Prehospital endotracheal intubation and survival after out-of-hospital cardiac arrest: results from the Korean nationwide registry

Prehospital factors predicting mortality in patients with shock: state-wide linkage study

BACKGROUND

Patients with shock treated by emergency medical services (EMS) have high morbidity and mortality. Knowledge of prehospital factors predicting outcomes in patients with shock remains limited. We aimed to describe the prehospital predictors of mortality in patients with non-traumatic shock transported to hospital by EMS.

METHOD

This is a retrospective cohort study of consecutive ambulance attendances for non-traumatic shock in Victoria, Australia (January 2015-June 2019) linked with government-held administrative data (emergency, admissions and mortality records). Predictors of 30-day mortality were assessed using Cox proportional regressions. The primary outcome was 30-day all-cause mortality.

RESULTS

Overall, 21 334 patients with non-traumatic shock (median age 69 years, 54.8% female) were successfully linked with state administrative records. Among this cohort, 9 149 (43%) patients died within 30-days. Compared with survivors, non-survivors had a longer median on-scene time: 60 (35-98) versus 30 (19-50), p <0.001. Non-survivors were more likely to be older (median age in years: 74 (61-84) vs 65 (47-78), p<0.001), had prehospital cardiac arrest requiring cardiopulmonary resuscitation (adjusted HR (aHR)=6.26, 95% CI 5.87, 6.69) and had prehospital intubation (aHR=1.07, CI 1.00, 1.14). Reduced 30-day mortality was associated with administration of epinephrine (aHR=0.66, CI 0.62, 0.71) and systolic blood pressures above 80 mm Hg in the prehospital setting.

CONCLUSION

The 30-day mortality from non-traumatic shock is high at 43%. Independent predictors of mortality included age, prehospital cardiac arrest and endotracheal intubation. Interventions that target reversible causes of short-term mortality in patients with non-traumatic shock are a high priority.

Evidence-Based Guideline for Prehospital Airway Management

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.

Prehospital Airway Management: A Systematic Review

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.

Association of transport time interval with neurologic outcome in out-of-hospital cardiac arrest patients without return of spontaneous circulation on scene and the interaction effect according to prehospital airway management

Objective

This study analyzed the association of transport time interval (TTI) with survival rate and neurologic outcome in out-of-hospital cardiac arrest (OHCA) patients without return of spontaneous circulation (ROSC) and the interaction effect of TTI according to prehospital airway management.

Methods

A retrospective observational study based on the nationwide OHCA database from January 2013 to December 2017 was designed. Emergency medical service (EMS)-treated OHCA patients aged ≥18 years were included. TTI was categorized into four groups of quartiles (≤4, 5–7, 8–11, ≥12 minutes). The primary outcome was favorable neurologic outcome at discharge. The secondary outcome was survival to discharge from the hospital. Multivariable logistic regression was used to analyze outcomes according to TTI. A different effect of TTI according to the administration of prehospital EMS advanced airway was evaluated.

Results

In total, 83,470 patients were analyzed. Good neurologic recovery decreased as TTI increased (1.0% for TTI ≤4 minutes, 0.9% for TTI 5–7 minutes, 0.6% for TTI 8–11 minutes, and 0.5% for TTI ≥12 minutes; P for trend <0.05). The adjusted odds ratio of prolonged TTI (≥12 minutes) was 0.73 (95% confidence interval, 0.57–0.93; P<0.01) for good neurologic recovery. However, the negative effect of prolonged TTI on neurological outcome was insignificant when advanced airway or entotracheal intubation were performed by EMS providers (adjusted odds ratio, 1.17; 95% confidence interval, 0.42–3.29; P=0.76).

Conclusion

EMS TTI was negatively associated with the neurologic outcome of OHCA without ROSC on scene. When advanced airway was performed on scene, TTI was insignificantly associated with the outcome.

Prehospital airway management for out-of-hospital cardiac arrest: A nationwide multicenter study from the KoCARC registry

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.

Endotracheal tube manipulation during cardiopulmonary resuscitation in the neonatal intensive care unit

OBJECTIVES

We sought to describe the approach to and impact of endotracheal tube (ETT) placement for cardiopulmonary resuscitation (CPR) occurring in the neonatal intensive care unit (NICU).

STUDY DESIGN

A retrospective review of in-NICU CPR from 2012 to 2017 across ten NICUs in San Antonio, Texas.

