cannulation center. RESULTS Patients receiving ETI had significantly higher median PaO2 (71 vs. 58 mmHg, p=0.001), lower median PaCO2 (55 vs. 75 mmHg, p<0.001), and higher median pH (7.03 vs. 6.93, p<0.001) compared to those receiving SGA. Patients receiving ETI were also significantly more likely to meet VA-ECMO eligibility criteria (85% vs. 74%, p=0.008). Of patients eligible for VA-ECMO, patients receiving ETI had significantly higher neurologically favorable survival compared to SGA (42% vs. 29%, p=0.02). CONCLUSIONS ETI was associated with improved oxygenation and ventilation after prolonged CPR. This resulted in increased rate of candidacy for ECPR and increased neurologically favorable survival to discharge with ETI compared to SGA. Short Title: Airway Effects in Refractory Cardiac Arrest.
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Affiliation(s)
- Jason A Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA.
| | - Arianne Clare Agdamag
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Rajat Kalra
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Lindsay Nutting
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - R J Frascone
- Department of Emergency Medicine, Regions Hospital, St. Paul, MN, USA
| | - Aaron Burnett
- Woodbury and Cottage Grove, Emergency Medical Services, MN, USA
| | - Nik Vuljaj
- M Health Fairview Emergency Medical Services, Minneapolis, MN, USA
| | - Charles Lick
- Allina Health Emergency Medical Services, Minneapolis, MN, USA
| | - Peter Tanghe
- Department of Emergency Medicine, North Memorial Health Ambulance Service, North Memorial Health Medical Center, Robbinsdale, MN, USA
| | | | | | - Bjorn Peterson
- Department of Emergency Medicine, Regions Hospital, St. Paul, MN, USA
| | - Kari Haley
- Department of Emergency Medicine, Regions Hospital, St. Paul, MN, USA
| | - Kevin Sipprell
- Department of Emergency Medicine, Ridgeview Medical Center, Waconia, MN, USA
| | - Demetris Yannopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
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25
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Song SR, Kim KH, Park JH, Song KJ, Shin SD. Association between prehospital airway type and oxygenation and ventilation in out-of-hospital cardiac arrest. Am J Emerg Med 2023; 65:24-30. [PMID: 36580697 DOI: 10.1016/j.ajem.2022.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 12/10/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES This study aimed to evaluate the association between prehospital airway type and oxygenation and ventilation in out-of-hospital cardiac arrest (OHCA). METHODS This retrospective observational study included OHCA patients who visited the emergency departments (EDs) between October 2015 and June 2021. The study groups were categorized according to the prehospital airway type: endotracheal intubation (ETI), supraglottic airway (SGA), or bag-valve-mask ventilation (BVM). The primary outcome was good oxygenation: partial pressure of oxygen (PaO2) ≥ 60 mmHg on the first arterial blood gas (ABG) test. The secondary outcome was good ventilation: partial pressure of carbon dioxide (PaCO2) ≤ 45 mmHg. Multivariate logistic regression was conducted to calculate the adjusted odds ratio (AOR) and 95% confidence interval (CI). RESULTS A total of 7,372 patients were enrolled during the study period: 1,819 patients treated with BVM, 706 with ETI, and 4,847 who underwent SGA. In multivariable logistic regression analysis for good oxygenation outcomes, the ETI group showed a higher AOR than the BVM group (AOR [95% CIs]: 1.30 [1.06-1.59] in ETI and 1.05 [0.93-1.20] in SGA groups). Regarding good ventilation, the ETI group showed a higher AOR, and the SGA group showed a lower AOR compared to the BVM group (AOR [95% CIs] 1.33 [1.02-1.74] in the ETI and 0.83 (0.70-0.99) in the SGA groups). There was no significant difference in survival to discharge. CONCLUSIONS ETI was significantly associated with good oxygenation and good ventilation compared to BVM in patients with OHCA, particularly during longer transports. This should be taken into consideration when deciding the prehospital advanced airway management in patients with OHCA.
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Affiliation(s)
- So Ra Song
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ki Hong Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
| | - Jeong Ho Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea
| | - Kyoung Jun Song
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
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26
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Amagasa S, Utsumi S, Moriwaki T, Yasuda H, Kashiura M, Uematsu S, Kubota M. Advanced airway management for pediatric out-of-hospital cardiac arrest: A systematic review and network meta-analysis. Am J Emerg Med 2023; 68:161-169. [PMID: 37027937 DOI: 10.1016/j.ajem.2023.03.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/19/2023] [Accepted: 03/23/2023] [Indexed: 03/31/2023] Open
Abstract
OBJECTIVES Although airway management is important in pediatric resuscitation, the effectiveness of bag-mask ventilation (BMV) and advanced airway management (AAM), such as endotracheal intubation (ETI) and supraglottic airway (SGA) devices, for prehospital resuscitation of pediatric out-of-hospital cardiac arrest (OHCA) remains unclear. We aimed to determine the efficacy of AAM during prehospital resuscitation of pediatric OHCA cases. METHODS We searched four databases from their inception to November 2022 and included randomized controlled trials and observational studies with appropriate adjustments for confounders that evaluated prehospital AAM for OHCA in children aged <18 years in quantitative synthesis. We compared three interventions (BMV, ETI, and SGA) via network meta-analysis using the GRADE Working Group approach. The outcome measures were survival and favorable neurological outcomes at hospital discharge or 1 month after cardiac arrest. RESULTS Five studies (including one clinical trial and four cohort studies with rigorous confounding adjustment) involving 4852 patients were analyzed in our quantitative synthesis. Compared with ETI, BMV was associated with survival (relative risk [RR] 0.44 [95% confidence intervals (CI) 0.25-0.77]) (very low certainty). There were no significant association with survival in the other comparisons (SGA vs. BMV: RR 0.62 [95% CI 0.33-1.15] [low certainty], ETI vs. SGA: RR 0.71 [95% CI 0.39-1.32] [very low certainty]). There was no significant association with favorable neurological outcomes in any comparison (ETI vs. BMV: RR 0.33 [95% CI 0.11-1.02]; SGA vs. BMV: RR 0.50 [95% CI 0.14-1.80]; ETI vs. SGA: RR 0.66 [95% CI 0.18-2.46]) (all very low certainty). In the ranking analysis, the hierarches for efficacy for survival and favorable neurological outcome were BMV > SGA > ETI. CONCLUSION Although the available evidence is from observational studies and its certainty is low to very low, prehospital AAM for pediatric OHCA did not improve outcomes.
