Out-of-hospital endotracheal intubation experience and patient outcomes

Emergency Medicine Postgraduate Year, Laryngoscopic View, and Endotracheal Tube Placement Success

STUDY OBJECTIVE

Prior work has found first-attempt success improves with emergency medicine (EM) postgraduate year (PGY). However, the association between PGY and laryngoscopic view - a key step in successful intubation - is unknown. We examined the relationship among PGY, laryngoscopic view (ie, Cormack-Lehane view), and first-attempt success.

METHODS

We performed a retrospective analysis of the National Emergency Airway Registry, including adult intubations by EM PGY 1 to 4 resident physicians. We used inverse probability weighting with propensity scores to balance confounders. We used weighted regression and model comparison to estimate adjusted odds ratios (aOR) with 95% confidence intervals (CIs) between PGY and Cormack-Lehane view, tested the interaction between PGY and Cormack-Lehane view on first-attempt success, and examined the effect modification of Cormack-Lehane view on the association between PGY and first-attempt success.

RESULTS

After exclusions, we included 15,453 first attempts. Compared to PGY 1, the aORs for a higher Cormack-Lehane grade did not differ from PGY 2 (1.01; 95% CI 0.49 to 2.07), PGY 3 (0.92; 0.31 to 2.73), or PGY 4 (0.80; 0.31 to 2.04) groups. The interaction between PGY and Cormack-Lehane view was significant (P-interaction<0.001). In patients with Cormack-Lehane grade 3 or 4, the aORs for first-attempt success were higher for PGY 2 (1.80; 95% CI 1.17 to 2.77), PGY 3 (2.96; 1.66 to 5.27) and PGY 4 (3.10; 1.60 to 6.00) groups relative to PGY 1.

CONCLUSION

Compared with PGY 1, PGY 2, 3, and 4 resident physicians obtained similar Cormack-Lehane views but had higher first-attempt success when obtaining a grade 3 or 4 view.

Association Between Emergency Medical Service Agency Intubation Rate and Intubation Success

STUDY OBJECTIVE

Airway management is a crucial part of out-of-hospital care. It is not known if the rate of overall agency intubation attempts is associated with intubation success. We sought to evaluate the association between agency intubation attempt rate and intubation success using a national out-of-hospital database.

METHODS

We conducted a retrospective secondary analysis of the ESO Data Collaborative from 2018 to 2019, and included all adult cases with an endotracheal intubation attempt. We calculated the number of intubations attempted per 100 responses, advanced life support responses, and transports for each agency. We excluded cases originating at health care facilities and outliers. We used multivariable logistic regression to evaluate the association between agency intubation attempt rate and 1) intubation success and 2) first-pass success. We adjusted for confounders.

RESULTS

We included 1,005 agencies attempting 58,509 intubations. Overall, the intubation success rate was 78.8%, and the first-pass success rate was 68.5%. Per agency, the median rate of intubation attempts per 100 emergency medical service responses was 0.8 (interquartile range 0.6 to 1.1). Rates of intubation attempts per 100 responses (adjusted odds ratio [aOR] 1.7; 95% confidence interval [CI] 1.6 to 1.8), advanced life support responses (aOR 1.18; 95% CI 1.16 to 1.20), and transports (aOR 1.21; 95% CI 1.18 to 1.22) were all associated with intubation success. These relationships were similar for first-pass success but with smaller effect sizes.

CONCLUSION

Higher agency rates of intubation attempts were associated with increased rates of intubation success and first-pass success.

Factors associated with 30- and 90-day mortality in intubations among critically ill patients

BACKGROUND

Emergency intubations are commonly associated with adverse events when performed in critically ill patients. A detailed look at intubation factors and their association with procedural success and mortality has yet to be fully conducted.

METHODS

A total of 299 successive intubations at a tertiary Veteran Affair hospital were analyzed. Situational factors, personnel involved, intubation indications, induction agents, and airway management techniques were prospectively collected and entered into univariable and multivariable analyses to identify factors associated with procedural difficulty and mortality.

RESULTS

The use of paralytics was associated with easier intubations (OR: 0.31, 95% CI: 0.11-0.87, p = .03). The use of direct laryngoscopy or video laryngoscopy had no significant association with difficult intubation. Factors associated with increased 30-day mortality were cardiac arrest (OR: 7.90, 95% CI: 2.77-22.50, p < .001), hypoxia as indication for intubation (OR: 2.31, 95% CI: 1.23-4.35, p = .009), and nadir SpO2  < 90% (OR: 2.70, 95% CI: 1.01-7.21, p = .048). Presence of an attending anesthesiologist during intubation was associated with a lower 30-day mortality (OR: 0.11, 95% CI: 0.04-0.29, p < .001). Factors associated with increased 90-day mortality were cardiac arrest (OR: 6.57, 95% CI: 2.23-19.34, p = .001), hypoxia as indication for intubation (OR: 1.97, 95% CI: 1.10-3.55, p = .023), and older age (OR: 1.38, 95% CI: 1.07-1.78, p = .013). Similarly, presence of an attending anesthesiologist was found to be associated with a lower 90-day mortality (OR: 0.19, 95% CI: 0.07-0.50, p = .001).

CONCLUSION

Cardiovascular and respiratory instability were associated with increased 30- and 90-day mortality. Presence of an attending anesthesiologist was associated with a better survival following intubation outside operating room.

Association Between Emergency Medical Service Agency Volume and Mortality in Trauma Patients

OBJECTIVE

The aim of this study was to evaluate the association of annual trauma patient volume on outcomes for emergency medical services (EMS) agencies.

BACKGROUND

Regionalization of trauma care saves lives. The underlying concept driving this is a volume-outcome relationship. EMS are the entry point to the trauma system, yet it is unknown if a volume-outcome relationship exists for EMS.

METHODS

A retrospective analysis of prospective cohort including 8 trauma centers and 20 EMS air medical and metropolitan ground transport agencies. Patients 18 to 90 years old with injury severity scores ≥9 transported from the scene were included. Patient and agency-level risk-adjusted regression determined the association between EMS agency trauma patient volume and early mortality.

RESULTS

A total of 33,511 were included with a median EMS agency volume of 374 patients annually (interquartile range: 90-580). Each 50-patient increase in EMS agency volume was associated with 5% decreased odds of 6-hour mortality (adjusted odds ratio=0.95; 95% CI: 0.92-0.99, P =0.03) and 3% decreased odds of 24-hour mortality (adjusted odds ratio=0.97; 95% CI: 0.95-0.99, P =0.04). Prespecified subgroup analysis showed EMS agency volume was associated with reduced odds of mortality for patients with prehospital shock, requiring prehospital airway placement, undergoing air medical transport, and those with traumatic brain injury. Agency-level analysis demonstrated that high-volume (>374 patients/year) EMS agencies had a significantly lower risk-standardized 6-hour mortality rate than low-volume (<374 patients/year) EMS agencies (1.9% vs 4.8%, P <0.01).

CONCLUSIONS

A higher volume of trauma patients transported at the EMS agency level is associated with improved early mortality. Further investigation of this volume-outcome relationship is necessary to leverage quality improvement, benchmarking, and educational initiatives.

Comparing Intubation Success Between Flight Nurses and Flight Paramedics in Helicopter Emergency Medical Services

OBJECTIVE

Intubation is a vital skill performed by flight nurses and paramedics. Before flight training, nurses do not routinely intubate and must be trained in proper techniques. Flight paramedics universally train in intubation before flight training and are the primary managers of in-flight airways. The aim of this study was to determine if a difference exists in intubation attempts and success rates between flight nurses and flight paramedics.

METHODS

A 5-year retrospective chart review was performed from a regional helicopter emergency medical service. Intubation attempts and the success of flight nurses compared with flight paramedics were the primary outcomes.

RESULTS

Three hundred three of 322 cases in which intubation was attempted were successful. Three hundred forty-four total intubation attempts were made. Two hundred seventy-one (88.9%) patients were intubated by paramedics, and 32 (10.5%) were intubated by nurses. Of the 19 unsuccessfully intubated patients, 14 (73.7%) were attempted by a paramedic and 5 (26.3%) by a nurse. Two hundred seventy-seven intubations were successful on the first attempt, 250 (90.3%) of which were performed by a paramedic and 27 (9.7%) by a nurse.

