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Vadeyar S, Buckle A, Hooper A, Booth S, Deakin CD, Fothergill R, Ji C, Nolan JP, Brown M, Cowley A, Harris E, Ince M, Marriott R, Pike J, Spaight R, Perkins GD, Couper K. Trends in use of intraosseous and intravenous access in out-of-hospital cardiac arrest across English ambulance services: A registry-based, cohort study. Resuscitation 2023; 191:109951. [PMID: 37648146 DOI: 10.1016/j.resuscitation.2023.109951] [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: 06/29/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION The optimum route for drug administration in cardiac arrest is unclear. Recent data suggest that use of the intraosseous route may be increasing. This study aimed to explore changes over time in use of the intraosseous and intravenous drug routes in out-of-hospital cardiac arrest in England. METHODS We extracted data from the UK Out-of-Hospital Cardiac Arrest Outcomes registry. We included adult out-of-hospital cardiac arrest patients between 2015-2020 who were treated by an English Emergency Medical Service that submitted vascular access route data to the registry. The primary outcome was any use of the intraosseous route during cardiac arrest. We used logistic regression models to describe the association between time (calendar month) and intraosseous use. RESULTS We identified 75,343 adults in cardiac arrest treated by seven Emergency Medical Service systems between January 2015 and December 2020. The median age was 72 years, 64% were male and 23% presented in a shockable rhythm. Over the study period, the percentage of patients receiving intraosseous access increased from 22.8% in 2015 to 42.5% in 2020. For each study-month, the odds of receiving any intraosseous access increased by 1.019 (95% confidence interval 1.019 to 1.020, p < 0.001). This observed effect was consistent across sensitivity analyses. We observed a corresponding decrease in use of intravenous access. CONCLUSION In England, the use of intraosseous access in out-of-hospital cardiac arrest has progressively increased over time. There is an urgent need for randomised controlled trials to evaluate the clinical effectiveness of the different vascular access routes in cardiac arrest.
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Affiliation(s)
- Sharvari Vadeyar
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alexandra Buckle
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Amy Hooper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Scott Booth
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Charles D Deakin
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, UK; University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Rachael Fothergill
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK; Clinical Audit & Research Unit, London Ambulance Service NHS Trust, London, UK
| | - Chen Ji
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Jerry P Nolan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK; Intensive Care Unit, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Martina Brown
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, UK
| | - Alan Cowley
- South East Coast Ambulance Service NHS Foundation Trust, Crawley, UK
| | - Emma Harris
- West Midlands Ambulance Service University NHS Foundation Trust, Brierley Hill, UK
| | - Maureen Ince
- North West Ambulance Service NHS Trust, Bolton, UK
| | - Robert Marriott
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - John Pike
- Isle of Wight NHS Trust, Newport, Isle of Wight, UK
| | - Robert Spaight
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | - Gavin D Perkins
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Keith Couper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.
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Hooper A, Nolan JP, Rees N, Walker A, Perkins GD, Couper K. Drug routes in out-of-hospital cardiac arrest: A summary of current evidence. Resuscitation 2022; 181:70-78. [PMID: 36309248 DOI: 10.1016/j.resuscitation.2022.10.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022]
Abstract
Recent evidence showing the clinical effectiveness of drug therapy in cardiac arrest has led to renewed interest in the optimal route for drug administration in adult out-of-hospital cardiac arrest. Current resuscitation guidelines support use of the intravenous route for intra-arrest drug delivery, with the intraosseous route reserved for patients in whom intravenous access cannot be established. We sought to evaluate current evidence on drug route for administration of cardiac arrest drugs, with a specific focus on the intravenous and intraosseous route. We identified relevant animal, manikin, and human studies through targeted searches of MEDLINE in June 2022. Across pre-hospital systems, there is wide variation in use of the intraosseous route. Early administration of cardiac arrest drugs is associated with improved patient outcomes. Challenges in obtaining intravenous access mean that the intraosseous access may facilitate earlier drug administration. However, time from administration to the central circulation is unclear with pharmacokinetic data limited mainly to animal studies. Observational studies comparing the effect of intravenous and intraosseous drug administration on patient outcomes are challenging to interpret because of resuscitation time bias and other confounders. To date, no randomised controlled trial has directly compared the effect on patient outcomes of intraosseous compared with intravenous drug administration in cardiac arrest. The International Liaison Committee on Resuscitation has described the urgent need for randomised controlled trials comparing the intravenous and intraosseous route in adult out-of-hospital cardiac arrest. Ongoing clinical trials will directly address this knowledge gap.
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Affiliation(s)
- Amy Hooper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jerry P Nolan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - Nigel Rees
- Pre-hospital Emergency Response Unit, Welsh Ambulance Services NHS Trust, St Asaph, UK; Institute of Life Sciences, Swansea University, Swansea, UK
| | - Alison Walker
- West Midlands Ambulance Service University NHS Foundation Trust, Brierley Hill, UK; Department of Emergency Medicine, Harrogate and District NHS Foundation Trust, Harrogate, UK
| | - Gavin D Perkins
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Keith Couper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.
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Direct vs. Video-Laryngoscopy for Intubation by Paramedics of Simulated COVID-19 Patients under Cardiopulmonary Resuscitation: A Randomized Crossover Trial. J Clin Med 2021; 10:jcm10245740. [PMID: 34945036 PMCID: PMC8707195 DOI: 10.3390/jcm10245740] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/04/2021] [Accepted: 12/07/2021] [Indexed: 02/07/2023] Open
Abstract
A safe way of securing the airway with an endotracheal tube is one of the priorities of an advanced cardiovascular life support algorithm for suspected or confirmed COVID-19 patients. The aim of this study was to compare intubation success rates (ISR) and intubation time (IT) of different laryngoscopes for simulated COVID-19 patients under cardiopulmonary resuscitation. The study was designed as a prospective, randomized, crossover trial. Fifty four active paramedics performed endotracheal intubation with a Macintosh direct laryngoscope (MAC) and McGrath videolaryngoscope (McGrath) with and without personal protective equipment (PPE). Without PPE, ISRs were 87% and 98% for MAC and McGrath, respectively (p = 0.32). ITs were 22.5 s (IQR: 19–26) and 19.5 s (IQR: 17–21) for MAC and McGrath, respectively (p = 0.005). With PPE, first-pass ISR were 30% and 89% with MAC and McGrath, respectively (p < 0.001). The overall success rates were 83% vs. 100% (p = 0.002). Median ITs were 34.0 s (IQR: 29.5–38.5) and 24.8 s (IQR: 21–29) for MAC and McGrath, respectively (p < 0.001). In conclusion, the McGrath videolaryngoscope appears to possess significant advantages over the Macintosh direct laryngoscope when used by paramedics in suspected or confirmed COVID-19 intubation scenarios.
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