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27
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Lou J, Tian S, Kang X, Lian H, Liu H, Zhang W, Peran D, Zhang J. Airway management in out-of-hospital cardiac arrest: A systematic review and network meta-analysis. Am J Emerg Med 2023; 65:130-138. [PMID: 36630861 DOI: 10.1016/j.ajem.2022.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 12/07/2022] [Accepted: 12/18/2022] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Airway management during cardiopulmonary resuscitation is particularly important for patients with out-of-hospital cardiac arrest (OHCA). This study was performed to compare the efficacy of the most commonly used out-of-hospital airway management methods in increasing the survival to discharge in patients with OHCA. METHODS We screened all relevant literature from database inception to 21st January 2019 in PubMed, Web of Science, Embase, and the Cochrane Library. We included all randomized controlled trials (RCTs) of airway management for OHCA in adults (≥16 years of age) with no limitations on publication status, publication date, or language. The primary outcome was survival to discharge. The secondary outcomes were the overall airway technique success rate, return of spontaneous circulation, and survival to hospital admission. RESULTS Overall, from 1986 to 2018, 9 RCTs involving 13,949 patients were included in the network meta-analysis, and the efficacy of six airway management methods for patients with OHCA were compared. However, none of the results were statistically significant. CONCLUSIONS As the gold standard of airway management for patients with out-of-hospital cardiac arrest in most countries, endotracheal intubation (ETI) has been widely used for many years. However, our systematic review and network meta-analysis showed that ETI is no better than other methods in increasing the survival to discharge. This is not directly proportional to the various preparations required before ETI. Additional randomized controlled trials are needed to identify more effective methods and improve patients' outcome.
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Affiliation(s)
- Jing Lou
- Beijing Emergency Medical Center, Beijing, China; Beijing Emergency Medicine Research Institute, Beijing, China
| | - Sijia Tian
- Beijing Emergency Medical Center, Beijing, China; Beijing Emergency Medicine Research Institute, Beijing, China
| | - Xuqin Kang
- Beijing Emergency Medical Center, Beijing, China; Beijing Emergency Medicine Research Institute, Beijing, China
| | - Huixin Lian
- Beijing Emergency Medical Center, Beijing, China
| | - Hongmei Liu
- Beijing Emergency Medical Center, Beijing, China
| | | | - David Peran
- Prague Emergency Medical Services, Prague, Czech Republic
| | - Jinjun Zhang
- Beijing Emergency Medical Center, Beijing, China; Beijing Emergency Medicine Research Institute, Beijing, China.
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Robinson AE, Driver BE, Prekker ME, Reardon RF, Horton G, Stang JL, Collins JD, Carlson JN. First attempt success with continued versus paused chest compressions during cardiac arrest in the emergency department. Resuscitation 2023; 186:109726. [PMID: 36764570 DOI: 10.1016/j.resuscitation.2023.109726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
AIM Tracheal intubation is associated with interruption in cardiopulmonary resuscitation (CPR). Current knowledge of tracheal intubation during active CPR focuses on the out-of-hospital environment. We aim to describe characteristics of tracheal intubation during active CPR in the emergency department (ED) and determine whether first attempt success was associated with CPR being continued vs paused. MEASUREMENTS We reviewed overhead video from adult ED patients receiving chest compressions at the start of the orotracheal intubation attempt. We recorded procedural detail including method of CPR, whether CPR was continued vs paused, and first attempt intubation success (primary outcome). We performed logistic regression to determine whether continuing CPR was associated with first attempt success. RESULTS We reviewed 169 instances of tracheal intubation, including 143 patients with continued CPR and 26 patients with paused CPR. Those with paused CPR were more likely to be receiving manual rather than mechanical chest compressions. Video laryngoscopy and bougie use were common. First attempt success was higher in the continued CPR group (87%, 95% CI 81% to 92%) than the interrupted CPR group (65%, 95% CI 44% to 83%, difference 22% [95% CI 3% to 41%]). The multivariable model demonstrated an adjusted odds ratio of 0.67 (95% CI 0.17 to 2.60) for first attempt intubation success when CPR was interrupted vs continued. CONCLUSIONS It was common to continue CPR during tracheal intubation, with success comparable to that achieved in patients without cardiac arrest. It is reasonable to attempt tracheal intubation without interrupting CPR, pausing only if necessary.
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Affiliation(s)
- Aaron E Robinson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55404, United States; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, United States.
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55404, United States; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55404, United States; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55404, United States; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - Gabriella Horton
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55404, United States
| | - Jamie L Stang
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55404, United States; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - Jacob D Collins
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55404, United States
| | - Jestin N Carlson
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA 15222, United States
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29
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Steffen R, Hischier S, Roten FM, Huber M, Knapp J. Airway management during ongoing chest compressions-direct vs. video laryngoscopy. A randomised manikin study. PLoS One 2023; 18:e0281186. [PMID: 36757942 PMCID: PMC9910718 DOI: 10.1371/journal.pone.0281186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 01/18/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Tracheal intubation is used for advanced airway management during cardiac arrest, particularly when basic airway techniques cannot ensure adequate ventilation. However, minimizing interruptions of chest compressions is of high priority. Video laryngoscopy has been shown to improve the first-pass success rate for tracheal intubation in emergency airway management. We aimed to compare first-pass success rate and time to successful intubation during uninterrupted chest compression using video laryngoscopy and direct laryngoscopy. METHODS A total of 28 anaesthetists and 28 anaesthesia nurses with varied clinical and anaesthesiological experience were recruited for the study. All participants performed a tracheal intubation on a manikin simulator during ongoing chest compressions by a mechanical resuscitation device. Stratified randomisation (physicians/nurses) was performed, with one group using direct laryngoscopy and the other using video laryngoscopy. RESULTS First-pass success rate was 100% (95% CI: 87.9% - 100.0%) in the video laryngoscopy group and 67.8% (95% CI: 49.3% - 82.1%) in the direct laryngoscopy group [difference: 32.2% (95% CI: 17.8% - 50.8%), p<0.001]. The median time for intubation was 27.5 seconds (IQR: 21.8-31.0 seconds) in the video laryngoscopy group and 30.0 seconds (IQR: 26.5-36.5 seconds) in the direct laryngoscopy group (p = 0.019). CONCLUSION This manikin study on tracheal intubation during ongoing chest compressions demonstrates that video laryngoscopy had a higher first-pass success rate and shorter time to successful intubation compared to direct laryngoscopy. Experience in airway management and professional group were not significant predictors. A clinical randomized controlled trial appears worthwhile.
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Affiliation(s)
- Richard Steffen
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simon Hischier
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fredy-Michel Roten
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürgen Knapp
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Hospital of Schwyz, Schwyz, Switzerland
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
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30
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Milne B. Con: We Should Not Routinely Intubate All Patients in Cardiac Arrest. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00040-X. [PMID: 36805378 DOI: 10.1053/j.jvca.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/22/2023] [Indexed: 01/30/2023]
Affiliation(s)
- Benjamin Milne
- Department of Anaesthetics & Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; Department of Critical Care, King's College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom.