CONCLUSION

Flight paramedics performed more intubations with greater success than flight nurses.

Association between First-pass Intubation Success and Enhanced PPE Use during the COVID-19 Pandemic

OBJECTIVES

We evaluated first-pass endotracheal intubation (ETI) success within the critical care transport (CCT) environment using a natural experiment created by the COVID-19 pandemic. Our primary objective was to evaluate if the use of personal protective equipment (PPE) or the COVID-19 time period was associated with differences in first-pass success rates of ETI within a large CCT system with a high baseline ETI first-pass success rate. We hypothesized that pandemic-related challenges would be associated with decreased first-pass success rates.

METHODS

We performed a retrospective before-after cohort study of airway management by CCT personnel relative to the COVID-19 pandemic. We used a mixed effects logistic regression to evaluate the association between enhanced PPE (N95 mask, eye protection) use and the pandemic time period on first-pass intubation success, while controlling for other factors potentially associated with intubation success. Variables in the final model included patient demographics (age, sex, and race), body mass index, medical category (trauma versus non-trauma), interfacility or scene response, blade size (Macintosh 3 versus 4), use of face mask, use of eye protection, and crew member length of service.

RESULTS

We identified 1279 cases involving intubation attempts on adult patients during the study period. A total of 1133 cases were included in the final analysis, with an overall first-pass success rate of 95.7% (96.4% pre-COVID-19 and 94.8% during COVID-19). In our final mixed effects logistic regression model, enhanced PPE use and the COVID-19 time period were not associated with first-pass intubation success rate.

CONCLUSION

In a large regional CCT system with a high ETI first-pass success rate, neither PPE use nor the COVID-19 time period were associated with differences in ETI first-pass success while controlling for relevant patient and operational factors. Other emergency medical services (EMS) systems may have encountered different effects of pandemic-related PPE use on intubation success rates. Further studies are needed to evaluate the influence of sustained use of enhanced PPE or changes in training or procedural experience on post-pandemic ETI first-pass success rates for non-CCT EMS clinicians.

Time to Antiarrhythmic and Association with Return of Spontaneous Circulation in the United States

INTRODUCTION

Recent clinical trials have failed to identify a benefit of antiarrhythmic administration during cardiac arrest. However, little is known regarding the time to administration of antiarrhythmic drugs in clinical practice or its impact on return of spontaneous circulation (ROSC). We utilized a national EMS registry to evaluate the time of drug administration and association with ROSC.

METHODS

We utilized the 2018 and 2019 NEMSIS datasets, including all non-traumatic, adult 9-1-1 EMS activations for cardiac arrests with initial shockable rhythm and that received an antiarrhythmic. We calculated the time from 9-1-1 call to administration of antiarrhythmic. We excluded cases with erroneous time stamps. Stratified by initial antiarrhythmic (amiodarone and lidocaine), we created a mixed-effect logistic regression model evaluating the association between every 5-minute increase in time to antiarrhythmic and ROSC. We modeled EMS agency as a random intercept and adjusted for confounders.

RESULTS

There were 449,630 adults, non-traumatic cardiac arrests identified with 11,939 meeting inclusion criteria. 9,236 received amiodarone and 1,327 received lidocaine initially. The median time in minutes to initial dose for amiodarone was 19.9 minutes (IQR 15.8-25.6) and for lidocaine was 19.5 minutes (IQR 15.2-25.4). Increasing time to initial antiarrhythmic was associated with decreased odds of ROSC for both amiodarone (aOR 0.9; 95% CI 0.9-0.94) and lidocaine (aOR 0.9; 95% CI 0.8-0.97).

CONCLUSION

Time to administration of anti-arrhythmic medication varied, but most patients received the first dose of anti-arrhythmic drug more than 19 minutes after the initial 9-1-1 call. Longer time to administration of an antiarrhythmic in patients with an initial shockable rhythm was associated with decreased ROSC rates.

Variations in Code Team Composition During Different Times of Day and Week and by Level of Hospital Complexity

BACKGROUND

Previous data demonstrated lower survival rates of in-hospital cardiac arrests during nights and weekends compared to weekday daytime. This study aimed to evaluate variations of personnel attending to codes based on day/night/weekend conditions within the US Veterans Affairs (VA) system, as well as variations of personnel responsible for intubations during codes.

METHODS

Hospital leaders were surveyed regarding code team membership, leadership, and intubations during four time periods (weekday daytime, weekday nighttime, weekend daytime, and weekend nighttime).

RESULTS

Surveys were completed for 93 of 123 eligible VA hospitals (response rate of 75.6%). Code teams were significantly smaller during "off-hours." Membership in code teams during regular vs. off-hours was significantly greater for ICU physicians (44.1% vs. 7.5%-15.0%, p < 0.001), anesthesiologists (34.4% vs. 12.9%, p < 0.001), and pharmacists (46.2% vs. 23.7%-26.9%, p < 0.01). Significant differences were found for codes led by ICU attendings (20.4% vs. 5.4%-7.5%, p < 0.05) and intubations performed by ICU attendings (21.5% vs. 6.5%-10.8%, p < 0.05). ICU-based physicians were team leaders more often in high-complexity hospitals (19.7%-50.0% vs. 0%-14.8%), while hospitalists led the majority in the low-complexity hospitals (28.8%-39.4% vs. 63.0%-70.4%). ICU physicians had significantly less involvement in code intubations in low-complexity hospitals (6.1%-22.7% vs. 3.7%-18.5%), while respiratory therapists took on most of this responsibility in low-complexity hospitals and particularly at night.

CONCLUSION

This study found significant differences in code team composition, leadership, and intubation responsibilities between regular and off-hours. Low-complexity hospitals, which are generally rural, had team compositions and responsibilities that were visibly different from higher-complexity hospitals.

Portable Handheld Point-of-Care Ultrasound for Detecting Unrecognized Esophageal Intubations

Esophageal intubations are not an uncommon occurrence in prehospital settings, occurring as high as 17%. These "never events" are associated with significant morbidity and mortality especially when unrecognized or when there is delayed recognition. Here, we review the currently available techniques for confirming endotracheal tube intubation and their limitations, and present the case for the application of portable handheld point-of-care ultrasound as an emerging technology for detection of potentially unrecognized esophageal intubations such as during cardiac arrest. We also provide algorithms for confirmation of tracheal intubation.

Influence of advanced life support response time on out-of-hospital cardiac arrest patient outcomes in Taipei

Background

The association between out-of-hospital cardiac arrest patient survival and advanced life support response time remained controversial. We aimed to test the hypothesis that for adult, non-traumatic, out-of-hospital cardiac arrest patients, a shorter advanced life support response time is associated with a better chance of survival. We analyzed Utstein-based registry data on adult, non-traumatic, out-of-hospital cardiac arrest patients in Taipei from 2011 to 2015.

Methods

Patients without complete data, witnessed by emergency medical technicians, or with response times of ≥ 15 minutes, were excluded. We used logistic regression with an exposure of advanced life support response time. Primary and secondary outcomes were survival to hospital discharge and favorable neurological outcomes (cerebral performance category ≤ 2), respectively. Subgroup analyses were based on presenting rhythms of out-of-hospital cardiac arrest, bystander cardiopulmonary resuscitation, and witness status.

Results

A total of 4,278 cases were included in the final analysis. The median advanced life support response time was 9 minutes. For every minute delayed in advanced life support response time, the chance of survival to hospital discharge would reduce by 7% and chance of favorable neurological outcome by 9%. Subgroup analysis showed that a longer advanced life support response time was negatively associated with the chance of survival to hospital discharge among out-of-hospital cardiac arrest patients with shockable rhythm and pulse electrical activity groups.

Conclusions

In non-traumatic, adult, out-of-hospital cardiac arrest patients in Taipei, a longer advanced life support response time was associated with declining odds of survival to hospital discharge and favorable neurologic outcomes, especially in patients presenting with shockable rhythm and pulse electrical activity.

Le mandrin long béquillé : est-ce systématique ?

