Advanced airway management during adult cardiac arrest: A systematic review

Identifying, Understanding, and Minimizing Unconscious Cognitive Biases in Perioperative Crisis Management: A Narrative Review

Rapid clinical decision-making behavior is often based on pattern recognition and other mental shortcuts. Although such behavior is often faster than deliberative thinking, it can also lead to errors due to unconscious cognitive biases (UCBs). UCBs may contribute to inaccurate diagnoses, hamper interpersonal communication, trigger inappropriate clinical interventions, or result in management delays. The authors review the literature on UCBs and discuss their potential impact on perioperative crisis management. Using the Scale for the Assessment of Narrative Review Articles (SANRA), publications with the most relevance to UCBs in perioperative crisis management were selected for inclusion. Of the 19 UCBs that have been most investigated in the medical literature, the authors identified 9 that were judged to be clinically relevant or most frequently occurring during perioperative crisis management. Formal didactic training on concepts of deliberative thinking has had limited success in reducing the presence of UCBs during clinical decision-making. The evolution of clinical decision support tools (CDSTs) has demonstrated efficacy in improving deliberative clinical decision-making, possibly by reducing the intrusion of maladaptive UCBs and forcing reflective thinking. Anesthesiology remains a leader in perioperative crisis simulation and CDST implementation, but spearheading innovations to reduce the adverse impact of UCBs will further improve diagnostic precision and patient safety during perioperative crisis management.

Early versus late advanced airway management for adult patients with out-of-hospital cardiac arrest: A time-dependent propensity score-matched analysis

OBJECTIVE

The objective was to investigate whether early advanced airway management during the entire resuscitation period is associated with favorable neurological outcomes and survival in patients with out-of-hospital cardiac arrest (OHCA).

METHODS

We performed a retrospective cohort study of patients with OHCA aged ≥18 years enrolled in OHCA registry in Japan who received advanced airway management during cardiac arrest between June 2014 and December 2020. To address resuscitation time bias, we performed risk set matching analyses in which patients who did and did not receive advanced airway management were matched at the same time point (min) using the time-dependent propensity score; further, we compared early (≤10 min) and late (>10 min) advanced airway management. The primary and secondary outcome measures were favorable neurological outcomes using Cerebral Performance Category scores and survival at 1 month after cardiac arrest.

RESULTS

Of the 41,101 eligible patients, 21,446 patients received early advanced airway management. Thus, risk set matching was performed with a total of 42,866 patients. In the main analysis, early advanced airway management was significantly associated with favorable neurological outcomes (risk ratio [RR] 0.997, 95% confidence interval [CI] 0.995-0.999) and survival (RR 0.990, 95% CI 0.986-0.994) at 1 month after cardiac arrest. In the sensitivity analysis with early advanced airway management defined as ≤5 min and ≤20 min, the results were comparable.

CONCLUSIONS

Although early advanced airway management was statistically significant for improved neurological outcomes and survival at 1 month after cardiac arrest, the RR was very close to 1, indicating that the timing of advanced airway management has minimal impact on clinical outcomes, and decisions should be made based on the individual needs of the patient.

Supraglottic Airway Versus Tracheal Intubation for Airway Management in Out-of-Hospital Cardiac Arrest: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Controlled Trials

OBJECTIVES

Given the uncertainty regarding the optimal approach for airway management for adult patients with out-of-hospital cardiac arrest (OHCA), we conducted a systematic review and meta-analysis to compare the use of supraglottic airways (SGAs) with tracheal intubation for initial airway management in OHCA.

DATA SOURCES

We searched MEDLINE, PubMed, Embase, Cochrane Library, as well as unpublished sources, from inception to February 7, 2023.

STUDY SELECTION

We included randomized controlled trials (RCTs) of adult OHCA patients randomized to SGA compared with tracheal intubation for initial prehospital airway management.

DATA EXTRACTION

Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model. We used the modified Cochrane risk of bias 2 tool and assessed certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We preregistered the protocol on PROSPERO (CRD42022342935).