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Santou N, Ueta H, Nakagawa K, Hata K, Kusunoki S, Sadamori T, Takyu H, Tanaka H. A comparative study of Video laryngoscope vs Macintosh laryngoscope for prehospital tracheal intubation in Hiroshima, Japan. Resusc Plus 2022; 13:100340. [PMID: 36582475 PMCID: PMC9792877 DOI: 10.1016/j.resplu.2022.100340] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/16/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
Background In Japan, there are no studies comparing endotracheal intubation performed by emergency medical technicians (EMTs) during out-of-hospital cardiac arrest (OHCA) using a Macintosh laryngoscope and a video laryngoscope. Objective The purpose of this study was to compare the success rate, complication rate, return of spontaneous circulation (ROSC), neurological prognosis (CPC1-2) and regional differences between Video laryngoscope (VL) and Macintosh laryngoscope (ML) for OHCA patients. Method This study is a retrospective cohort study using 10,067 OHCA data extracted from the national Utstein Form and emergency medical transport data. The primary endpoint was the success rate of tracheal intubation and the complication rate and the secondary endpoints were the incidence of ROSC and CPC1-2. Results A total of 885 tracheal Intubated OHCA patients were enrolled in this study. The success rate was 94.1% (490/521) in the VL group and 89.3% (325/364) in the ML group (RR, 1.05; 95%CI, 1.01-1.10, P = 0.01), the VL group shows significantly higher success rate than that of the ML group. In the complication rates, oesophageal intubation occurred in 0.2% (1/521) of in the VL group and in 6.0% (22/364) in the ML group, Indicating significantly higher complication rates in the ML group compared with the VL group (RR, 1.06; 95% CI, 1.03-1.09, P < 0.001). The ROSC rate and CPC1-2 rate are similar among the groups. Conclusion Our data suggest that using VL had a little advantage with a higher success rate and lower complication rate. Further discussion is necessary for the future development of Emergency Medical Services (EMS) intubation devices.
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Affiliation(s)
- N. Santou
- Research Institute of Disaster Management and EMS, Kokushikan University,Tokyo, Japan,Corresponding author at: Research Institute of Disaster Management and EMS, Kokushikan University, 7-3-1, Nagayama, Tama city, Tokyo 205-8515, Japan.
| | - H. Ueta
- Research Institute of Disaster Management and EMS, Kokushikan University,Tokyo, Japan
| | - K. Nakagawa
- Department of Emergency Medical System, Graduate School, Kokushikan University , Tokyo, Japan
| | - K. Hata
- Department of Emergency Medical System, Graduate School, Kokushikan University , Tokyo, Japan,Research Center for Mathematical Medicine, Tokyo, Japan
| | - S. Kusunoki
- Hiroshima Prefectural Hospital Emergency and Critical Care Medicine
| | - T. Sadamori
- Emergency and Intensive Care Medicine, Hiroshima University
| | - H. Takyu
- Department of Emergency Medical System, Graduate School, Kokushikan University , Tokyo, Japan
| | - H. Tanaka
- Research Institute of Disaster Management and EMS, Kokushikan University,Tokyo, Japan,Department of Emergency Medical System, Graduate School, Kokushikan University , Tokyo, Japan
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Penketh J, Nolan JP. In-hospital cardiac arrest: the state of the art. Crit Care 2022; 26:376. [PMID: 36474215 PMCID: PMC9724368 DOI: 10.1186/s13054-022-04247-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022] Open
Abstract
In-hospital cardiac arrest (IHCA) is associated with a high risk of death, but mortality rates are decreasing. The latest epidemiological and outcome data from several cardiac arrest registries are helping to shape our understanding of IHCA. The introduction of rapid response teams has been associated with a downward trend in hospital mortality. Technology and access to defibrillators continues to progress. The optimal method of airway management during IHCA remains uncertain, but there is a trend for decreasing use of tracheal intubation and increased use of supraglottic airway devices. The first randomised clinical trial of airway management during IHCA is ongoing in the UK. Retrospective and observational studies have shown that several pre-arrest factors are strongly associated with outcome after IHCA, but the risk of bias in such studies makes prognostication of individual cases potentially unreliable. Shared decision making and advanced care planning will increase application of appropriate DNACPR decisions and decrease rates of resuscitation attempts following IHCA.
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Affiliation(s)
- James Penketh
- grid.416091.b0000 0004 0417 0728Intensive Care Unit, Royal United Hospital, Bath, UK
| | - Jerry P. Nolan
- grid.416091.b0000 0004 0417 0728Intensive Care Unit, Royal United Hospital, Bath, UK ,grid.7372.10000 0000 8809 1613Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
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Knapp J, Huber M, Gräsner JT, Bernhard M, Fischer M. Outcome differences between PARAMEDIC2 and the German Resuscitation Registry: a secondary analysis of a randomized controlled trial compared with registry data. Eur J Emerg Med 2022; 29:421-430. [PMID: 35791269 PMCID: PMC9605191 DOI: 10.1097/mej.0000000000000958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 05/28/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND IMPORTANCE There has been much discussion of the results of the PARAMEDIC2 trial, as resuscitation outcome rates are considerably lower in this trial than in country-level registries on out-of-hospital cardiac arrest (OHCA). Here, we developed a statistical framework to investigate this gap and to examine possible sources for observed discrepancies in outcome rates. DESIGN Summary data from the PARAMEDIC2 trial were used as available in the publication of this study. We developed a modelling framework based on logistic regression to compare data from this randomized controlled trial and registry data from the German Resuscitation Registry (GRR), where we considered 26 019 patients treated with epinephrine for OHCA in the GRR. To account and adjust for differences in patient characteristics and baseline variables predictive for outcomes after OHCA between the GRR cohort and the PARAMEDIC2 study sample, we included all available variables determined at the arrival of EMS personnel in the modelling framework: age, sex, initial cardiac rhythm, cause of cardiac arrest, witness of cardiac arrest, CPR performed by a bystander, and the interval between emergency call and arrival of the ambulance at the scene (baseline model). In order to find possible explanations for the discrepancies in outcome between PARAMEDIC2 and GRR, in a second (baseline plus treatment) model, we additionally included all available variables related to the interventions of the EMS personnel (type of airway management, type of vascular access, and time to administration of epinephrine). MAIN RESULTS A patient cohort with baseline variables as in the PARAMEDIC2 trial would have survived to hospital discharge in 7.7% and survived with favourable neurological outcome in 5.0% in an EMS and health care system as in Germany, compared with 3.2 and 2.2%, respectively, in the Epinephrine group of the trial. Adding treatment-related variables to our logistic regression model, the rate of survival to discharge would decrease from 7.7 (for baseline variables only) to 5.6% and the rate of survival with favourable neurological outcome from 5.0 to 3.4%. CONCLUSION Our framework helps in the medical interpretation of the PARAMEDIC2 trial and the transferability of the trial's results for other EMS systems. Significantly higher rates of survival and favourable neurological outcome than reported in this trial could be possible in other EMS and health care systems.