L’intubation trachéale (IT) est un geste fréquent en médecine d’urgence extra-hospitalière (MUEH) mais elle est associée à un taux élevé d’échec de la première tentative et à certaines complications graves. Le taux de ces dernières augmente avec le nombre de tentative d’IT. La Société française d’anesthésie et de réanimation (SFAR) et la Société de réanimation de langue française (SRLF) avec la collaboration de la Société française de médecine d’urgence (SFMU) ont publié en 2016 des recommandations formalisées d’experts (RFE) sur l’intubation du patient de réanimation. La question qui se pose est la pertinence de ces recommandations pour la MUEH. En effet, la mesure du risque de difficulté est basée sur le score de MACOCHA et en cas de difficulté prévue les outils à utiliser d’emblée sont le vidéo-laryngoscope ou le mandrin long béquillé en laryngoscopie directe. Or il apparait que le score de MACOCHA n’est pas adapté à la MUEH et de façon plus générale, il est complexe de mesurer le risque d’intubation difficile (ID) dans ce contexte. La vidéolaryngoscopie n’a pas encore fait la preuve de sa supériorité par rapport à la laryngoscopie directe en MUEH. Par contre des travaux récents en médecine d’urgence ont démontré que l’utilisation en première intention du mandrin long béquillé augmente significativement le taux de succès de la première tentative de l’IT, même en l’absence de facteur de risque d’ID. Au total, on pourrait considérer chaque IT en MUEH comme a priori à risque de difficulté ce qui justifierait une utilisation d’emblée du mandrin long béquillé. Il semble nécessaire de proposer des recommandations spécifiques à la médecine d’urgence.

Developing a Profile of Procedural Expertise: A Simulation Study of Tracheal Intubation Using 3-Dimensional Motion Capture

BACKGROUND

Improving the assessment and training of tracheal intubation is hindered by the lack of a sufficiently validated profile of expertise. Although several studies have examined biomechanics of tracheal intubation, there are significant gaps in the literature. We used 3-dimensional motion capture to study pediatric providers performing simulated tracheal intubation to identify candidate kinematic variables for inclusion in an expert movement profile.

METHODS

Pediatric anesthesiologists (experienced) and pediatric residents (novices) were recruited from a pediatric institution to perform tracheal intubation on airway mannequins in a motion capture laboratory. Subjects performed 21 trials of tracheal intubation, 3 each of 7 combinations of laryngoscopic visualization (direct or indirect), blade type (straight or curved), and mannequin size (adult or pediatric). We used repeated measures analysis of variance to determine whether various kinematic variables (3-trial average for each participant) were associated with experience.

RESULTS

Eleven experienced and 15 novice providers performed 567 successful tracheal intubation attempts (9 attempts unsuccessful). For laryngoscopy, experienced providers exhibited shorter path length (total distance traveled by laryngoscope handle; 77.6 ± 26.0 cm versus 113.9 ± 53.7 cm; P = 0.013) and greater angular variability at the left wrist (7.4 degrees versus 5.5 degrees, P = 0.013) and the left elbow (10.1 degrees versus 7.6 degrees, P = 0.03). For intubation, experienced providers exhibited shorter path length of the right hand (mean = 61.1 cm versus 99.9 cm, P < 0.001), lower maximum acceleration of the right hand (0.19 versus 0.14 m/s, P = 0.033), and smaller angular, variability at the right elbow (9.7 degrees versus 7.9 degrees, P = 0.03).

CONCLUSIONS

Our study and the available literature suggest specific kinematic variables for inclusion in an expert profile for tracheal intubation. Future studies should include a larger sample of practitioners, actual patients, and measures of the cognitive and affective components of expertise.

Association between case volume of ambulance stations and clinical outcomes of out-of-hospital cardiac arrest: A nationwide multilevel analysis

OBJECTIVES

The case volume effects of ambulance stations on the survival of out-of-hospital cardiac arrest (OHCA) patients are uncertain. This study was conducted to evaluate the association between the case volume of ambulance stations and clinical outcomes in OHCAs by the number of emergency medical services (EMS) providers at the scene.

METHODS

Adult cardiac EMS-treated OHCAs between 2015 and 2018 were enrolled. The main exposure was the annual OHCA case volumes of 204 ambulance stations in Korea, which were categorized into three groups; low-volume (<100), moderate-volume (100-159) and high-volume (≥160). The primary and secondary outcomes were good neurological recovery and survival to discharge. Multilevel multivariable logistic regression analysis was conducted to calculate adjusted odds ratios (AORs). Interaction analysis between the number of EMS providers at the scene and the exposure variable was performed.

RESULTS

A total of 92,534 patients were enrolled. OHCAs in the low-volume group tended to be arrest in a public place or a non-metropolitan area, less prehospital administration of an advanced airway and intravenous management. Significant differences were found the main analysis: AORs (95% CIs) compared to the low-volume group were 1.15 (1.03-1.29) and 1.14 (1.03-1.27) in the high-volume and moderate-volume groups for good neurological recovery and 1.19 (1.07-1.33) and 1.14 (1.04-1.25) in the high-volume and moderate-volume groups for survival to discharge. Significant interaction effects between the number of EMS providers at the scene and case volume on clinical outcomes were found.

CONCLUSION

OHCA case volumes of ambulance stations are associated with clinical outcomes after cardiac arrest.

Inexperienced but Confident: A Survey of Advanced Life Support Providers and Life-saving Interventions in the Israel Defense Forces

OBJECTIVE

The objective of this study was to assess the current experience of Israel Defense Forces' (IDF) advanced life support (ALS) providers in performing life-saving interventions (LSIs), the rate of doctors and paramedics achieving the Trauma and Combat Medicine Branch benchmarks, and the rate of providers feeling confident in performing the interventions although not achieving the benchmarks.

METHODS

This study was based on an online survey delivered to IDF ALS providers. The survey investigated demographics; experience in performing endotracheal intubation, cricothyroidotomy, tube thoracostomy, and intraosseous access on human patients; and confidence in performing these LSIs. All benchmarks chosen referred to the number of times performed in the previous year. The benchmarks were 20 for intubation, 3 for cricothyroidotomy, 4 for tube thoracostomy, and 3 for intraosseous access.

RESULTS

During the survey period, 175 IDF ALS providers started the survey, but only 138 (79%) completed it, 93 (67%) of them were paramedics. Doctors had higher rates than paramedics of failing to achieve the benchmarks for intubation (96 vs. 57%, P < .001) and intraosseous access (100 vs. 66%, P < .001). All respondents failed to achieve the benchmark for cricothyroidotomy, and all but one paramedic failed to achieve the tube thoracostomy benchmark. Doctors had lower rates of high confidence when failing to achieve the benchmark for intubation (35 vs. 64%, P = .008) and intraosseous access (7 vs. 31%, P = .005) compared to paramedics.

CONCLUSION

IDF ALS providers have alarmingly limited experience in performing LSIs. Many of them are confident in their ability despite not achieving evidence-based benchmarks. Additional training is required, maybe as a part of an annual medical fitness test.

Video laryngoscopy for out of hospital cardiac arrest

INTRODUCTION

Endotracheal intubation is an import component of out-of-hospital cardiac arrest (OHCA) resuscitation. In this analysis, we evaluate the association of video laryngoscopy (VL) with first pass success and return of spontaneous circulation (ROSC) using a national OHCA cohort.

METHODS

We analyzed 2018 data from ESO Inc. (Austin, TX), a national prehospital electronic health record. We included all adult, non-traumatic cardiac arrests undergoing endotracheal intubation. We defined VL and direct laryngoscopy (DL) based on paramedic recorded intubation device. The primary outcomes were first pass success, ROSC, and sustained ROSC. Using multivariable, mixed models, we determined the association between VL and first pass success rate, ROSC, and sustained ROSC (survival to ED or ROSC in the field for greater than 20 min), fitting agency as a random intercept and adjusting for confounders.

RESULTS

We included 22,132 patients cared for by 914 EMS agencies, including 5702 (25.7%) VL and 16,430 (74.2%) DL. Compared to DL, VL had a lower rate of bystander CPR, but other characteristics were similar between the groups. VL exhibited higher first pass success than DL (75.1% v 69.5%, p < .001). On mixed model analysis, VL was associated with a higher first pass success (OR 1.5, CI 1.3-1.6) but not ROSC (OR 1.1, CI 0.97-1.2) or sustained ROSC (OR 1.1, CI 0.9-1.2).