RESULTS

Of 209 CPR events, 22 (10.5%) patients required ETT placement at CPR onset, 23 (11%) had an existing ETT removed and replaced, and 8 (3.4%) both. We found no association between time without an ETT tube during CPR and time to return of spontaneous circulation (ROSC) or rate of ROSC. We found no documented use of a laryngeal mask airway during in-NICU CPR.

CONCLUSIONS

For CPR occurring in the NICU, the achievement of ROSC or time to ROSC is not impacted by the need to place an initial AA at the onset of CPR in this contemporary cohort.

Characteristics and outcomes of public bath-related out-of-hospital cardiac arrests in South Korea

Objective

To analyze the differences in characteristics and outcomes between public bath (PB)-related and non-PB-related out-of-hospital cardiac arrest (OHCA) patients in South Korea.

Methods

We performed a retrospective observational analysis of collected data from the Smart Advanced Cardiac Life Support (SALS) registry between September 2015 and December 2018. We included adult OHCA patients (aged >18 years) with presumed OHCA of non-traumatic etiology who were attended by dispatched emergency medical services. SALS is a field advanced life support with smartphone-based direct medical direction. The primary outcome was the survival to discharge rate measured at the time of discharge.

Results

Of 38,995 cardiac arrest patients enrolled in the SALS registry, 11,889 were included in the final analysis. In total, 263 OHCAs occurred in PBs. Male sex and bystander cardiopulmonary resuscitation proportions appeared to be higher among PB patients than among non-PB patients. Percentages for shockable rhythm, witnessed rate, and number of underlying disease were lower in the PB group than in the non-PB group. Prehospital return of spontaneous circulation (11.4% vs. 19.5%, P=0.001), survival to discharge (2.3% vs. 9.9%, P<0.001), and favorable neurologic outcome (1.9% vs. 5.8%, P=0.007) in PB patients were significantly poorer than those in non-PB patients.

Conclusion

Patient characteristics and emergency medical services factors differed between PB and non-PB patients. All outcomes of PB-related OHCA were poorer than those of non-PB-related OHCA. Further treatment strategies should be developed to improve the outcomes of PB-related cardiac arrest.

A review of ventilation in adult out-of-hospital cardiac arrest

Out-of-hospital cardiac arrest continues to be a devastating condition despite advances in resuscitation care. Ensuring effective gas exchange must be weighed against the negative impact hyperventilation can have on cardiac physiology and survival. The goals of this narrative review are to evaluate the available evidence regarding the role of ventilation in out-of-hospital cardiac arrest resuscitation and to provide recommendations for future directions. Ensuring successful airway patency is fundamental for effective ventilation. The airway management approach should be based on professional skill level and the situation faced by rescuers. Evidence has explored the influence of different ventilation rates, tidal volumes, and strategies during out-of-hospital cardiac arrest; however, other modifiable factors affecting out-of-hospital cardiac arrest ventilation have limited supporting data. Researchers have begun to explore the impact of ventilation in adult out-of-hospital cardiac arrest outcomes, further stressing its importance in cardiac arrest resuscitation management. Capnography and thoracic impedance signals are used to measure ventilation rate, although these strategies have limitations. Existing technology fails to reliably measure real-time clinical ventilation data, thereby limiting the ability to investigate optimal ventilation management. An essential step in advancing cardiac arrest care will be to develop techniques to accurately and reliably measure ventilation parameters. These devices should allow for immediate feedback for out-of-hospital practitioners, in a similar way to chest compression feedback. Once developed, new strategies can be established to guide out-of-hospital personnel on optimal ventilation practices.

Personalized physiology-guided resuscitation in highly monitored patients with cardiac arrest-the PERSEUS resuscitation protocol

Resuscitation guidelines remain uniform across all cardiac arrest patients, focusing on the delivery of chest compressions to a standardized rate and depth and algorithmic vasopressor dosing. However, individualizing resuscitation to the appropriate hemodynamic and ventilatory goals rather than a standard "one-size-fits-all" treatment seems a promising new therapeutic strategy. In this article, we present a new physiology-guided treatment strategy to titrate the resuscitation efforts to patient's physiologic response after cardiac arrest. This approach can be applied during resuscitation attempts in highly monitored patients, such as those in the operating room or the intensive care unit, and could serve as a method for improving tissue perfusion and oxygenation while decreasing post-resuscitation adverse effects.