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Affiliation(s)
- Jürgen Knapp
- Department of Anaesthesiology and Pain Medicine, Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute for Emergency Medicine, University Hospital Schleswig-Holstein, Kiel
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Michael Bernhard
- Emergency Department, University Hospital of Duesseldorf, Heinrich Heine University, Duesseldorf
| | - Matthias Fischer
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, ALB FILS Kliniken, Goeppingen, Germany
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Robba C, Battaglini D, Badenes R, Nielsen N, Pelosi P. Airway management in cardiac arrest and outcomes. Author's reply. Intensive Care Med 2022; 48:1829-1832. [PMID: 36173414 PMCID: PMC9520998 DOI: 10.1007/s00134-022-06888-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/05/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Chiara Robba
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy.
| | - Denise Battaglini
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care and Clinical Sciences Helsingborg, Helsingborg Hospital, Lund University, Lund, Sweden
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy
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The association of delayed advanced airway management and neurological outcome after out-of-hospital cardiac arrest in Japan. Am J Emerg Med 2022; 62:89-95. [DOI: 10.1016/j.ajem.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 10/04/2022] [Accepted: 10/09/2022] [Indexed: 11/06/2022] Open
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Onoe A, Kajino K, Daya MR, Nakamura F, Nakajima M, Kishimoto M, Sakuramoto K, Muroya T, Ikegawa H, Hock Ong ME, Kuwagata Y. Improved neurologically favorable survival after OHCA is associated with increased pre-hospital advanced airway management at the prefecture level in Japan. Sci Rep 2022; 12:20498. [PMID: 36443385 PMCID: PMC9705308 DOI: 10.1038/s41598-022-25124-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Out-of-hospital cardiac arrest (OHCA) has high incidence and mortality. The survival benefit of pre-hospital advanced airway management (AAM) for OHCA remains controversial. In Japan, pre-hospital AAM are performed for OHCA by emergency medical services (EMS), however the relationship between resuscitation outcomes and AAM at the prefecture level has not been evaluated. The purpose of this study was to describe the association between AAM and neurologically favorable survival (cerebral performance category (CPC) ≦2) at prefecture level. This was a retrospective, population-based study of adult OHCA patients (≧ 18) from January 1, 2014 to December 31, 2017 in Japan. We excluded patients with EMS witnessed arrests. We also only included patients that had care provided by an ELST with the ability to provided AAM and excluded cases that involved prehospital care delivered by a physician. We categorized OHCA into four quartiles (four group: G1-G4) based on frequency of pre-hospital AAM approach rate by prefecture, which is the smallest geographical classification unit, and evaluated the relationship between frequency of pre-hospital AAM approach rates and CPC ≦ 2 for each quartile. Multivariable logistic regression was used to assess effectiveness of AAM on neurologically favorable survival. Among 493,577 OHCA cases, 403,707 matched our inclusion criteria. The number of CPC ≦ 2 survivors increased from G1 to G4 (p for trend < 0.001). In the adjusted multivariable regression, higher frequency of pre-hospital AAM approach was associated with CPC ≦ 2 (p < 0.001). High prefecture frequency of pre-hospital AAM approach was associated with neurologically favorable survival (CPC ≦ 2) in OHCA.
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Affiliation(s)
- Atsunori Onoe
- grid.410783.90000 0001 2172 5041Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka 573-1010 Japan
| | - Kentaro Kajino
- grid.410783.90000 0001 2172 5041Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka 573-1010 Japan
| | - Mohamud R. Daya
- grid.5288.70000 0000 9758 5690Department of Emergency Medicine, Oregon Health and Science University, Portland, OR USA
| | - Fumiko Nakamura
- grid.410783.90000 0001 2172 5041Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka 573-1010 Japan
| | - Mari Nakajima
- grid.410783.90000 0001 2172 5041Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka 573-1010 Japan
| | - Masanobu Kishimoto
- grid.410783.90000 0001 2172 5041Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka 573-1010 Japan
| | - Kazuhito Sakuramoto
- grid.410783.90000 0001 2172 5041Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka 573-1010 Japan
| | - Takashi Muroya
- grid.410783.90000 0001 2172 5041Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka 573-1010 Japan
| | - Hitoshi Ikegawa
- grid.410783.90000 0001 2172 5041Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka 573-1010 Japan
| | - Marcus Eng Hock Ong
- grid.163555.10000 0000 9486 5048Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore ,grid.428397.30000 0004 0385 0924Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Yasuyuki Kuwagata
- grid.410783.90000 0001 2172 5041Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka 573-1010 Japan
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Li Y, He X, Li Z, Li D, Yuan X, Yang J. Double sequential external defibrillation versus standard defibrillation in refractory ventricular fibrillation: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:1017935. [PMID: 36505388 PMCID: PMC9729543 DOI: 10.3389/fcvm.2022.1017935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/10/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Double sequential external defibrillation (DSED) in cardiopulmonary resuscitation has shown different results in comparison with standard defibrillation in the treatment of refractory ventricular fibrillation (RVF). This review aims to compare the advantages of DSED with standard defibrillation in the treatment of refractory ventricular fibrillation. Materials and methods PubMed, Embase, Web of Science, and Cochrane Library were searched from inception to May 1, 2022. Studies included adult patients who developed RVF. The study used random-effects and fixed-effects models for meta-analysis, which was reported by risk ratio (RR) with 95% confidence interval (CI), mean difference (MD), or standardized mean difference (SMD). The risk of bias in individual studies was assessed using the Robins-I tool for observational studies and the Cochrane Risk of Bias 2 (ROB-2) tool for clinical trials. Primary outcomes included the termination of RVF, prehospital return of spontaneous circulation (ROSC), survival to hospital admission, survival to hospital discharge, and good neurological recovery. Secondary outcomes included age, total defibrillation attempts, emergency medical system arrival time, and dose of epinephrine and amiodarone used. Results In this systematic review and meta-analysis, 10 studies containing 1347 patients with available data on treatment outcomes were included. The pooled estimate was (RR 1.03, 95% CI, 0.89 to 1.19; Z = 0.42, P = 0.678 > 0.05) for Termination of RVF, (RR 0.84, 95% CI, 0.63 to 1.11; Z = 1.23, P = 0.219 > 0.05) for ROSC, (RR 0.86, 95% CI, 0.69 to 1.06; Z = 1.4, P = 0.162 > 0.05) for survival to hospital admission, (RR 0.77, 95%CI, 0.52 to 1.15; Z = 1.26, P = 0.206 > 0.05) for survival to hospital discharge, (RR 0.65, 95%CI, 0.35 to 1.22; Z = 1.33, P = 0.184 > 0.05) for good neurologic recovery, (MD -1.01, 95%CI, -3.07 to 1.06; Z = 0.96, P = 0.34 > 0.05) for age, (MD 2.27, 95%CI, 1.80 to 2.73; Z = 9.50, P = 0.001 < 0.05) for total defibrillation attempts, (MD 1.10, 95%CI, -0.45 to 66; Z = 1.39, P = 0.16 > 0.05) for emergency medical system arrival time, (SMD 0.34, 95%CI, 0.17 to 0.50; Z = 4.04, P = 0.001 < 0.05) for epinephrine, and (SMD -0.30, 95%CI, -0.65 to -0.05; Z = 1.66, P = 0.1 > 0.05) for amiodarone. Conclusion We discovered no differences between DSED and standard defibrillation in termination of RVF, prehospital return of spontaneous circulation, survival to hospital admission, survival to hospital discharge, good neurological outcome, emergency medical system arrival time, and amiodarone doses in patients with RVF. There were some differences in the number of defibrillations and epinephrine doses utilized during resuscitation. Systematic review registration [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=329354], identifier [CRD42022329354].