DATA SYNTHESIS

We included four RCTs ( n = 13,412 patients). Compared with tracheal intubation , SGA use probably increases return of spontaneous circulation (ROSC) (relative risk [RR] 1.09; 95% CI, 1.02-1.15; moderate certainty) and leads to a faster time to airway placement (mean difference 2.5 min less; 95% CI, 1.6-3.4 min less; high certainty). SGA use may have no effect on survival at longest follow-up (RR 1.06; 95% CI, 0.84-1.34; low certainty), has an uncertain effect on survival with good functional outcome (RR 1.11; 95% CI, 0.82-1.50; very low certainty), and may have no effect on risk of aspiration (RR 1.04; 95% CI, 0.94 to 1.16; low certainty).

CONCLUSIONS

In adult patients with OHCA, compared with tracheal intubation, the use of SGA for initial airway management probably leads to more ROSC, and faster time to airway placement, but may have no effect on longer-term survival outcomes or aspiration events.

Association Between Advanced Airway Management With Adrenaline Injection and Prognosis in Adult Patients With Asystole Asphyxia Out-of-hospital Cardiac Arrest

BACKGROUND

The neurological prognosis of asphyxia is poor and the effect of advanced airway management (AAM) in the prehospital setting remains unclear. This study aimed to evaluate the association between AAM with adrenaline injection and prognosis in adult patients with asystole asphyxia out-of-hospital cardiac arrest (OHCA).

METHODS

This study assessed all-Japan Utstein cohort registry data between January 1, 2013 and December 31, 2019. We used propensity score matching analyses before logistic regression analysis to evaluate the effect of AAM on favorable neurological outcome.

RESULTS

There were 879,057 OHCA cases, including 70,299 cases of asphyxia OHCAs. We extracted the data of 13,642 cases provided with adrenaline injection by emergency medical service. We divided 7,945 asphyxia OHCA cases in asystole into 5,592 and 2,353 with and without AAM, respectively. After 1:1 propensity score matching, 2,338 asphyxia OHCA cases with AAM were matched with 2,338 cases without AAM. Favorable neurological outcome was not significantly different between the AAM and no AAM groups (adjusted odds ratio [OR] 1.1; 95% confidence interval [CI], 0.5-2.5). However, the return of spontaneous circulation (ROSC) (adjusted OR 1.7; 95% CI, 1.5-1.9) and 1-month survival (adjusted OR 1.5; 95% CI, 1.1-1.9) were improved in the AAM group.

CONCLUSION

AAM with adrenaline injection for patients with asphyxia OHCA in asystole was associated with improved ROSC and 1-month survival rate but showed no differences in neurologically favorable outcome. Further prospective studies may comprehensively evaluate the effect of AAM for patients with asphyxia.

Out-of-Hospital emergency airway management practices: A nationwide observational study from Aotearoa New Zealand

Background and Objectives

Airway management is crucial for emergency care in critically ill patients outside the hospital setting. An Airway Registry is useful in providing essential information for quality improvement purposes. Therefore, this study aimed to develop an out-of-hospital airway registry and describe airway management practices in Aotearoa New Zealand (AoNZ).

Methods

Data from the Aotearoa New Zealand Paramedic Care Collection (ANZPaCC) database were used in a retrospective cohort study covering July 2020 to June 2021. All patients receiving airway interventions were included. An airway intervention was defined as one or more of the following: non-drug assisted endotracheal intubation (NDA-ETI), drug-assisted endotracheal intubation (DA-ETI; where a combination of paralytic agent and sedative were used to aid in intubation), laryngeal mask airway (LMA), oropharyngeal airway (OPA), nasopharyngeal airway (NPA), surgical airway (cricothyroidotomy), suction, jaw thrust. Descriptive statistics were analysed using Chi-Square and logistic regression modelling investigated the relationship between advanced airway success and patient characteristics.

Results

The study included 4,529 patients who underwent 7,779 airway interventions. Basic airway interventions were used most frequently: OPA (45.1%), NPA (29.3%), LMA (28.9%), suction (19.9%) and jaw thrust (17.6%). Advanced airway interventions were used less frequently: NDA-ETI (19.8%), DA-ETI (8.7%), and surgical airways (0.2%). The success rate for ETI (including both NDA-ETI and DA-ETI) was 89.4%, with NDA-ETI success at 85.8% and DA-ETI success at 97.7%. ETI first-pass success rates were significantly lower for males (aOR 0.65, 95%CI 0.48-0.87, p < 0.001) and higher for non-cardiac arrest injury patients (aOR 2.94, 95%CI 1.43-6.00, p < 0.001). In this cohort receiving airway interventions the 1-day mortality rate was 41.1%, demonstrating that a high proportion of these patients were severely clinically compromised.