Comparing the neurologic outcomes of patients with out-of-hospital cardiac arrest according to prehospital advanced airway management method and transport time interval

OBJECTIVE

The incidences of prehospital advanced airway management by emergency medical technicians in South Korea are increasing; however, whether this procedure improves the survival outcomes of patients experiencing out-of-hospital cardiac arrest remains unclear. The present study aimed to investigate the association between prehospital advanced airway management and neurologic outcomes according to a transport time interval (TTI) using the Korean Cardiac Arrest Research Consortium database.

METHODS

We retrospectively analyzed the favorable database entries that were prospectively collected between October 2015 and December 2016. Patients aged 18 years or older who experienced cardiac arrest that was presumed to be of a medical etiology and that occurred prior to the arrival of emergency medical service personnel were included. The exposure variable was the type of prehospital airway management provided by emergency medical technicians. The primary endpoint was a favorable neurologic outcome.

RESULTS

Of 1,871 patients who experienced out-of-hospital cardiac arrest, 785 (42.0%), 121 (6.5%), and 965 (51.6%) were managed with bag-valve-mask ventilation, endotracheal intubation (ETI), and supraglottic airway (SGA) devices, respectively. SGAs and ETI provided no advantage in terms of favorable neurologic outcome in patients with TTIs ≥12 minutes (odds ratio [OR], 1.37; confidence interval [CI], 0.65-2.87 for SGAs; OR, 1.31; CI, 0.30-5.81 for ETI) or in patients with TTI <12 minutes (OR, 0.57; CI, 0.31-1.07 for SGAs; OR, 0.63; CI, 0.12-3.26 for ETI).

CONCLUSION

Neither the prehospital use of SGA nor administration of ETI was associated with superior neurologic outcomes compared with bag-valve-mask ventilation.

Bag-Valve Mask versus Endotracheal Intubation in Out-of-Hospital Cardiac Arrest on Return of Spontaneous Circulation: A National Database Study

Background

Out-of-hospital cardiac arrest is the main issue for pre-hospital emergency care. There are several airway managements during the out-of-hospital cardiopulmonary resuscitation (CPR) such as endotracheal intubation (ETI) or alternative airway device: bag-valve mask (BVM). Data comparing both methods showed inconclusive results on survival and limited results on CPR outcome. This study aimed to add additional results on comparing the ETI and BVM in cardiac arrest outside hospitals; focused on the CPR outcome.

Methods

This study was a retrospective, analytical study. The inclusion criteria were adult patients (age of 18 years or over) with out-of-hospital cardiac arrest, who received emergency life support, and received either BVM or ETI. Data were retrieved from the Information Technology of Emergency Medical Service. The outcome was a return of spontaneous circulation (ROSC).

Results

During the study period, there were 1070 patients with out-of-hospital cardiac arrest who met the study criteria. Of those, 800 patients (74.77%) received BVM, while the other 270 patients (25.23%) received ETI. There were five significant factors between both groups including mean distance to scene, proportions of response time less than 8 mins, defibrillation, intravenous fluid administration, and adrenaline administration. There was no significant difference on the outcome: ROSC. The BVM group had slightly higher rate of ROSC than the ETI group (19.63% vs 15.56%; p value 0.148).

Conclusion

The BVM and ETI had comparable ROSC rate for out-of-hospital cardiac arrest victims. However, the study population of the BVM group had less severe conditions and received faster treatment than the ETI group.

The suction-assisted laryngoscopy assisted decontamination technique toward successful intubation during massive vomiting simulation: A pilot before-after study

This study demonstrated a training program of the suction-assisted laryngoscopy assisted decontamination (S.A.L.A.D.) technique for emergency medical technician paramedic (EMT-P). The effectiveness of the training program on the improvements of skills and confidence in managing soiled airway was evaluated.In this pilot before-after study, 41 EMT-P participated in a training program which consisted of 1 training course and 3 evaluation scenarios. The training course included lectures, demonstration, and practice and focused on how to perform endotracheal intubation in soiled airway with the S.A.L.A.D technique. The first scenario was performed on standard airway mannequin head with clean airway (control scenario). The second scenario (pre-training scenario) and the third scenario (post-training scenario) were performed in airway with simulated massive vomiting. The post-training scenario was applied immediately after the training course. All trainees were requested to perform endotracheal intubation for 3 times in each scenario. The "pass" of a scenario was defined as more than twice successful intubation in a scenario. The intubation time, count of successful intubation, pass rate, and the confidence in endotracheal intubation were evaluated.The intubation time in the post-training scenario was significantly shorter than that in the pre-training scenario (P = .031). The pass rate of the control, pre-training, and post-training scenario was 100%, 82.9%, and 92.7%, respectively. The proportion of trainees reporting confident or very confident in endotracheal intubation in soiled airway increased from 22.0% to 97.6% after the training program. Kaplan-Meier analysis revealed that the adjusted hazard ratio of successful intubation for post-training versus pre-training scenario was 2.13 (95% confidence interval of 1.57-2.91).The S.A.L.A.D. technique training could efficiently help EMT-P performing endotracheal intubation during massive vomiting simulation.