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Affiliation(s)
- Yongkai Li
- Emergency Trauma Center, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Xiaojing He
- Seven Section of Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Zhuanyun Li
- Department of Emergency Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dandan Li
- Emergency Trauma Center, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Xin Yuan
- Emergency Trauma Center, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Jianzhong Yang
- Emergency Trauma Center, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China,*Correspondence: Jianzhong Yang,
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Ohashi-Fukuda N, Fukuda T, Doi K. Association between time to advanced airway management and survival during pediatric out-of-hospital cardiac arrest. Resusc Plus 2022; 11:100260. [PMID: 35782310 PMCID: PMC9240636 DOI: 10.1016/j.resplu.2022.100260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/27/2022] [Accepted: 05/30/2022] [Indexed: 11/22/2022] Open
Abstract
Background Respiratory care, including advanced airway management (AAM), is an important part of pediatric resuscitation. This study aimed to determine whether time to AAM is associated with outcomes after out-of-hospital cardiac arrest (OHCA) in children. Methods This was a nationwide population-based observational study using the Japanese government-led registry of OHCA patients. Children (aged 1–17 years) who experienced OHCA and received AAM by emergency medical service (EMS) personnel in the prehospital setting from 2014 to 2019 were included. Multivariable logistic regression models were used to assess the associations between time to AAM (defined as time in minutes from emergency call to the first successful AAM) and outcomes after OHCA. The primary outcome was one-month overall survival. The secondary outcomes were prehospital return of spontaneous circulation (ROSC) and one-month neurologically favorable survival. Results A total of 761 patients (mean [SD] age, 12.7 [4.8] years) were included. The mean time to AAM was 18.9 min (SD, 7.9). Overall, 77 (10.1%) patients survived one month after OHCA. After adjusting for potential confounders, longer time to AAM was significantly associated with a decreased chance of one-month survival (multivariable adjusted OR per minute delay, 0.93 [95% CI, 0.89–0.97]; P = 0.001). Similar association was observed for prehospital ROSC (adjusted OR, 0.94 [95% CI, 0.90–0.99]; P = 0.01) and neurologically favorable survival (adjusted OR, 0.83 [95% CI, 0.72–0.95]; P = 0.006). This association between time to AAM and survival was consistent across a variety of sensitivity and subgroup analyses. Conclusions Among pediatric OHCA patients, delayed AAM was associated with a decreased chance of survival, although the influence of resuscitation time bias might remain.
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Affiliation(s)
- Naoko Ohashi-Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Toranomon Hospital, Tokyo, Japan.,Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Carney N, Totten AM, Cheney T, Jungbauer R, Neth MR, Weeks C, Davis-O'Reilly C, Fu R, Yu Y, Chou R, Daya M. Prehospital Airway Management: A Systematic Review. PREHOSP EMERG CARE 2022; 26:716-727. [PMID: 34115570 DOI: 10.1080/10903127.2021.1940400] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/31/2021] [Accepted: 06/04/2021] [Indexed: 10/21/2022]
Abstract
Objective: To assess comparative benefits and harms across three airway management approaches (bag valve mask [BVM], supraglottic airway [SGA], and endotracheal intubation [ETI]) used by prehospital emergency medical services (EMS) to treat patients with trauma, cardiac arrest, or medical emergencies, and how they differ based on techniques and devices, EMS personnel and patient characteristics. Data sources: We searched electronic citation databases (Ovid® MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus®) from 1990 to September 2020. Review methods: We followed Agency for Healthcare Research and Quality Effective Health Care Program Methods guidance. Outcomes included mortality, neurological function, return of spontaneous circulation (ROSC), and successful advanced airway insertion. Meta-analyses using profile-likelihood random effects models were conducted, with analyses stratified by study design, emergency type, and age. Results: We included 99 studies involving 630,397 patients. We found few differences in primary outcomes across airway management approaches. For survival, there was no difference for BVM versus ETI or SGA in adult and pediatric patients with cardiac arrest or trauma. For neurological function, there was no difference for BVM versus ETI and SGA versus ETI in pediatric patients with cardiac arrest. There was no difference in BVM versus ETI in adults with cardiac arrest, but improved neurological function with BVM or ETI versus SGA. There was no difference in ROSC for patients with cardiac arrest for BVM versus ETI or SGA in adults and pediatrics, or SGA versus ETI in pediatrics. There was higher frequency of ROSC in adults with SGA versus ETI. For successful advanced airway insertion, there was higher first-pass success with SGA versus ETI for all patients except adult medical patients (no difference), and no difference in overall success using SGA versus ETI in adults. Conclusions: The currently available evidence does not indicate benefits of more invasive airway approaches based on survival, neurological function, ROSC, or successful airway insertion. Strength of evidence was low or moderate; most included studies were observational. This supports the need for high-quality randomized controlled trials to advance clinical practice and EMS education and policy, and improve patient-centered outcomes.
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40
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Nichols M, Fouche PF, Bendall JC. Video versus direct laryngoscopy by specialist paramedics in New South Wales: Preliminary results from a new airway registry. Emerg Med Australas 2022; 34:984-988. [PMID: 35717028 DOI: 10.1111/1742-6723.14033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/18/2022] [Accepted: 05/25/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Video laryngoscopy (VL) is increasingly used as an alternative to direct laryngoscopy (DL) to improve airway visualisation and endotracheal intubation (ETI) success. Intensive Care Paramedics in New South Wales Ambulance, Australia started using VL in 2020, and recorded success in a new advanced airway registry. We used this registry to compare VL to DL. METHODS The present study was a retrospective analysis of out-of-hospital data for ETI by specialist paramedics using an airway registry. We calculated overall and first-pass success for VL versus DL, and compared success using a Χ2 test. RESULTS The DL overall success was 61 out of 78 (78.2%) and VL was 233 out of 246 (94.7%); difference of 16.5% (P < 0.001). First-pass for DL was successful for 49 out of 78 (62.8%) and for VL in 195 out of 246 (79.3%); difference of 16.5% (P = 0.003). There were five (1.6%) patients where both VL and DL were used and in all instances, DL was used first. CONCLUSIONS This analysis of a new airway registry used by specialist paramedics in New South Wales shows a substantial increase in overall and first-pass intubation success with the use of VL when compared to DL.
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Affiliation(s)
- Martin Nichols
- Clinical Systems, New South Wales Ambulance, Sydney, New South Wales, Australia
| | - Pieter F Fouche
- Clinical Systems, New South Wales Ambulance, Sydney, New South Wales, Australia
| | - Jason C Bendall
- Clinical Systems, New South Wales Ambulance, Sydney, New South Wales, Australia
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41
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Jung E, Ro YS, Ryu HH, Shin SD. Association of prehospital airway management technique with survival outcomes of out-of-hospital cardiac arrest patients. PLoS One 2022; 17:e0269599. [PMID: 35666760 PMCID: PMC9170082 DOI: 10.1371/journal.pone.0269599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/24/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Despite numerous studies on airway management in out-of-hospital cardiac arrest (OHCA) patients, the choice of prehospital airway management technique remains controversial. Our study aimed to investigate the association between prehospital advanced airway management and survival outcomes according to a transport time interval (TTI) using nationwide OHCA registry database in Korea. Methods The inclusion criteria were patients with OHCA aged over 18 years old with a presumed cardiac etiology between January 2015 and December 2018. The primary outcome was survival to hospital discharge. The main exposure was the prehospital airway management technique performed by the emergency medical technicians (EMTs), classified as bag-valve mask (BVM), supraglottic airway (SGA), or endotracheal intubation (ETI).We performed multivariable logistic regression analysis and interaction analysis between the type of airway management and TTI for adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Results Of a total of 70,530 eligible OHCA patients, 26,547 (37.6%), 38,391 (54.4%), and 5,592 (7.9%) were managed with BVM, SGA, ETI, respectively. Patients in the SGA and ETI groups had a higher odds of survival to discharge than BVM groups (aOR, 1.11 (1.05–1.16) and 1.13 (1.05–1.23)). And the rates of survival to discharge with SGA and ETI were significantly higher in groups with TTI more than 8 minutes (1.17 (1.08–1.27) and 1.38 (1.20–1.59)). Conclusion The survival to discharge was significantly higher among patients who received ETI and SGA than in those who received BVM. The transport time interval influenced the effect of prehospital airway management on the clinical outcomes after OHCA.