Conclusions

Out-of-hospital airway management practices and success rates in AoNZ are comparable to those elsewhere. This research has determined the variables to be used as the AoNZ Paramedic Airway Registry ongoing and has demonstrated baseline outcomes in airway management for ongoing quality improvement using this registry.

Harrison D, Hossain A, Lall R, Mason J, Nolan JP, Nwankwo H, Perkins GD, Samuel K, Schofield B, Soar J, Starr K, Thomas M, Voss S, Benger JR. Randomised trial of the clinical and cost effectiveness of a supraglottic airway device compared with tracheal intubation for in-hospital cardiac arrest (AIRWAYS-3): Protocol, design and implementation

Survival from in-hospital cardiac arrest is approximately 18%, but for patients who require advanced airway management survival is lower. Those who do survive are often left with significant disability. Traditionally, resuscitation of cardiac arrest patients has included tracheal intubation, however insertion of a supraglottic airway has gained popularity as an alternative approach to advanced airway management. Evidence from out-of-hospital cardiac arrest suggests no significant differences in mortality or morbidity between these two approaches, but there is no randomised evidence for airway management during in-hospital cardiac arrest. The aim of the AIRWAYS-3 randomised trial, described in this protocol paper, is to determine the clinical and cost effectiveness of a supraglottic airway versus tracheal intubation during in-hospital cardiac arrest. Patients will be allocated randomly to receive either a supraglottic airway or tracheal intubation as the initial advanced airway management. We will also estimate the relative cost-effectiveness of these two approaches. The primary outcome is functional status, measured using the modified Rankin Scale at hospital discharge or 30 days post-randomisation, whichever occurs first. AIRWAYS-3 presents ethical challenges regarding patient consent and data collection. These include the enrolment of unconscious patients without prior consent in a way that avoids methodological bias. Other complexities include the requirement to randomise patients efficiently during a time-critical cardiac arrest. Many of these challenges are encountered in other emergency care research; we discuss our approaches to addressing them. Trial registration: ISRCTN17720457. Prospectively registered on 29/07/2022.

Association of Glasgow coma scale and endotracheal intubation in predicting mortality among patients admitted to the intensive care unit

BACKGROUND

We assessed predictors of mortality in the intensive care unit (ICU) and investigated if Glasgow coma scale (GCS) is associated with mortality in patients undergoing endotracheal intubation (EI).

METHODS

From February 2020, we performed a 1-year study on 2,055 adult patients admitted to the ICU of two teaching hospitals. The outcome was mortality during ICU stay and the predictors were patients' demographic, clinical, and laboratory features.

RESULTS

EI was associated with a decreased risk for mortality compared with similar patients (adjusted odds ratio [AOR], 0.32; P=0.030). This shows that EI had been performed correctly with proper indications. Increasing age (AOR, 1.04; P<0.001) or blood pressure (AOR, 1.01; P<0.001), respiratory problems (AOR, 3.24; P<0.001), nosocomial infection (AOR, 1.64; P=0.014), diabetes (AOR, 5.69; P<0.001), history of myocardial infarction (AOR, 2.52; P<0.001), chronic obstructive pulmonary disease (AOR, 3.93; P<0.001), immunosuppression (AOR, 3.15; P<0.001), and the use of anesthetics/sedatives/hypnotics for reasons other than EI (AOR, 4.60; P<0.001) were directly; and GCS (AOR, 0.84; P<0.001) was inversely related to mortality. In patients with trauma surgeries (AOR, 0.62; P=0.014) or other surgical categories (AOR, 0.61; P=0.024) undergoing EI, GCS had an inverse relation with mortality (accuracy=82.6%, area under the receiver operator characteristic curve=0.81).

CONCLUSIONS

A variety of features affected the risk for mortality in patients admitted to the ICU. Considering GCS score for EI had the potential of affecting prognosis in subgroups of patients such as those with trauma surgeries or other surgical categories.

The impact of COVID-19 pandemic on out-of-hospital cardiac arrest system-of-care: Which survival chain factor contributed the most?

OBJECTIVES

In many communities, out-of-hospital cardiac arrest (OHCA) survival outcomes decreased after the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to identify and compare the impacts of each survival chain factor on the change of survival outcomes after COVID-19.