Application of a Dual-Dispatch System for Out-of-Hospital Cardiac Arrest Patients: Will More Hands Save More Lives?

BACKGROUND

Recovery after out-of-hospital cardiac arrest (OHCA) is difficult, and emergency medical services (EMS) systems apply various strategies to improve outcomes. Multi-dispatch is one means of providing high-quality cardiopulmonary resuscitation (CPR), but no definitive best-operation guidelines are available. We assessed the effects of a basic life support (BLS)-based dual-dispatch system for OHCA.

METHODS

This prospective observational study of 898 enrolled OHCA patients, conducted in Daegu, Korea from March 1, 2015 to June 30, 2016, involved patients > 18 years old with suspected cardiac etiology OHCA. In Daegu, EMS started a BLS-based dual-dispatch system in March 2015, for cases of cardiac arrest recognition by a dispatch center. We assessed the association between dual-dispatch and OHCA outcomes using multivariate logistic regressions. We also analyzed the effect of dual-dispatch according to the stratified on-scene time.

RESULTS

Of 898 OHCA patients (median, 69.0 years; 65.5% men), dual-dispatch was applied in 480 (53.5%) patients. There was no difference between the single-dispatch group (SDG) and the dual-dispatch group (DDG) in survival at discharge and neurological outcomes (survival discharge, P = 0.176; neurological outcomes, P = 0.345). In the case of less than 10 minutes of on-scene time, the adjusted odds ratio was 1.749 (95% confidence interval [CI], 0.490-6.246) for survival discharge and 6.058 (95% CI, 1.346-27.277) for favorable neurological outcomes in the DDG compared with the SDG.

CONCLUSION

Dual-dispatch was not associated with better OHCA outcomes for the entire study population, but showed favorable neurological outcomes when the on-scene time was less than 10 minutes.

Location of arrest and effect of prehospital advanced airway management after emergency medical service-witnessed out-of-hospital cardiac arrest: nationwide observational study

OBJECTIVES

To investigate the association of prehospital advanced airway management (AAM) on outcomes of emergency medical service (EMS)-witnessed out-of-hospital cardiac arrest (OHCA) according to the location of arrest.

METHODS

We evaluated a Korean national OHCA database from 2012 to 2016. Adults with EMS-witnessed, non-traumatic OHCA were included. Patients were categorised into four groups according to whether prehospital AAM was conducted (yes/no) and location of arrest ('at scene' or 'in the ambulance'). The primary outcome was discharge with good neurological recovery (cerebral performance category 1 or 2). Multivariable logistic regression analysis was conducted to evaluate the association between AAM and outcome according to the location of arrest.

RESULTS

Among 6620 cases, 1425 (21.5%) cases of arrest occurred 'at the scene', and 5195 (78.5%) cases of arrest occurred 'in an ambulance'. Prehospital AAM was performed in 272 (19.1%) OHCAs occurring 'at the scene' and 645 (12.4%) OHCAs occurring 'in an ambulance'. Patients with OHCA in the ambulance who had prehospital AAM showed the lowest good neurological recovery rate (6.0%) compared with OHCAs in the ambulance with no AAM (8.9%), OHCA at scene with AAM (10.7%) and OHCA at scene with no AAM (7.7%). For OHCAs occurring in the ambulance, the use of AAM had an adjusted OR of 0.67 (95% CI 0.45 to 0.98) for good neurological recovery.

CONCLUSION

Our data show no benefit of AAM in patients with EMS-witnessed OHCA. For patients with OHCA occurring in the ambulance, AAM was associated with worse clinical outcome.