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Affiliation(s)
- Eujene Jung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Young Sun Ro
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun Ho Ryu
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University College of Medicine, Gwangju, Republic of Korea
- * E-mail:
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Segond N, Bellier A, Duhem H, Sanchez C, Busi O, Deutsch S, Aguilera L, Truan D, Koch FX, Viglino D, Debaty G. Supraglottic airway device to improve ventilation success and reduce pulmonary aspiration during cardio-pulmonary resuscitation by basic life support rescuers: a randomised cross-over human cadaver study. PREHOSP EMERG CARE 2022:1-9. [PMID: 35543652 DOI: 10.1080/10903127.2022.2075994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Objectives: Early airway management during cardiopulmonary resuscitation (CPR) prevents aspiration of gastric contents. Endotracheal intubation is the gold standard to protect airways, but supraglottic airway devices (SGA) may provide some protection with less training. Bag-mask ventilation (BMV) is the most common method used by rescuers. We hypothesized that SGA use by first rescuers during CPR could increase ventilation success rate and also decrease intragastric pressure and pulmonary aspiration.Methods: We performed a randomized cross-over experimental trial on human cadavers. Protocol A: we assessed the rate of successful ventilation (chest rise), intragastric pressure, and CPR key time metrics. Protocol B: cadaver stomachs were randomized to be filled with 300 mL of either blue or green serum saline solution through a Foley catheter. Each rescuer was randomly assigned to use SGA or BMV during a 5-minute standard CPR period. Then, in a crossover design, the stomach was filled with the second colour solution and another 5-minute CPR period was performed using the other airway method. Pulmonary aspiration, defined as the presence of coloured solution below the vocal cords, was assessed by a blinded operator using bronchoscopy. A generalized linear mixed model was used for statistical analysis.Results: Protocol A: Forty-eight rescuers performed CPR on 11 cadavers. Median ventilation success was higher with SGA than BMV: 75.0% (IQR: 59.8-87.3) vs. 34.7% (IQR: 25.0-50.0), (p = 0.003). Gastric pressure and differential (maximum minus minimum) gastric pressure were lower in the SGA group: 2.21 mmHg (IQR: 1.66; 2.68) vs. 3.02 mmHg (IQR: 2.02; 4.22) (p = 0.02) and 5.70 mmHg (IQR: 4.10; 7.60) vs. 8.05 mmHg (IQR: 5.40; 11.60) (p = 0.05). CPR key times were not different between groups. Protocol B: Ten cadavers were included with 20 CPR periods. Aspiration occurred in 2 (20%) SGA procedures and 5 (50%) BMV procedures (p = 0.44).Conclusion: Use of SGA by rescuers improved the ventilation success rate, decreased intragastric pressure, and did not affect key CPR metrics. SGA use by basic life support rescuers appears feasible and efficient.
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Affiliation(s)
- N Segond
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France.,CNRS TIMC Laboratory, UMR 5525, Univ. Grenoble Alpes, Grenoble, France
| | - A Bellier
- CNRS TIMC Laboratory, UMR 5525, Univ. Grenoble Alpes, Grenoble, France.,LADAF-Laboratoire d'Anatomie Des Alpes Françaises, Univ. Grenoble Alpes, Grenoble, France
| | - H Duhem
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France.,CNRS TIMC Laboratory, UMR 5525, Univ. Grenoble Alpes, Grenoble, France
| | - C Sanchez
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France
| | - O Busi
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France
| | - S Deutsch
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France
| | - L Aguilera
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France
| | - D Truan
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France
| | - F X Koch
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France
| | - D Viglino
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France.,INSERM U1300, HP2 Laboratory, Univ. Grenoble Alpes, Grenoble, France
| | - G Debaty
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France.,CNRS TIMC Laboratory, UMR 5525, Univ. Grenoble Alpes, Grenoble, France
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43
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Chang H, Jeong D, Park JE, Kim T, Lee GT, Yoon H, Hwang SY, Cha WC, Shin TG, Sim MS, Jo IJ, Lee S, Shin SD, Choi J. Prehospital airway management for out-of-hospital cardiac arrest: A nationwide multicenter study from the KoCARC registry. Acad Emerg Med 2022; 29:581-588. [PMID: 35064725 DOI: 10.1111/acem.14443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 12/31/2021] [Accepted: 01/07/2022] [Indexed: 01/01/2023]
Abstract
AIM This study investigated whether prehospital advanced airway management (AAM) is associated with improved survival of out-of-hospital cardiac arrest (OHCA) compared with conventional bag-valve-mask (BVM) ventilation. METHODS We investigated the neurologically favorable survival of adult patients with OHCA who underwent BVM or AAM using the Korean Cardiac Arrest Research Consortium (KoCARC), a multicenter OHCA registry of Korea. The differences in clinical characteristics were adjusted by matching or weighting the clinical propensity for use of AAM or by least absolute shrinkage and selection operator (LASSO). The primary outcome was 30-day survival with neurologically favorable status defined by cerebral performance category 1 or 2. RESULTS Of the 9,616 patients enrolled (median age = 71 years; 65% male), there were 6,243 AAM and 3,354 BVM patients. In unadjusted analysis, the 30-day neurologically favorable survival was lower in the AAM group compared with the BVM group (5.5% vs. 10.0%; hazard ratio [HR] = 1.21, 95% confidence interval [CI] = 1.16 to 1.27; all p < 0.001). In propensity score matching-adjusted analysis, these differences were not found (9.6% vs. 10.0%; HR = 0.98, 95% CI = 0.93 to 1.03, p > 0.05). Inverse probability of treatment weighting- and LASSO-adjusted analyses replicated these results. CONCLUSIONS In this nationwide real-world data analysis of OHCA, the 30-day neurologically favorable survival did not differ between prehospital AAM and BVM after adjustment for clinical characteristics.