CONCLUSION

While associated with higher FPS, VL was not associated with increased rate of ROSC. The role of VL in OHCA remains unclear.

Influence of prehospital physician presence on survival after severe trauma: Systematic review and meta-analysis

BACKGROUND

As trauma is one of the leading causes of death worldwide, there is great potential for reducing mortality in trauma patients. However, there is continuing controversy over the benefit of deploying emergency medical systems (EMS) physicians in the prehospital setting. The objective of this systematic review and meta-analysis is to assess how out-of-hospital hospital management of severely injured patients by EMS teams with and without physicians affects mortality.

METHODS

PubMed and Google Scholar were searched for relevant articles, and the search was supplemented by a hand search. Injury severity in the group of patients treated by an EMS team including a physician had to be comparable to the group treated without a physician. Primary outcome parameter was mortality. Helicopter transport as a confounder was accounted for by subgroup analyses including only the studies with comparable modes of transport. Quality of all included studies was assessed according to the Cochrane handbook.

RESULTS

There were 2,249 publications found, 71 full-text articles assessed, and 22 studies included. Nine of these studies were matched or adjusted for injury severity. The odds ratio (OR) of mortality was significantly lower in the EMS physician-treated group of patients: 0.81; 95% confidence interval (CI): 0.71-0.92. When analysis was limited to the studies that were adjusted or matched for injury severity, the OR was 0.86 (95% CI, 0.73-1.01). Analyzing only studies published after 2005 yielded an OR for mortality of 0.75 (95% CI, 0.64-0.88) in the overall analysis and 0.81 (95% CI, 0.67-0.97) in the analysis of adjusted or matched studies. The OR was 0.80 (95% CI, 0.65-1.00) in the subgroup of studies with comparable modes of transport and 0.74 (95% CI, 0.53-1.03) in the more recent studies.

CONCLUSION

Prehospital management of severely injured patients by EMS teams including a physician seems to be associated with lower mortality. After excluding the confounder of helicopter transport we have shown a nonsignificant trend toward lower mortality.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

The critical care literature 2018

An emergency physician (EP) is often the first health care provider to evaluate, resuscitate, and manage a critically ill patient. In recent years, the annual hours of critical care delivered in emergency departments (EDs) across the United States increased more than 200% (Herring et al., 2013). In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. In fact, more than 50% of ED patients that require admission to the intensive care unit (ICU) remain in the ED for more than 6 h (Rose et al., 2016). Longer ED boarding times for critically ill patients is associated with a negative impact on inpatient morbidity and mortality (Mathews et al., 2018). It is during these early hours of critical illness, while the patient is in the ED, where lives can be saved or lost. Therefore, it is important for the EP to be knowledgeable about recent developments in critical care medicine. This review summarizes important articles published in 2018 pertaining to the resuscitation and care of select critically ill patients. We chose these articles based on our opinion of the importance of the study findings and their application to clinical care in the ED. The following topics are covered: cardiac arrest, post-arrest care, septic shock, rapid sequence intubation, mechanical ventilation, fluid resuscitation, and metabolic acidosis.

Effect of Implementation of Cardiopulmonary Resuscitation-Targeted Multi-Tier Response System on Outcomes After Out-of-Hospital Cardiac Arrest: A Before-and-After Population-Based Study

Objective: A multi-tiered response (MTR) system has been controversial in terms of cost-effectiveness and outcome improvement. It remains uncertain whether a cardiopulmonary resuscitation (CPR)-targeted tiered response system is associated with better outcomes after out-of-hospital cardiac arrest (OHCA). This study aimed to investigate the effect of an MTR on OHCA outcomes. Methods: A natural experimental study was conducted for resuscitation-attempted adult OHCAs. The MTR system was implemented in Korea by the National Fire Agency in 2015 across the country where the single-tiered ambulance response system existed. The MTR program had the following 3 components: 1) detection of OHCA by dispatcher, 2) dispatch of ambulance or fire engine in addition to routine dispatch of ambulance, and 3) performance of team CPR. The study period of 2015-2016 was divided by 6 months (phases I [reference], II, III, and IV). The endpoints were prehospital defibrillation, prehospital return of spontaneous circulation (PROSC), survival to discharge and good neurological recovery. A multivariable logistic regression analysis was performed to evaluate the effect of the intervention, and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were calculated, adjusting for potential confounders. Results: A total of 32,663 eligible OHCA cases were evaluated during the study period. As the intervention program spread, the MTR with ambulance increased (from 7.0% in phase I to 53.7% in phase IV, p for trend < 0.01). During the study period, prehospital defibrillation increased from 23.6% in phase I to 26.9% in phase IV and the study outcome was improved from 7.4 to 12.6% for PROSC, from 6.7 to 9.1% for survival to discharge, and from 4.5 to 5.8% for good neurological outcome (p for trend < 0.01 for all). Compared with phase I, the AORs (95% CI) of phase IV were 1.16 (1.08-1.25) for prehospital defibrillation, 1.82 (1.63-2.04) for PROSC, 1.37 (1.21-1.56) for survival to discharge, and 1.23 (1.06-1.43) for good neurological outcome. Conclusion: The nationwide implementation of a multi-tiered response system for OHCA was associated with increased prehospital defibrillation and improved outcomes of OHCA patients.

Establishing the Key Outcomes for Pediatric Emergency Medical Services Research

The evidence supporting best practices when treating children in the prehospital setting or even the effect emergency medical services (EMS) has on patient outcomes is limited. Standardizing the critical outcomes for EMS research will allow for focused and comparable effort among the small but growing group of pediatric EMS investigators on specific topics. Standardized outcomes will also provide the opportunity to collectively advance the science of EMS for children and demonstrate the effect of EMS on patient outcomes. This article describes a consensus process among stakeholders in the pediatric emergency medicine and EMS community that identified the critical outcomes for EMS care in five clinical areas (traumatic brain injury, general injury, respiratory disease/failure, sepsis, and seizures). These areas were selected based on both their known public health importance and their commonality in EMS encounters. Key research outcomes identified by participating stakeholders using a modified nominal group technique for consensus building, which included small group brainstorming and independent voting for ranking outcomes that were feasible and/or important for the field.

CPR Guidance by an Emergency Physician via Video Call: A Simulation Study

Background

In South Korea, the prehospital treatment of cardiac arrest is generally led by an emergency medical technician-paramedic (EMT-P), and defibrillation is delivered by the automatic external defibrillator (AED). This study aimed at examining the effects of direct medical guidance by an emergency physician through a video call that enabled prompt manual defibrillation.

Methods

Two-hundred eighty-eight paramedics based in Gyeonggi Province were studied for four months, from July to November 2015. The participants were divided into 96 teams, and the teams were randomly divided into either a conventional group that was to use the AED or a video call guidance group which was to use the manual defibrillators, with 48 teams in each group. The time to first defibrillation, total hands-off time, and hands-off ratio were compared between the two groups.

Results

The median value of the time to the first defibrillation was significantly shorter in the video call guidance group (56 s) than in the conventional group (73 s) (p<0.001). The median value of the total hands-off time was also significantly shorter (228 vs. 285.5 s) (p<0.001), and the hands-off ratio, defined as the proportion of hands-off time out of the total CPR time, was significantly shorter in the video call guidance group (0.32 vs. 0.41) (p<0.001).

Conclusion

Physician-guided CPR with a video call enabled prompt manual defibrillation and significantly shortened the time required for first defibrillation, hands-off time, and hands-off ratio in simulated cases of prehospital cardiac arrest.

Out-of-hospital endotracheal intubation experience, confidence and confidence-associated factors among Northern Japanese emergency life-saving technicians: a population-based cross-sectional study

OBJECTIVE

Clinical procedural experience and confidence are both important when performing complex medical procedures. Since out-of-hospital endotracheal intubation (ETI) is a complex intervention, we sought to clarify clinical ETI experience among prehospital rescuers as well as their confidence in performing ETI and confidence-associated factors.

DESIGN

Population-based cross-sectional study conducted from January to September 2017.

SETTING

Northern Japan, including eight prefectures.

PARTICIPANTS

Emergency life-saving technicians (ELSTs) authorised to perform ETI.