Effect of endotracheal intubation and supraglottic airway device placement during cardiopulmonary resuscitation on carotid blood flow over resuscitation time: An experimental porcine cardiac arrest study

BACKGROUND

Supraglottic airway devices (SGDs) are widely used during the resuscitation of out-of-hospital cardiac arrest (OHCA). The effect of SGDs on carotid blood flow (CBF) as resuscitation time passes is controversial. We assessed the effects of endotracheal intubation (ETI) and 3 types of SGD placement on CBF over time in prolonged resuscitation through an experimental porcine cardiac arrest study.

METHODS

We conducted a randomized crossover study using 12 female pigs. After 4 min of untreated ventricular fibrillation, 3 pairs of ETI for 3 min and each type of SGD placement, including Combitube, I-gel, and laryngeal mask airway, for 3 min were conducted. The order of the 3 pairs of ETI and SGD were randomly assigned for each pig. We measured physiological parameters including CBF and mean arterial pressure (MAP). We compared CBF and MAP between the last 1 min of the insertion period for each of the 3 types of SGD and the preceding ETI period. Trends of CBF and MAP according to ETI and SGD transition were also plotted during the prolonged resuscitation duration.

RESULTS

CBF decreased after inserting I-gel and Combitube compared to ETI (mean difference (95% CI): -685 ml (-1052 to -318) for Combitube, -369 ml (-623 to -114) for I-gel). MAP subsequently decreased after transitioning airway devices as resuscitation was prolonged, regardless of the device type. The mean CBF during the transition from ETI to SGD decreased by -480 ml (95% CI: -675 to -286), but the decrease in CBF during the transition from SGD to ETI was only -4 ml (95% CI: -182 to 175).

CONCLUSION

SGD placement was associated with decreased carotid blood flow during cardiopulmonary resuscitation in an experimental porcine model. As time passed during prolonged resuscitation, reduction in CBF was aggravated after the transition to SGD placement compared to the reduction after the transition to ETI. This study was approved by the study institution IACUC 16-0140-S1A0.

Advanced airway management during adult cardiac arrest: A systematic review

AIM

To systematically review the literature on advanced airway management during adult cardiac arrest in order to inform the International Liaison Committee of Resuscitation (ILCOR) consensus on science and treatment recommendations.

METHODS

The review was performed according to PRISMA guidelines and registered on PROSPERO (CRD42018115556). We searched Medline, Embase, and Evidence-Based Medicine Reviews for controlled trials and observational studies published before October 30, 2018. The population included adult patients with cardiac arrest. Two investigators reviewed studies for relevance, extracted data, and assessed the risk of bias of individual studies.

RESULTS

We included 78 observational studies and 11 controlled trials. Most of the observational studies and all of the controlled trials only included patients with out-of-hospital cardiac arrest. The risk of bias for individual observational studies was overall assessed as critical or serious, with confounding and selection bias being the primary sources of bias. Three of the controlled trials, all published in 2018, were powered for clinical outcomes with two comparing a supraglottic airway to tracheal intubation and one comparing bag-mask ventilation to tracheal intubation. All three trials had some concerns regarding risk of bias primarily due to lack of blinding and variable adherence to the protocol. Clinical and methodological heterogeneity across studies, for both the observational studies and the controlled trials, precluded any meaningful meta-analyses.

CONCLUSIONS

We identified a large number of studies related to advanced airway management in adult cardiac arrest. Three recently published, large randomized trials in out-of-hospital cardiac arrest will help to inform future guidelines. Trials of advanced airway management during in-hospital cardiac arrest are lacking.

Association between ambulance response time and neurologic outcome in patients with cardiac arrest

PURPOSE

Emergency medical services (EMS) response time is one of prehospital factors associated with survival rate of patients with out-of-hospital cardiac arrest (OHCA). The objective of this study was to determine whether short EMS response time was associated with improved neurologic outcome of patients with OHCA through prospective analysis.

METHODS

We performed a prospective observational analysis of collected data from KoCARC registry between October 2015 and December 2016. OHCA patients aged 18 years or older with presumed cardiac etiology by emergency physicians in emergency department were included in this study.

RESULTS

Of 3187 cardiac arrest patients enrolled in the KoCARC registry, 2309 patients were included in the final analysis. Response time threshold was 11.5 min for prehospital return of spontaneous circulation and 7.5 min for survival to discharge and favorable neurologic outcome. Patients in the ≤7.5 min response time group showed increased odds of survival to discharge (OR: 1.54, 95% CI: 1.13-2.10, p = .006) and favorable neurologic recovery (OR: 2.01, 95% CI: 1.36-2.99, p = .001). When response time was decreased by 1 min, all outcomes were improved (survival to discharge, OR: 1.08; 95% CI: 1.04-1.12, p < .001; favorable neurological outcome, OR: 1.14, 95% CI: 1.07-1.21, p < .001).