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Affiliation(s)
- Hansol Chang
- Department of Emergency Medicine Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul Republic of Korea
- Department of Digital Health SAIHST, Sungkyunkwan University Seoul South Korea
| | - Daun Jeong
- Department of Emergency Medicine Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Jong Eun Park
- Department of Emergency Medicine Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Taerim Kim
- Department of Emergency Medicine Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Gun Tak Lee
- Department of Emergency Medicine Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Hee Yoon
- Department of Emergency Medicine Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Sung Yeon Hwang
- Department of Emergency Medicine Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Won Chul Cha
- Department of Emergency Medicine Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul Republic of Korea
- Department of Digital Health SAIHST, Sungkyunkwan University Seoul South Korea
| | - Tae Gun Shin
- Department of Emergency Medicine Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Min Seob Sim
- Department of Emergency Medicine Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Ik Joon Jo
- Department of Emergency Medicine Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Seung‐Hwa Lee
- Department of Medicine Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Sang Do Shin
- Department of Emergency Medicine College of Medicine, Seoul National University Seoul Republic of Korea
| | - Jin‐Ho Choi
- Department of Emergency Medicine Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul Republic of Korea
- Department of Digital Health SAIHST, Sungkyunkwan University Seoul South Korea
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Kane A, Nolan J. Changes to the European Resuscitation Council guidelines for adult resuscitation. BJA Educ 2022; 22:265-272. [DOI: 10.1016/j.bjae.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 11/26/2022] Open
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45
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Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H, South A, Stokes EA, Taylor J, Thomas M, Voss S, Wordsworth S, Rogers CA. Supraglottic airway device versus tracheal intubation in the initial airway management of out-of-hospital cardiac arrest: the AIRWAYS-2 cluster RCT. Health Technol Assess 2022; 26:1-158. [PMID: 35426781 PMCID: PMC9082259 DOI: 10.3310/vhoh9034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND When a cardiac arrest occurs, cardiopulmonary resuscitation should be started immediately. However, there is limited evidence about the best approach to airway management during cardiac arrest. OBJECTIVE The objective was to determine whether or not the i-gel® (Intersurgical Ltd, Wokingham, UK) supraglottic airway is superior to tracheal intubation as the initial advanced airway management strategy in adults with non-traumatic out-of-hospital cardiac arrest. DESIGN This was a pragmatic, open, parallel, two-group, multicentre, cluster randomised controlled trial. A cost-effectiveness analysis accompanied the trial. SETTING The setting was four ambulance services in England. PARTICIPANTS Patients aged ≥ 18 years who had a non-traumatic out-of-hospital cardiac arrest and were attended by a participating paramedic were enrolled automatically under a waiver of consent between June 2015 and August 2017. Follow-up ended in February 2018. INTERVENTION Paramedics were randomised 1 : 1 to use tracheal intubation (764 paramedics) or i-gel (759 paramedics) for their initial advanced airway management and were unblinded. MAIN OUTCOME MEASURES The primary outcome was modified Rankin Scale score at hospital discharge or 30 days after out-of-hospital cardiac arrest, whichever occurred earlier, collected by assessors blinded to allocation. The modified Rankin Scale, a measure of neurological disability, was dichotomised: a score of 0-3 (good outcome) or 4-6 (poor outcome/death). The primary outcome for the economic evaluation was quality-adjusted life-years, estimated using the EuroQol-5 Dimensions, five-level version. RESULTS A total of 9296 patients (supraglottic airway group, 4886; tracheal intubation group, 4410) were enrolled [median age 73 years; 3373 (36.3%) women]; modified Rankin Scale score was known for 9289 patients. Characteristics were similar between groups. A total of 6.4% (311/4882) of patients in the supraglottic airway group and 6.8% (300/4407) of patients in the tracheal intubation group had a good outcome (adjusted difference in proportions of patients experiencing a good outcome: -0.6%, 95% confidence interval -1.6% to 0.4%). The supraglottic airway group had a higher initial ventilation success rate than the tracheal intubation group [87.4% (4255/4868) vs. 79.0% (3473/4397), respectively; adjusted difference in proportions of patients: 8.3%, 95% confidence interval 6.3% to 10.2%]; however, patients in the tracheal intubation group were less likely to receive advanced airway management than patients in the supraglottic airway group [77.6% (3419/4404) vs. 85.2% (4161/4883), respectively]. Regurgitation rate was similar between the groups [supraglottic airway group, 26.1% (1268/4865); tracheal intubation group, 24.5% (1072/4372); adjusted difference in proportions of patients: 1.4%, 95% confidence interval -0.6% to 3.4%], as was aspiration rate [supraglottic airway group, 15.1% (729/4824); tracheal intubation group, 14.9% (647/4337); adjusted difference in proportions of patients: 0.1%, 95% confidence interval -1.5% to 1.8%]. The longer-term outcomes were also similar between the groups (modified Rankin Scale: at 3 months, odds ratio 0.89, 95% confidence interval 0.69 to 1.14; at 6 months, odds ratio 0.91, 95% confidence interval 0.71 to 1.16). Sensitivity analyses did not alter the overall findings. There were no unexpected serious adverse events. Mean quality-adjusted life-years to 6 months were 0.03 in both groups (supraglottic airway group minus tracheal intubation group difference -0.0015, 95% confidence interval -0.0059 to 0.0028), and total costs were £157 (95% confidence interval -£270 to £583) lower in the tracheal intubation group. Although the point estimate of the incremental cost-effectiveness ratio suggested that tracheal intubation may be cost-effective, the huge uncertainty around this result indicates no evidence of a difference between groups. LIMITATIONS Limitations included imbalance in the number of patients in each group, caused by unequal distribution of high-enrolling paramedics; crossover between groups; and the fact that participating paramedics, who were volunteers, might not be representative of all paramedics in the UK. Findings may not be applicable to other countries. CONCLUSION Among patients with out-of-hospital cardiac arrest, randomisation to the supraglottic airway group compared with the tracheal intubation group did not result in a difference in outcome at 30 days. There were no notable differences in costs, outcomes and overall cost-effectiveness between the groups. FUTURE WORK Future work could compare alternative supraglottic airway types with tracheal intubation; include a randomised trial of bag mask ventilation versus supraglottic airways; and involve other patient populations, including children, people with trauma and people in hospital. TRIAL REGISTRATION This trial is registered as ISRCTN08256118. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and supported by the NIHR Comprehensive Research Networks and will be published in full in Health Technology Assessment; Vol. 26, No. 21. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jonathan R Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Kim Kirby
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
- Research, Audit and Improvement Department, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Sarah Black
- Research, Audit and Improvement Department, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Stephen J Brett
- Department of Surgery and Cancer, Imperial College Healthcare NHS Trust, London, UK
| | - Madeleine Clout
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Michelle J Lazaroo
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Jerry P Nolan
- Bristol Medical School, University of Bristol, Bristol, UK
- Department of Anaesthesia, Royal United Hospital, Bath, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Maria Robinson
- Research, Audit and Improvement Department, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Lauren J Scott
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West), Bristol, UK
| | - Helena Smartt
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Adrian South
- Research, Audit and Improvement Department, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Elizabeth A Stokes
- Health Economic Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- National Institute for Health and Care Research Oxford Biomedical Research Centre, Oxford, UK