METHODS

Using a Korean out-of-hospital cardiac arrest registry, we analyzed OHCA patients whose arrest was not witnessed by emergency medical service (EMS) providers between 2017 and 2021. Because lack of hospital and survival information in 2021, the 2021 data were used only to identify the expected trend. We developed a prediction model for survival to discharge using patients from 2017 to 2019 (Pre-COVID-19 set) and validated it using patients from 2020 (post-COVID-19 set). Using Utstein elements, a stepwise logistic regression model was constructed, and discrimination and calibration were evaluated by c-statistics and scaled Brier score. Using the distribution change of predictors from one year before the pandemic (2019) to post-COVDI-19, we calculated the magnitude of survival difference according to each predictor's distribution change using the marginal standardization method.

RESULTS

Among 83,273 patients (mean age 67.2 years and 64.3% males), 61,180 and 22,092 patients belonged to pre-COVOD-19 and post-COVID-19 sets. Survival to discharge was 5019 (8.2%) in pre-COVID-19 set and 1457 (6.6%) in post-COVID-19 set. The proportion of bystander cardiopulmonary resuscitation was 59.0% in the pre-COVID-19 set and 61.0% in the post-COVID-19 set. The median (interquartile range) response time was 7 (5-9) minutes in the pre-COVID-19 set and 8 (6-10) minutes in the post-COVID-19 set. The area under the receiver operating characteristic (AUROC) curve (95% confidence interval) was 0.907 (0.902-0.912) in the pre-COVID-19 set, and 0.924 (0.916-0.931) in the post-COVID-19 set, and scaled Brier score were 0.39 in pre-COVID-19 sets, and 0.40 in the post-COVID-19 set. Among various predictors, EMS factors showed the highest impact. Response time and on-scene management of EMS showed the highest impact on decreased survival. A similar trend was also expected in the 2021.

CONCLUSION

The effort to create a rapid response system for OHCA patients could have priority for the recovery of survival outcomes in OHCA patients in the post-COVID-19 period. Further studies to recover survival outcomes of OHCA are warranted.

Association between time to advanced airway management and survival during pediatric out-of-hospital cardiac arrest

Background

Respiratory care, including advanced airway management (AAM), is an important part of pediatric resuscitation. This study aimed to determine whether time to AAM is associated with outcomes after out-of-hospital cardiac arrest (OHCA) in children.

Methods

This was a nationwide population-based observational study using the Japanese government-led registry of OHCA patients. Children (aged 1–17 years) who experienced OHCA and received AAM by emergency medical service (EMS) personnel in the prehospital setting from 2014 to 2019 were included. Multivariable logistic regression models were used to assess the associations between time to AAM (defined as time in minutes from emergency call to the first successful AAM) and outcomes after OHCA. The primary outcome was one-month overall survival. The secondary outcomes were prehospital return of spontaneous circulation (ROSC) and one-month neurologically favorable survival.

Results

A total of 761 patients (mean [SD] age, 12.7 [4.8] years) were included. The mean time to AAM was 18.9 min (SD, 7.9). Overall, 77 (10.1%) patients survived one month after OHCA. After adjusting for potential confounders, longer time to AAM was significantly associated with a decreased chance of one-month survival (multivariable adjusted OR per minute delay, 0.93 [95% CI, 0.89–0.97]; P = 0.001). Similar association was observed for prehospital ROSC (adjusted OR, 0.94 [95% CI, 0.90–0.99]; P = 0.01) and neurologically favorable survival (adjusted OR, 0.83 [95% CI, 0.72–0.95]; P = 0.006). This association between time to AAM and survival was consistent across a variety of sensitivity and subgroup analyses.

Conclusions

Among pediatric OHCA patients, delayed AAM was associated with a decreased chance of survival, although the influence of resuscitation time bias might remain.

Cardiac arrest: An interdisciplinary scoping review of clinical literature from 2020

Objectives

The Interdisciplinary Cardiac Arrest Research Review (ICARE) group was formed in 2018 to conduct an annual search of peer-reviewed literature relevant to cardiac arrest. Now in its third year, the goals of the review are to highlight annual updates in the interdisciplinary world of clinical cardiac arrest research with a focus on clinically relevant and impactful clinical and population-level studies from 2020.