CONCLUSION

We found that shorter EMS response time could lead to favorable neurologic outcome in patients with OHCA of presumed cardiac origin. EMS response time threshold associated with improved favorable outcome was ≤7.5 min.

[Supraglottic airway devices and intraosseous access in the treatment of patients after out-of-hospital cardiac arrest : Do we use the wrong tool too often?]

INTRODUCTION

Only a little is known about the frequency of use of supraglottic airway devices (SADs) and intraosseous (IO) access in patients who have had out-of-hospital cardiac arrest (OHCA).

MATERIALS AND METHODS

We analyzed data from all patients who had had OHCA admitted to our hospital between 1 January 2008 and 31 December 2017.

RESULTS

A total of 135 (33.8%) patients who had had OHCA were admitted with a SAD, 223 (55.8%) with an endotracheal tube, 3 (0.8%) with mask ventilation, and 32 (8.0%) breathed spontaneously on admission to hospital. Three hundred and twenty-eight patients (82.0%) were admitted with a peripheral intravenous line, one (0.3%) with a central venous catheter, one (0.3%) with a port catheter, and 32 (8.0%) with IO access.

CONCLUSIONS

Irrespective of an increasing number of studies that raise the question whether the airway management of patients who have had OHCA using an SGA might be inferior to that with endotracheal tubes, approximately one third of all patients who have had OHCA were admitted with an SAD in this study. On the other hand, IO access is significantly less frequently used, despite fewer critical study results overall.

Advanced airway management in out of hospital cardiac arrest: A systematic review and meta-analysis

OBJECTIVES

To assess the difference in survival and neurological outcomes between endotracheal tube (ETT) intubation and supraglottic airway (SGA) devices used during out-of-hospital cardiac arrest (OHCA).

METHODS

A systematic search of five databases was performed by two independent reviewers until September 2018. Included studies reported on (1) OHCA or cardiopulmonary resuscitation, and (2) endotracheal intubation versus supraglottic airway device intubation. Exclusion criteria (1) stimulation studies, (2) selectively included/excluded patients, (3) in-hospital cardiac arrest. Odds Ratios (OR) with random effect modelling was used. Primary outcomes: (1) return of spontaneous circulation (ROSC), (2) survival to hospital admission, (3) survival to hospital discharge, (4) discharge with a neurologically intact state.

RESULTS

Twenty-nine studies (n = 539,146) showed that overall, ETT use resulted in a heterogeneous, but significant increase in ROSC (OR = 1.44; 95%CI = 1.27 to 1.63; I² = 91%; p < 0.00001) and survival to admission (OR = 1.36; 95%CI = 1.12 to 1.66; I² = 91%; p = 0.002). There was no significant difference in survival to discharge or neurological outcome (p > 0.0125). On sensitivity analysis of RCTs, there was no significant difference in ROSC, survival to admission, survival to discharge or neurological outcome (p > 0.0125). On analysis of automated chest compression, without heterogeneity, ETT provided a significant increase in ROSC (OR = 1.55; 95%CI = 1.20 to 2.00; I² = 0%; p = 0.0009) and survival to admission (OR = 2.16; 95%CI = 1.54 to 3.02; I² = 0%; p < 0.00001).

CONCLUSIONS

The overall heterogeneous benefit in survival with ETT was not replicated in the low risk RCTs, with no significant difference in survival or neurological outcome. In the presence of automated chest compressions, ETT intubation may result in survival benefits.

Prehospital Supraglottic Airway Was Associated With Good Neurologic Outcome in Cardiac Arrest Victims Especially Those Who Received Prolonged Cardiopulmonary Resuscitation

OBJECTIVES

We performed this study to investigate the association of prehospital supraglottic airway (SGA) on neurologic outcome in cardiac arrest victims with adjustment of postresuscitation variables as well as prehospital and resuscitation variables.

METHODS

This study was a retrospective study based on a multicenter prospective cohort registry from December 2013 to April 2016. According to the 28-day cerebral performance categories (CPCs) scale, patients were divided into the good-outcome group (CPC 1-2) and the poor-outcome group (CPC 3-5). We compared the two groups with respect to demographic variables, prehospital and in-hospital resuscitation variables, and postresuscitation variables.