| | - Jodi Taylor
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew Thomas
- Intensive Care Unit, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Sarah Voss
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Sarah Wordsworth
- Health Economic Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- National Institute for Health and Care Research Oxford Biomedical Research Centre, Oxford, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
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Tang Y, Sun M, Zhu A. Outcome of cardiopulmonary resuscitation with different ventilation modes in adults: A meta-analysis. Am J Emerg Med 2022; 57:60-69. [DOI: 10.1016/j.ajem.2022.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 04/17/2022] [Accepted: 04/20/2022] [Indexed: 10/18/2022] Open
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Hongo T, Yumoto T, Naito H, Mikane T, Nakao A. Impact of different medical direction policies on prehospital advanced airway management for out-of hospital cardiac arrest patients: A retrospective cohort study. Resusc Plus 2022; 9:100210. [PMID: 35252900 PMCID: PMC8888968 DOI: 10.1016/j.resplu.2022.100210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/28/2021] [Accepted: 01/19/2022] [Indexed: 12/26/2022] Open
Abstract
Background Although optimal prehospital airway management after out-of-hospital cardiac arrest (OHCA) remains undetermined, no studies have compared different advanced airway management (AAM) policies adopted by two hospitals in charge of online medical direction by emergency physicians. We examined the impact of two different AAM policies on OHCA patient survival. Methods This observational cohort study included adult OHCA patients treated in Okayama City from 2013 to 2016. Patients were divided into two groups: the O group - those treated on odd days when a hospital with a policy favoring laryngeal tube ventilation (LT) supervised, and the E group - those treated on even days when the other hospital with a policy favoring endotracheal intubation (ETI) supervised. Multiple logistic regression analysis was performed to assess airway device effects. The primary outcome measure was seven-day survival. Results Of 2,406 eligible patients, 50.1% were in the O group and 49.9% were in the E group. O group patients received less ETI (1.0% vs. 12.0%) and more LT (53.3% vs. 43.0%) compared with E group patients. In univariate analysis, no differences were observed in seven-day survival (9.4% vs 10.1%). Multiple regression analysis revealed neither LT nor ETI had a significant independent effect on seven-day survival, considering bag-valve mask ventilation as a reference (OR, 0.78; 95% CI, 0.54 to 1.13, OR, 0.79; 95% CI, 0.36 to 1.72, respectively). Conclusion Despite different advanced airway medical direction policies in a single city, there were no substantial impact on outcomes for OHCA patients.
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Affiliation(s)
- Takashi Hongo
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Japan
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Japan
- Corresponding author at: Okayama University Hospital, Advanced Emergency and Critical Care Medical Center, 2-5-1 Shikata, Okayama 700-8558, Japan.
| | - Takeshi Mikane
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Okayama Hospital, Japan
| | - Atsunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Japan
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Lyng JW, Baldino KT, Braude D, Fritz C, March JA, Peterson TD, Yee A. Prehospital Supraglottic Airways: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:32-41. [PMID: 35001830 DOI: 10.1080/10903127.2021.1983680] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Supraglottic airway (SGA) devices provide effective conduits for oxygenation and ventilation and may offer protection from gastric aspiration. SGA devices are widely used by EMS clinicians as both rescue and primary airway management devices. While in common use for more than four decades, major developments in SGA education, science, and technology have influenced clinical strategies of SGA insertion and use in prehospital airway management for patients of all ages. NAEMSP recommends:SGAs have utility as a primary or secondary EMS airway intervention. EMS agencies should select SGA strategies that best suit available resources and local clinician skillset, as well as the nature of their clinical practice setting.EMS agencies that perform endotracheal intubation must also equip their clinicians with SGA devices and ensure adequate training and competence.In select situations, drug-assisted airway management may be used by properly credentialed EMS clinicians to facilitate SGA insertion.Confirmation of initial and continuous SGA placement using waveform capnography is strongly encouraged as a best practice.When it is functioning properly, EMS clinicians should refrain from converting an SGA to an endotracheal tube. The decision to convert an SGA to an endotracheal tube must consider the patient's condition, the effectiveness of SGA ventilations, and the clinical context and course of initial SGA insertionSGA training, competency, and clinical use must be continuously evaluated by EMS agencies using focused quality management programs.
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Carlson JN, Colella MR, Daya MR, J De Maio V, Nawrocki P, Nikolla DA, Bosson N. Prehospital Cardiac Arrest Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:54-63. [PMID: 35001831 DOI: 10.1080/10903127.2021.1971349] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Airway management is a critical component of out-of-hospital cardiac arrest (OHCA) resuscitation. Multiple cardiac arrest airway management techniques are available to EMS clinicians including bag-valve-mask (BVM) ventilation, supraglottic airways (SGAs), and endotracheal intubation (ETI). Important goals include achieving optimal oxygenation and ventilation while minimizing negative effects on physiology and interference with other resuscitation interventions. NAEMSP recommends:Based on the skill of the clinician and available resources, BVM, SGA, or ETI may be considered as airway management strategies in OHCA.Airway management should not interfere with other key resuscitation interventions such as high-quality chest compressions, rapid defibrillation, and treatment of reversible causes of the cardiac arrest.EMS clinicians should take measures to avoid hyperventilation during cardiac arrest resuscitation.Where available for clinician use, capnography should be used to guide ventilation and chest compressions, confirm and monitor advanced airway placement, identify return of spontaneous circulation (ROSC), and assist in the decision to terminate resuscitation.
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Abstract
OBJECTIVES Airway management during in-hospital cardiac arrest represents a fundamental component of resuscitative efforts, yet little is known about temporal trends in intubation during in-hospital cardiac arrest. Our objective was to investigate changes in in-hospital cardiac arrest airway management over time and in response to national guideline updates. DESIGN Observational cohort study of a prospectively collected database. SETTING Multicenter study of hospitals participating in the "Get With The Guidelines-Resuscitation" registry from January 1, 2001, to December 31, 2018. SUBJECTS Adult patients who experienced an in-hospital cardiac arrest and did not have an invasive airway in place prior to the arrest. INTERVENTIONS The primary outcome was the rate of intra-arrest intubation from 2001 to 2018. We constructed multivariable regression models with generalized estimating equations to determine the annual adjusted odds of intubation. We also assessed the timing of intubation relative to the onset of pulselessness and other arrest measures. We used an interrupted time-series analysis to assess the association between the 2010 Advanced Cardiac Life Support guideline update and intubation rates. MEASUREMENTS AND MAIN RESULTS One thousand sixty-six eight hundred patients from 797 hospitals were included. From 2001 to 2018, the percentage of patients intubated during an arrest decreased from 69% to 55% for all rhythms, 73% to 60% for nonshockable rhythms, and 58% to 36% for shockable rhythms (p < 0.001 for trend for all 3 groups). The median time from onset of pulselessness to intubation increased from 5 minutes in 2001 (interquartile range, 2-8 min) to 6 minutes in 2018 (interquartile range, 4-10 min) (p < 0.001 for trend). Following the 2010 guideline update, there was a downward step change and a steeper decrease over time in the rate of intubation as compared to the preintervention period (p < 0.001). CONCLUSIONS Endotracheal intubation rates during in-hospital cardiac arrest have decreased significantly over time, with a more substantial decline following the updated 2010 guideline that prioritized chest compressions over airway management.
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