OUTCOME MEASURES

Annual ETI exposure and confidence in performing ETI, according to a five-point Likert scale. To determine factors associated with ETI confidence, differences between confident ELSTs (those scoring 4 or 5 on the Likert scale) and non-confident ELSTs were evaluated.

RESULTS

Questionnaires were sent to 149 fire departments (FDs); 140 agreed to participate. Among the 2821 ELSTs working at responding FDs, 2620 returned the questionnaire (response rate, 92.9%); complete data sets were available for 2567 ELSTs (complete response rate, 91.0%). Of those 2567 respondents, 95.7% performed two or fewer ETI annually; 46.6% reported lack of confidence in performing ETI. Multivariable logistic regression analysis showed that years of clinical experience (adjusted OR (AOR) 1.09; 95% CI 1.05 to 1.13), annual ETI exposure (AOR 1.79; 95% CI 1.59 to 2.03) and the availability of ETI skill retention programmes including regular simulation training (AOR 1.31; 95% CI 1.02 to 1.68) and operating room training (AOR 1.44; 95% CI 1.14 to 1.83) were independently associated with confidence in performing ETI.

CONCLUSIONS

ETI is an uncommon event for most ELSTs, and nearly half of respondents did not have confidence in performing this procedure. Since confidence in ETI was independently associated with availability of regular simulation and operating room training, standardisation of ETI re-education that incorporates such methods may be useful for prehospital rescuers.

Defining the plateau point: When are further attempts futile in out-of-hospital advanced airway management?

BACKGROUND

We sought to characterize the number of attempts required to achieve advanced airway management (AAM) success.

METHODS

Using 4 years of data from a national EMS electronic health record system, we examined the following subsets of attempted AAM: 1) cardiac arrest intubation (CA-ETI), 2) non-arrest medical intubation (MED-ETI), 3) non-arrest trauma intubation (TRA-ETI), 4) rapid-sequence intubation (RSI), 5) sedation-assisted ETI (SAI), and 6) supraglottic airway (SGA). We determined the first pass and overall success rates, as well as the point of additional attempt futility ("plateau point").

RESULTS

Among 57,209 patients there were 64,291 AAM. CA-ETI performance was: first-pass success (FPS) 71.4% (95% CI: 70.9-71.9%), 4 attempts to reach 91.5% (91.2-91.9%) success plateau. MED-ETI performance was: FPS 66.0% (95% CI: 65.1-67.0%), 3 attempts to reach 79.2% (78.4-80.0%) success plateau. TRA-ETI performance was: FPS 61.6% (95% CI: 59.3-63.9%), 3 attempts to reach 75.8% (73.7-77.8%) success plateau. RSI performance was: FPS 76.1% (95% CI: 75.1-77.1%), 5 attempts to reach 95.8% (95.3-96.2%) success plateau. SAI performance was: FPS 66.9% (95% CI: 65.1-68.6%), 3 attempts to 85.3% (83.9-86.6%) success plateau. SGA performance was: FPS 88.7% (95% CI: 88.0-89.3%), 5 attempts to reach 92.8% (92.3-93.4%) success plateau.

CONCLUSION

Multiple attempts are often needed to accomplish successful AAM. The number of attempts needed to accomplish AAM varies with AAM technique. These results may guide AAM practices.

Paramedic Out-of-hospital Cardiac Arrest Case Volume Is a Predictor of Return of Spontaneous Circulation

Introduction

Many factors contribute to the survival of out-of-hospital cardiac arrest (OHCA). One such factor is the quality of resuscitation efforts, which in turn may be a function of OHCA case volume. However, few studies have investigated the OHCA case volume-survival relationship. Consequently, we sought to develop a model describing the likelihood of return of spontaneous circulation (ROSC) as a function of paramedic cumulative OHCA experience.

Methods

We conducted a statewide retrospective study of cardiac arrest using the North Carolina Prehospital Care Reporting System. Adult patients suffering a witnessed, non-traumatic cardiac arrest between January 2012 and June 2014 were included. Using logistic regression, we calculated an adjusted odds ratio (OR) for the influence of the preceding five-year paramedic OHCA case volume on ROSC while controlling for the potentially confounding variables identified a priori as patient age, gender, and non-Caucasian race; shockable presenting rhythm; layperson/first responder cardiopulmonary resuscitation (CPR); and emergency medical services (EMS) response time.

Results

Of the 6,405 patients meeting inclusion criteria, 3,155 (49.3%) experienced ROSC. ROSC was more likely among patients treated by paramedics with ≥ 15 OHCA experiences during the preceding five years (OR [1.21], p<0.01). ROSC was also more likely among patients with shockable initial rhythms (OR [2.35], p<0.01) and who received layperson/first responder CPR (OR [1.77], p<0.01). Increasing patient age (OR [0.996], p=0.02), male gender (OR [0.742], p<0.01), and increasing EMS response time (OR [0.954], p<0.01) were associated with a decreased likelihood of ROSC. Non-Caucasian race was not an independent predictor of ROSC.

Conclusion

We found that a paramedic five-year OHCA case volume of ≥ 15 is significantly associated with ROSC. Further study is needed to determine the specific actions of these more experienced paramedics who are responsible for the increased likelihood of ROSC, as well as the influence of case volume on the longer-term outcome measures of hospital discharge and neurological function.

Advanced vs. Basic Life Support in the Treatment of Out-of-Hospital Cardiopulmonary Arrest in the Resuscitation Outcomes Consortium

BACKGROUND

Prior observational studies suggest no additional benefit from advanced life support (ALS) when compared with providing basic life support (BLS) for patients with out-of-hospital cardiac arrest (OHCA). We compared the association of ALS care with OHCA outcomes using prospective clinical data from the Resuscitation Outcomes Consortium (ROC).

METHODS

Included were consecutive adults OHCA treated by participating emergency medical services (EMS) agencies between June 1, 2011, and June 30, 2015. We defined BLS as receipt of cardiopulmonary resuscitation (CPR) and/or automated defibrillation and ALS as receipt of an advanced airway, manual defibrillation, or intravenous drug therapy. We compared outcomes among patients receiving: 1) BLS-only; 2) BLS + late ALS; 3) BLS + early ALS; and 4) ALS-first care. Using multivariable logistic regression, we evaluated the associations between level of care and return of spontaneous circulation (ROSC), survival to hospital discharge, and survival with good functional status, adjusting for age, sex, witnessed arrest, bystander CPR, shockable initial rhythm, public location, EMS response time, CPR quality, and ROC site.

RESULTS

Among 35,065 patients with OHCA, characteristics were median age 68 years (IQR 56-80), male 63.9%, witnessed arrest 43.8%, bystander CPR 50.6%, and shockable initial rhythm 24.2%. Care delivered was: 4.0% BLS-only, 31.5% BLS + late ALS, 17.2% BLS + early ALS, and 47.3% ALS-first. ALS care with or without initial BLS care was independently associated with increased adjusted ROSC and survival to hospital discharge unless delivered greater than 6 min after BLS arrival (BLS + late ALS). Regardless of when it was delivered, ALS care was not associated with significantly greater functional outcome.

CONCLUSION

ALS care was associated with survival to hospital discharge when provided initially or within six minutes of BLS arrival. ALS care, with or without initial BLS care, was associated with increased ROSC, however it was not associated with functional outcome.

Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia

STUDY OBJECTIVE

Peri-intubation hypoxia is an important adverse event of out-of-hospital rapid sequence intubation. The aim of this project is to determine whether a clinical bundle encompassing positioning, apneic oxygenation, delayed sequence intubation, and goal-directed preoxygenation is associated with decreased peri-intubation hypoxia compared with standard out-of-hospital rapid sequence intubation.

METHODS

We conducted a retrospective, before-after study using data from a suburban emergency medical services (EMS) system in central Texas. The study population included all adults undergoing out-of-hospital intubation efforts, excluding those in cardiac arrest. The before-period intervention was standard rapid sequence intubation using apneic oxygenation at flush flow, ketamine, and a paralytic. The after-period intervention was a care bundle including patient positioning (elevated head, sniffing position), apneic oxygenation, delayed sequence intubation (administration of ketamine to facilitate patient relaxation and preoxygenation with a delayed administration of paralytics), and goal-directed preoxygenation. The primary outcome was the rate of peri-intubation hypoxia, defined as the percentage of patients with a saturation less than 90% during the intubation attempt.