RESULTS

A total of 869 cardiac arrest victims who received in-progress cardiopulmonary resuscitation (CPR) were delivered to the emergency department of three hospitals, and 310 patients were admitted to the intensive care unit. The use of a prehospital SGA was independently associated with 28-day good neurologic outcome (odds ratio [OR] = 7.88; 95% confidence interval [CI] = 1.33-46.53; p = 0.023] when postresuscitation variables were adjusted, although there were no significant association with the acquisition of sustained return of spontaneous circulation (OR = 0.992; 95% CI = 0.591-1.666; p = 0.976). Furthermore, a prehospital SGA was significantly associated with good neurologic outcome, especially in patients who received prolonged CPR (low flow time > 15 minutes; OR = 3.41; 95% CI = 1.23-9.45; p = 0.018) rather than in patients with nonprolonged CPR (OR = 4.50; 95% CI = 0.75-27.13; p = 0.101).

CONCLUSIONS

When postresuscitation variables were adjusted, the prehospital SGA was independently associated with 28-day good neurologic outcome in cardiac arrest victims.

The Effect of Successful Intubation on Patient Outcomes After Out-of-Hospital Cardiac Arrest in Taipei

STUDY OBJECTIVE

The effect of out-of-hospital intubation in patients with out-of-hospital cardiac arrest remains controversial. The Taipei City paramedics are the earliest authorized to perform out-of-hospital intubation among Asian areas. This study evaluates the association between successful intubation and out-of-hospital cardiac arrest survival in Taipei.

METHODS

We analyzed 6 years of Utstein-based registry data from nontrauma adult patients with out-of-hospital cardiac arrest who underwent out-of-hospital airway management including intubation, laryngeal mask airway, or bag-valve-mask ventilation. The primary analysis was intubation success on patient outcomes. The primary outcome was survival to discharge and the secondary outcomes included sustained return of spontaneous circulation and favorable neurologic survival. Sensitivity analysis was performed with intubation attempts rather than intubation success. Subgroup analysis of advanced life support-serviced districts was also performed.

RESULTS

A total of 10,853 cases from 2008 to 2013 were analyzed. Among out-of-hospital cardiac arrest patients receiving airway management, successful intubation, laryngeal mask airway, and bag-valve-mask ventilation was reported in 1,541, 3,099, and 6,213 cases, respectively. Compared with bag-valve-mask device use, successful out-of-hospital intubation was associated with improved chances of sustained return of spontaneous circulation (adjusted odds ratio [aOR] 1.91; 95% confidence interval [CI] 1.66 to 2.19), survival to discharge (aOR 1.98; 95% CI 1.57 to 2.49), and favorable neurologic outcome (aOR 1.44; 95% CI 1.03 to 2.03). The results were comparable in sensitivity and subgroup analyses.

CONCLUSION

In nontrauma adult out-of-hospital cardiac arrest in Taipei, successful out-of-hospital intubation was associated with improved odds of sustained return of spontaneous circulation, survival to discharge, and favorable neurologic outcome.

Paramedic Intubation Experience Is Associated With Successful Tube Placement but Not Cardiac Arrest Survival

STUDY OBJECTIVE

Paramedic experience with intubation may be an important factor in skill performance and patient outcomes. Our objective is to examine the association between previous intubation experience and successful intubation. In a subcohort of out-of-hospital cardiac arrest cases, we also measure the association between patient survival and previous paramedic intubation experience.

METHODS

We analyzed data from Ambulance Victoria electronic patient care records and the Victorian Ambulance Cardiac Arrest Registry for January 1, 2008, to September 26, 2014. For each patient case, we defined intubation experience as the number of intubations attempted by each paramedic in the previous 3 years. Using logistic regression, we estimated the association between intubation experience and (1) successful intubation and (2) first-pass success. In the out-of-hospital cardiac arrest cohort, we determined the association between previous intubation experience and patient survival.

RESULTS

During the 6.7-year study period, 769 paramedics attempted intubation in 14,857 patients. Paramedics typically performed 3 intubations per year (interquartile range 1 to 6). Most intubations were successful (95%), including 80% on the first attempt. Previous intubation experience was associated with intubation success (odds ratio 1.04; 95% confidence interval 1.03 to 1.05) and intubation first-pass success (odds ratio 1.02; 95% confidence interval 1.01 to 1.03). In the out-of-hospital cardiac arrest subcohort (n=9,751), paramedic intubation experience was not associated with patient survival.

CONCLUSION

Paramedics in this Australian cohort performed few intubations. Previous experience was associated with successful intubation. Among out-of-hospital cardiac arrest patients for whom intubation was attempted, previous paramedic intubation experience was not associated with patient survival.

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival

IMPORTANCE

Tracheal intubation is common during adult in-hospital cardiac arrest, but little is known about the association between tracheal intubation and survival in this setting.

OBJECTIVE

To determine whether tracheal intubation during adult in-hospital cardiac arrest is associated with survival to hospital discharge.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study of adult patients who had an in-hospital cardiac arrest from January 2000 through December 2014 included in the Get With The Guidelines-Resuscitation registry, a US-based multicenter registry of in-hospital cardiac arrest. Patients who had an invasive airway in place at the time of cardiac arrest were excluded. Patients intubated at any given minute (from 0-15 minutes) were matched with patients at risk of being intubated within the same minute (ie, still receiving resuscitation) based on a time-dependent propensity score calculated from multiple patient, event, and hospital characteristics.

EXPOSURE

Tracheal intubation during cardiac arrest.

MAIN OUTCOMES AND MEASURES

The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and a good functional outcome. A cerebral performance category score of 1 (mild or no neurological deficit) or 2 (moderate cerebral disability) was considered a good functional outcome.

RESULTS

The propensity-matched cohort was selected from 108 079 adult patients at 668 hospitals. The median age was 69 years (interquartile range, 58-79 years), 45 073 patients (42%) were female, and 24 256 patients (22.4%) survived to hospital discharge. Of 71 615 patients (66.3%) who were intubated within the first 15 minutes, 43 314 (60.5%) were matched to a patient not intubated in the same minute. Survival was lower among patients who were intubated compared with those not intubated: 7052 of 43 314 (16.3%) vs 8407 of 43 314 (19.4%), respectively (risk ratio [RR] = 0.84; 95% CI, 0.81-0.87; P < .001). The proportion of patients with ROSC was lower among intubated patients than those not intubated: 25 022 of 43 311 (57.8%) vs 25 685 of 43 310 (59.3%), respectively (RR = 0.97; 95% CI, 0.96-0.99; P < .001). Good functional outcome was also lower among intubated patients than those not intubated: 4439 of 41 868 (10.6%) vs 5672 of 41 733 (13.6%), respectively (RR = 0.78; 95% CI, 0.75-0.81; P < .001). Although differences existed in prespecified subgroup analyses, intubation was not associated with improved outcomes in any subgroup.

CONCLUSIONS AND RELEVANCE

Among adult patients with in-hospital cardiac arrest, initiation of tracheal intubation within any given minute during the first 15 minutes of resuscitation, compared with no intubation during that minute, was associated with decreased survival to hospital discharge. Although the study design does not eliminate the potential for confounding by indication, these findings do not support early tracheal intubation for adult in-hospital cardiac arrest.

The role of prehospital advanced airway management on outcomes for out-of-hospital cardiac arrest patients: a meta-analysis

OBJECTIVE

The objective of this meta-analysis was to compare the benefits of prehospital advanced airway management (AAM) and basic airway management (BAM) for out-of-hospital cardiac arrest (OHCA) patients.

METHODS

Two investigators performed a systematic review of PubMed, EMBASE, and the Cochrane Database to identify all peer-reviewed articles relevant to this meta-analysis. We included all articles describing emergency medical system-treated nontraumatic OHCAs; specifically, all articles that described intervention of the prehospital AAM type were considered. The primary outcome was survival to discharge, whereas the secondary outcome was neurologic recovery after an OHCA event. For subgroup analysis, we compared the clinical outcome of endotracheal intubation (ETI), a specific type of AAM, vs BAM.

RESULTS

We reviewed 1452 studies, 10 of which satisfied all the inclusion criteria and involved 17 380 patients subjected to AAM and 67 525 subjected to BAM. Based on the full random effects model, patients who received AAM had lower odds of survival (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.29-0.90) compared with BAM. Subgroup analysis for ETI vs BAM showed no significant association with respect to survival (OR, 0.44; 95% CI, 0.16-1.23). There were no significant differences in the odds of neurologic recovery between AAM and BAM (OR, 0.64; 95% CI, 0.03-1.37).

CONCLUSIONS

Our results reveal decreased survival odds for OHCA patients treated with AAM by emergency medical service personnel compared with BAM. However, the role of prehospital AAM, especially ETI, on achieving neurologic recovery remains unclear.