RESULTS

The before group (October 2, 2013, to December 13, 2015) included 104 patients and the after group (August 8, 2015, to July 14, 2017) included 87 patients. The 2 groups were similar in regard to sex, age, weight, ethnicity, rate of trauma, initial oxygen saturation, rates of initial hypoxia, peri-intubation peak SpO₂, preintubation pulse rate and systolic blood pressure, peri-intubation cardiac arrest, and first-pass and overall success rates. Compared with the before group, the after group experienced less peri-intubation hypoxia (44.2% versus 3.5%; difference -40.7% [95% confidence interval -49.5% to -32.1%]) and higher peri-intubation nadir SpO₂ values (100% versus 93%; difference 5% [95% confidence interval 2% to 10%]).

CONCLUSION

In this single EMS system, a care bundle encompassing patient positioning, apneic oxygenation, delayed sequence intubation, and goal-directed preoxygenation was associated with lower rates of peri-intubation hypoxia than standard out-of-hospital rapid sequence intubation.

A Continuous Quality Improvement Airway Program Results in Sustained Increases in Intubation Success

INTRODUCTION

Airway management is a critical skill for air medical providers, including the use of rapid sequence intubation (RSI) medications. Mediocre success rates and a high incidence of complications has challenged air medical providers to improve training and performance improvement efforts to improve clinical performance.

OBJECTIVES

The aim of this research was to describe the experience with a novel, integrated advanced airway management program across a large air medical company and explore the impact of the program on improvement in RSI success.

METHODS

The Helicopter Advanced Resuscitation Training (HeART) program was implemented across 160 bases in 2015. The HeART program includes a novel conceptual framework based on thorough understanding of physiology, critical thinking using a novel algorithm, difficult airway predictive tools, training in the optimal use of specific airway techniques and devices, and integrated performance improvement efforts to address opportunities for improvement. The C-MAC video/direct laryngoscope and high-fidelity human patient simulation laboratories were implemented during the study period. Chi-square test for trend was used to evaluate for improvements in airway management and RSI success (overall intubation success, first-attempt success, first-attempt success without desaturation) over the 25-month study period following HeART implementation.

RESULTS

A total of 5,132 patients underwent RSI during the study period. Improvements in first-attempt intubation success (85% to 95%, p < 0.01) and first-attempt success without desaturation (84% to 94%, p < 0.01) were observed. Overall intubation success increased from 95% to 99% over the study period, but the trend was not statistically significant (p = 0.311).

CONCLUSIONS

An integrated advanced airway management program was successful in improving RSI intubation performance in a large air medical company.

The effect of the number and level of emergency medical technicians on patient outcomes following out of hospital cardiac arrest in Taipei

AIM

The effect of the number and level of on-scene emergency medical technicians (EMTs) on the outcomes of patients with out-of-hospital cardiac arrest (OHCA) remains unclear. We aimed to test the association between the number and level of EMTs and the outcomes of patients with OHCA.

METHODS

We analysed Utstein-based registry data on OHCA in Taipei from 2011 to 2015. The eligible patients were adults, aged ≥20 years, with non-traumatic OHCA who underwent resuscitation attempts. The exposures were the total number of EMTs or the EMT-Paramedic (EMT-P) ratio >50%. The outcome of interest was survival to discharge.

RESULTS

During study period, total 8262 OHCA cases were included, of which 1085 (13.1%) were approached by crews with an EMT-P ratio >50%. While an increase in the number of EMTs on-scene was not associated with better chances of survival (adjusted odds ratio [aOR] 0.98, 95% confidence interval [CI] 0.89-1.08), an EMT-P ratio >50% was significantly associated with improved outcome (aOR 1.36, 95% CI 1.06-1.76). Subgroup analyses showed that EMT-P >50% significantly benefited survival in witnessed OHCA cases with non-shockable rhythm (aOR 1.69, 95% CI 1.01-2.58). Survival was the highest among cases seen by four EMTs with an EMT-P ratio >50% (aOR 2.54, 95% CI 1.43-4.50).

CONCLUSION

An on-scene EMT-P ratio >50% was associated with improved survival to discharge of OHCA cases, especially in those with witnessed, non-shockable rhythm. The presence of four EMTs with an EMT-P ratio >50% at the scene of OHCA was associated with the best 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.

Video laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators

AIM

This study compared endotracheal intubation (ETI) performance during cardiopulmonary resuscitation (CPR) between direct laryngoscopy (DL) and video laryngoscopy (VL) (GlideScope(®)) by experienced intubators (>50 successful ETIs).

METHODS

This was a prospective randomized controlled study conducted in an emergency department between 2011 and 2013. Intubators who used DL or VL were randomly allocated to ETI during CPR. Data were collected from recorded video clips and rhythm sheets. The success, speed, complications, and chest compressions interruption were compared between the two devices.

RESULTS

Total 140 ETIs by experienced intubators using DL (n=69) and VL (n=71) were analysed. There were no significant differences between DL and VL in the ETI success rate (92.8% vs. 95.8%; p=0.490), first-attempt success rate (87.0% vs. 94.4%; p=0.204), and median time to complete ETI (51 [36-67] vs. 42 [34-62]s; p=0.143). In both groups, oesophageal intubation and dental injuries seldom occurred. However, longer chest compressions interruption occurred using DL (4.0 [1.0-11.0]s) compared with VL (0.0 [0.0-1.0]s) and frequent serious no-flow (interruption>10s) occurred with DL (18/69 [26.1%]) compared with VL (0/71) (p<0.001). For highly experienced intubators (>80 successful ETIs), frequent serious no-flow occurred in DL (14/55 [25.5%] vs. 0/57 in VL).

CONCLUSIONS

The ETI success, speed and complications during CPR did not differ significantly between the two devices for experienced intubators. However, the VL was superior in terms of completion of ETI without chest compression interruptions.

TRIAL REGISTRATION

Clinical Research Information Service (CRIS) in South Korea KCT0000849.

Design and implementation of the Resuscitation Outcomes Consortium Pragmatic Airway Resuscitation Trial (PART)

Airway management is an important component of resuscitation from out-of-hospital cardiac arrest (OHCA). The optimal approach to advanced airway management is unknown. The Pragmatic Airway Resuscitation Trial (PART) will compare the effectiveness of endotracheal intubation (ETI) and Laryngeal Tube (LT) insertion upon 72-h survival in adult OHCA. Encompassing United States Emergency Medical Services agencies affiliated with the Resuscitation Outcomes Consortium (ROC), PART will use a cluster-crossover randomized design. Participating subjects will include adult, non-traumatic OHCA requiring bag-valve-mask ventilation. Trial interventions will include (1) initial airway management with ETI and (2) initial airway management with LT. The primary and secondary trial outcomes are 72-h survival and return of spontaneous circulation. Additional clinical outcomes will include airway management process and adverse events. The trial will enroll a total of 3000 subjects. Results of PART may guide the selection of advanced airway management strategies in OHCA.

Paramedic Exposure to Out-of-Hospital Cardiac Arrest Resuscitation Is Associated With Patient Survival

BACKGROUND

Although out-of-hospital cardiac arrest (OHCA) is a major public health problem, individual paramedics are rarely exposed to these cases. In this study, we examined whether previous paramedic exposure to OHCA resuscitation is associated with patient survival.

METHODS AND RESULTS

For the period 2003 to 2012, we linked data from the Victorian Ambulance Cardiac Arrest Registry to Ambulance Victoria's employment data set. We defined exposure as the number of times a paramedic attended an OHCA where resuscitation was attempted in the 3 years preceding each case. Using a multivariable model adjusting for known predictors of survival, we measured the association between paramedic OHCA exposure and patient survival to hospital discharge. During the study period, there were 4151 paramedics employed and 48 291 OHCAs (44% with resuscitation attempted). The median exposure of all paramedics was 2 (interquartile range 1-3) OHCAs/year. Eleven percent of paramedics were not exposed to any OHCA cases. Increased paramedic exposure was associated with reduced odds of attempted resuscitation (P<0.001). In the 3 years preceding each OHCA where resuscitation was attempted, the median exposure of the treating paramedics was 11 (interquartile range 6-17) OHCAs. Compared with patients treated by paramedics with a median of ≤6 exposures during the previous 3 years (7% survival), the odds of survival were higher for patients treated by paramedics with >6 to 11 (12%, adjusted odds ratio 1.26, 95% confidence interval 1.04-1.54), >11 to 17 (14%, adjusted odds ratio 1.29, 95% confidence interval 1.04-1.59), and >17 exposures (17%, adjusted odds ratio 1.50, 95% confidence interval 1.22-1.86). Paramedic years of experience were not associated with survival.

CONCLUSIONS

Patient survival after OHCA significantly increases with the number of OHCAs that paramedics have previously treated.

Influence of EMS-physician presence on survival after out-of-hospital cardiopulmonary resuscitation: systematic review and meta-analysis

BACKGROUND

Evidence suggests that EMS-physician-guided cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OOHCA) may be associated with improved outcomes, yet randomized controlled trials are not available. The goal of this meta-analysis was to determine the association between EMS-physician- versus paramedic-guided CPR and survival after OOHCA.

METHODS AND RESULTS

Studies that compared EMS-physician- versus paramedic-guided CPR in OOHCA published until June 2014 were systematically searched in MEDLINE, EMBASE and Cochrane databases. All studies were required to contain survival data. Data on study characteristics, methods, and as well as survival outcomes were extracted. A random-effects model was used for the meta-analysis due to a high degree of heterogeneity among the studies (I(2) = 44%). Return of spontaneous circulation [ROSC], survival to hospital admission, and survival to hospital discharge were the outcome measures. Out of 3,385 potentially eligible studies, 14 met the inclusion criteria. In the pooled analysis (n = 126,829), EMS-physician-guided CPR was associated with significantly improved outcomes compared to paramedic-guided CPR: ROSC 36.2% (95% confidence interval [CI] 31.0 - 41.7%) vs. 23.4% (95% CI 18.5 - 29.2%) (pooled odds ratio [OR] 1.89, 95% CI 1.36 - 2.63, p < 0.001); survival to hospital admission 30.1 % (95% CI 24.2 - 36.7%) vs. 19.2% (95% CI 12.7 - 28.1%) (pooled OR 1.78, 95% CI 0.97 - 3.28, p = 0.06); and survival to discharge 15.1% (95% CI 14.6 - 15.7%) vs. 8.4% (95% CI 8.2 - 8.5%) (pooled OR 2.03, 95% CI 1.48 - 2.79, p < 0.001).

CONCLUSIONS

This systematic review suggests that EMS-physician-guided CPR in out-of-hospital cardiac arrest is associated with improved survival outcomes.

Low oxygen saturation is associated with pre-hospital mortality among non-traumatic patients using emergency medical services: A national database of Thailand

BACKGROUND

Pre-hospital emergency medical services are an important network for Emergency Medicine. It has been shown to reduce morbidity and mortality of patients by medical procedures. The Thai government established pre-hospital emergency medical services in 2008 to improve emergency medical care. Since then, there are limited data at the national level on mortality rates with pre-hospital care and the risk factors associated with mortality in non-traumatic patients.

AIMS

To study the pre-hospital mortality rate and factors associated with mortality in non-traumatic patients using the emergency medical service in Thailand.

METHODS

This study retrieved medical data from the National Institute for Emergency Medicine, NIEMS. The inclusion criteria were adult patients above the age of 15 who received medical services by the emergency medical services in Thailand (except Bangkok) from April 1st, 2011 to March 31st, 2012. Patients were excluded if there was no treatment during pre-hospital period, if they were trauma patients, or if their medical data was incomplete. Patients were categorized as either in the survival or non-survival group. Factors associated with mortality were examined by multivariate logistic regression analysis.

RESULTS

During the study period, there were 127,602 non-traumatic patients who used pre-hospital emergency medical services in Thailand. Of those, 98,587 patients met the study criteria. For the statistical analyses, there were 66,760 patients who had complete clinical investigations. The mortality rate in this group was 1.89%. Only oxygen saturation was associated with mortality by multivariate logistic regression analysis. The adjusted OR was 0.922 (95% CI 0.8550.994).

CONCLUSION

Low oxygen saturation is significantly associated with pre-hospital mortality in a national database of non-traumatic patients using emergency medical services in Thailand. During pre-hospital care, oxygen level should be monitored and promptly treated. Pulse oximetry devices should be available in all pre-hospital services.

Should laryngeal tubes or masks be used for out-of-hospital cardiac arrest patients?

OBJECTIVE

Few studies have compared airway management via laryngeal masks (LM) or laryngeal tubes (LT) in patients with out-of-hospital cardiac arrest (OHCA). This study evaluated whether LT insertion by emergency medical service (EMS) personnel affected ventilation and outcomes in OHCA patients (vs. the standard LM treatment).

METHODS

This prospective, cluster-randomized, and open-label study evaluated data that were collected by the Sapporo Fire Department between June 2012 and January 2013. We selected the 14 EMS teams that treated the greatest number of OHCA patients in Sapporo, Japan during 2011, and randomized the teams into Groups A and B. In the first study period (June 2012 to September 2012), Group A treated OHCA patients via LT and Group B treated OHCA patients via LM. In the second period (October 2012 to January 2013), Group A treated OHCA patients via LM and Group B treated OHCA patients via LT. If necessary, both groups were allowed to use an esophageal obturator airway (EOA) kit. The primary endpoints were time from cardiopulmonary resuscitation to device insertion and the rate of successful pre-hospital ventilation. The secondary endpoints were return of spontaneous circulation and survival and favorable neurological outcomes at 1 month after cardiac arrest.

RESULTS

LT was used in 148 OHCA patients and LM was used in 165 OHCA patients. Our intention-to-treat analyses revealed no significant differences in the primary and secondary outcomes of the LT- and LM-treated groups.

CONCLUSION

Prehospital advanced airway management via LT provides similar outcomes to those of LM in OHCA patients.

Patient safety in ambulance services: a scoping review

Background

The role of ambulance services has changed dramatically over the last few decades with the introduction of paramedics able to provide life-saving interventions, thanks to sophisticated equipment and treatments available. The number of 999 calls continues to increase, with adverse events theoretically possible with each one. Most patient safety research is based on hospital data, but little is known concerning patient safety when using ambulance services, when things can be very different. There is an urgent need to characterise the evidence base for patient safety in NHS ambulance services.

Objective

To identify and map available evidence relating to patient safety when using ambulance services.

Design

Mixed-methods design including systematic review and review of ambulance service documentation, with areas for future research prioritised using a Delphi process.

Setting and participants

Ambulance services, their staff and service users in UK.

Data sources

A wide range of data sources were explored. Multiple databases, reference lists from key papers and citations, Google and the NHS Confederation website were searched, and experts contacted to ensure that new data were included in the review. The databases MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Science Direct, Emerald, Education Resources Information Center (ERIC), Applied Social Sciences Index and Abstracts, Social Services Abstracts, Sociological Abstracts, International Bibliography of the Social Sciences (IBSS), PsycINFO, PsycARTICLES, Health Management Information Consortium (HMIC), NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED),Health Technology Assessment, the FADE library, Current Awareness Service for Health (CASH), OpenDOAR (Directory of Open Access Repositories) and Open System for Information on Grey Literature in Europe (OpenSIGLE) and Zetoc (The British Library's Electronic Table of Contents) were searched from 1 January 1980 to 12 October 2011. Publicly available documents and issues identified by National Patient Safety Agency (NPSA), NHS Litigation Authority (NHSLA) and coroners’ reports were considered. Opinions and perceptions of senior managers, ambulance staff and service users were solicited.

Review methods

Data were extracted from annual reports using two-stage thematic analysis, data from quality accounts were collated with safety priorities tabulated and considered using thematic analysis, NPSA incident report data were collated and displayed comparatively using descriptive statistics, claims reported to NHSLA were analysed to identify number and cost of claims from mistakes and/or poor service, and summaries of coroners’ reports were assessed using thematic analysis to identify underlying safety issues. The depth of analysis is limited by the remit of a scoping exercise and availability of data.

Results

We identified studies exploring different aspects of safety, which were of variable quality and with little evidence to support activities currently undertaken by ambulance services. Adequately powered studies are required to address issues of patient safety in this service, and it appeared that national priorities were what determined safety activities, rather than patient need. There was inconsistency of information on attitudes and approaches to patient safety, exacerbated by a lack of common terminology.

Conclusion

Patient safety needs to become a more prominent consideration for ambulance services, rather than operational pressures, including targets and driving the service. Development of new models of working must include adequate training and monitoring of clinical risks. Providers and commissioners need a full understanding of the safety implications of introducing new models of care, particularly to a mobile workforce often isolated from colleagues, which requires a body of supportive evidence and an inherent critical evaluation culture. It is difficult to extrapolate findings of clinical studies undertaken in secondary care to ambulance service practice and current national guidelines often rely on consensus opinion regarding applicability to the pre-hospital environment. Areas requiring further work include the safety surrounding discharging patients, patient accidents, equipment and treatment, delays in transfer/admission to hospital, and treatment and diagnosis, with a clear need for increased reliability and training for improving handover to hospital.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Prehospital endotracheal intubation vs extraglottic airway device in blunt trauma

OBJECTIVE

The objective of the study is to compare outcomes in blunt trauma patients managed with prehospital insertion of an extraglottic airway device (EGD) vs endotracheal intubation (ETI). The null hypothesis was that there would be no difference in mortality for the 2 groups.

METHODS

This is a retrospective study of blunt trauma patients with Glasgow Coma Scale score less than or equal to 8 transported by ground emergency medical services directly from the scene of injury to a single urban level 1 trauma center. Patients managed with only noninvasive airway techniques were excluded, leaving patients undergoing either EGD placement or ETI. Outcomes included in-emergency department (ED) traumatic arrest and hospital mortality. Multivariable logistic regression was used to control for the potential confounding effects of demographic and clinical variables. For all analyses, P < .05 was used to establish statistical significance.

RESULTS

In bivariate analysis, patients managed with EGD were more likely than those managed with ETI to have an in-ED traumatic arrest (36.5% vs 17.1%; P = .005), but eventual hospital mortality did not significantly differ between the 2 groups (75.7% vs 67.1%; P = .228). After controlling for demographic and clinical characteristics, patients managed with EGD were no more likely than patients managed with ETI to experience traumatic arrest in the ED (adjusted odds ratio, 1.67; 95% confidence interval, 0.72-3.89), and there was also no difference in overall hospital mortality (adjusted odds ratio, 0.912; 95% confidence interval, 0.36-2.30).

CONCLUSION

In this preliminary, retrospective analysis, we found no difference in overall survival among trauma patients managed with prehospital EGD and those managed with prehospital ETI.

Feasibility of LMA Supreme for airway management in unconscious patients by ALS paramedics

Background

Airway management to ensure sufficient gas exchange is of major importance in emergency care. The accepted basic technique is to maintain an open airway and perform artificial ventilation in emergency situations is bag-valve mask (BVM) ventilation with manual airway management without airway adjuncts or with an oropharyngeal tube (OPA) only. Endotracheal intubation (ETI) is often referred to as the golden standard of airway management, but is associated with low success rates and significant insertion-related complications when performed by non-anaesthetists. Supraglottic devices (SADs) are one alternative to ETI in these situations, but there is limited evidence regarding the use of SAD in non-cardiac arrest situations. LMA Supreme (LMA-S) is a new SAD which theoretically has an advantage concerning the risk of aspiration due to an oesophageal inlet gastric tube port.

Methods

Forty paramedics were recruited to participate in the study. Adult (>18 years) patients, unconscious due to medical or traumatic cause with a GCS score corresponding to 3–5 and needed airway management were included in the study. Our aim was to study the feasibility of LMA-S as a primary airway method in unconscious patients by advanced life support (ALS) trained paramedics in prehospital care.

Results

Three regional Emergency Medical Service (EMS) services participated and 21 patients were treated during the survey. The LMA-S was placed correctly on the first attempt in all instances 21/21 (100%), with a median time to first ventilation of 9.8 s. Paramedics evaluated the insertion to be easy in every case 21/21 (100%). Because of air leak later in the patient care, the LMA-S was exchanged to an LT-D in two cases and to ETI in three cases (23.81%) by the paramedics. Regurgitation occurred after insertion two times out of 21 (9.52%) and in one of these cases (4.76%), paramedics reported regurgitation inside the LMA-S.

Conclusion

We conclude that the LMA-S seems to be relatively easy and quick to insert in unconscious patients by paramedics. However, we found out that there were ventilation related problems with the LMA-S. Further studies are warranted.

Multiple failed intubation attempts are associated with decreased success rates on the first rescue intubation in the emergency department: a retrospective analysis of multicentre observational data

Background

Although the international guidelines emphasize early and systematic use of rescue intubation techniques, there is little evidence to support this notion. We aimed to test the hypothesis that preceding multiple failed intubation attempts are associated with a decreased success rate on the first rescue intubation in emergency departments (EDs).

Methods

We analysed data from two multicentre prospective registries designed to characterize current ED airway management in Japan between April 2010 and June 2013. All patients who underwent a rescue intubation after a failed attempt or a series of failed attempts were included for the analysis. Multiple failed intubation attempts were defined as ≥2 consecutive failed intubation attempts before a rescue intubation. Primary outcome measure was success rate on the first rescue intubation attempt.

Results

Of 6,273 consecutive patients, 1,151 underwent a rescue intubation. The success rate on the first rescue intubation attempt declined as the number of preceding failed intubation attempts increased (81% [95% CI, 79%-84%] after one failed attempt; 71% [95% CI, 66%-76%] after two failed attempts; 67% [95% CI, 55%-78%] after three or more failed attempts; P_trend <0.001). In the multivariable analysis adjusting for age, sex, principal indication, change in methods, devices, and intubator specialty, and clustering of patients within EDs, success rate on the first rescue intubation after two failed attempts was significantly lower (OR, 0.56; 95% CI, 0.41-0.77) compared to that after one failed attempt. Similarly, success rate on the first rescue intubation attempt after three or more failed attempts was significantly lower (OR, 0.49; 95% CI, 0.25-0.94) compared to that after one failed attempt.

Conclusion

Preceding multiple failed intubation attempts was independently associated with a decreased success rate on the first rescue intubation in the ED.

Risk Factors for Failed Tracheal Intubation in Pediatric and Neonatal Critical Care Specialty Transport

Abstract Objective. Nearly 200,000 pediatric and neonatal transports occur in the United States each year with some patients requiring tracheal intubation. First-pass intubation rates in both pediatric and adult transport literature are variable as are the factors that influence intubation success. This study sought to determine risk factors for failed tracheal intubation in neonatal and pediatric transport. Methods. A retrospective chart review was performed over a 2.5-year period. Data were collected from a hospital-based neonatal/pediatric critical care transport team that transports 2,500 patients annually, serving 12,000 square miles. Patients were eligible if they were transported and tracheally intubated by the critical care transport team. Patients were categorized into two groups for data analysis: (1) no failed intubation attempts and (2) at least one failed intubation attempt. Data were tabulated using Epi Info Version 3.5.1 and analyzed using SPSSv17.0. Results. A total of 167 patients were eligible for enrollment and were cohorted by age (48% pediatric versus 52% neonatal). Neonates were more likely to require multiple attempts at intubation when compared to the pediatric population (69.6% versus 30.4%, p = 0.001). Use of benzodiazepines and neuromuscular blockade was associated with increased successful first attempt intubation rates (p = 0.001 and 0.008, respectively). Use of opiate premedication was not associated with first-attempt intubation success. The presence of comorbid condition(s) was associated with at least one failed intubation attempt (p = 0.006). Factors identified with increasing odds of at least one intubation failure included, neonatal patients (OR 3.01), tracheal tube size ≤ 2.5 mm (OR 3.78), use of an uncuffed tracheal tube (OR 6.85), and the presence of a comorbid conditions (OR 2.64). Conclusions. There were higher rates of tracheal intubation failure in transported neonates when compared to pediatric patients. This risk may be related to the lack of benzodiazepine and neuromuscular blocking agents used to facilitate intubation. The presence of a comorbid condition is associated with a higher risk of tracheal intubation failure.