Methods

A search of PubMed using keywords related to clinical research in cardiac arrest was conducted. Titles and abstracts were screened for relevance and sorted into 7 categories: Epidemiology & Public Health Initiatives; Prehospital Resuscitation, Technology & Care; In-Hospital Resuscitation & Post-Arrest Care; Prognostication & Outcomes; Pediatrics; Interdisciplinary Guidelines & Reviews; and a new section dedicated to the coronavirus disease 2019 (COVID-19) pandemic. Screened manuscripts underwent standardized scoring of methodological quality and impact on the respective fields by reviewer teams lead by a subject matter expert editor. Articles scoring higher than 99 percentiles by category were selected for full critique. Systematic differences between editors' and reviewers' scores were assessed using Wilcoxon signed-rank test.

Results

A total of 3594 articles were identified on initial search; of these, 1026 were scored after screening for relevance and deduplication, and 51 underwent full critique. The leading category was Prehospital Resuscitation, Technology & Care representing 35% (18/51) of fully reviewed articles. Four COVID-19 related articles were included for formal review that was attributed to a relative lack of high-quality data concerning cardiac arrest and COVID-19 specifically by the end of the 2020 calendar year. No significant differences between editor and reviewer scoring were found among review articles (P = 0.697). Among original research articles, section editors scored a median 1 point (interquartile range, 0-3; P < 0.01) less than reviewers.

Conclusions

Several clinically relevant studies have added to the evidence base for the management of cardiac arrest patients including methods for prognostication of neurologic outcome following arrest, airway management strategy, timing of coronary intervention, and methods to improve expeditious performance of key components of resuscitation such as chest compressions in adults and children.

Supraglottic airway device versus tracheal intubation in the initial airway management of out-of-hospital cardiac arrest: the AIRWAYS-2 cluster RCT

BACKGROUND

When a cardiac arrest occurs, cardiopulmonary resuscitation should be started immediately. However, there is limited evidence about the best approach to airway management during cardiac arrest.

OBJECTIVE

The objective was to determine whether or not the i-gel® (Intersurgical Ltd, Wokingham, UK) supraglottic airway is superior to tracheal intubation as the initial advanced airway management strategy in adults with non-traumatic out-of-hospital cardiac arrest.

DESIGN

This was a pragmatic, open, parallel, two-group, multicentre, cluster randomised controlled trial. A cost-effectiveness analysis accompanied the trial.

SETTING

The setting was four ambulance services in England.

PARTICIPANTS

Patients aged ≥ 18 years who had a non-traumatic out-of-hospital cardiac arrest and were attended by a participating paramedic were enrolled automatically under a waiver of consent between June 2015 and August 2017. Follow-up ended in February 2018.

INTERVENTION

Paramedics were randomised 1 : 1 to use tracheal intubation (764 paramedics) or i-gel (759 paramedics) for their initial advanced airway management and were unblinded.

MAIN OUTCOME MEASURES

The primary outcome was modified Rankin Scale score at hospital discharge or 30 days after out-of-hospital cardiac arrest, whichever occurred earlier, collected by assessors blinded to allocation. The modified Rankin Scale, a measure of neurological disability, was dichotomised: a score of 0-3 (good outcome) or 4-6 (poor outcome/death). The primary outcome for the economic evaluation was quality-adjusted life-years, estimated using the EuroQol-5 Dimensions, five-level version.

RESULTS

A total of 9296 patients (supraglottic airway group, 4886; tracheal intubation group, 4410) were enrolled [median age 73 years; 3373 (36.3%) women]; modified Rankin Scale score was known for 9289 patients. Characteristics were similar between groups. A total of 6.4% (311/4882) of patients in the supraglottic airway group and 6.8% (300/4407) of patients in the tracheal intubation group had a good outcome (adjusted difference in proportions of patients experiencing a good outcome: -0.6%, 95% confidence interval -1.6% to 0.4%). The supraglottic airway group had a higher initial ventilation success rate than the tracheal intubation group [87.4% (4255/4868) vs. 79.0% (3473/4397), respectively; adjusted difference in proportions of patients: 8.3%, 95% confidence interval 6.3% to 10.2%]; however, patients in the tracheal intubation group were less likely to receive advanced airway management than patients in the supraglottic airway group [77.6% (3419/4404) vs. 85.2% (4161/4883), respectively]. Regurgitation rate was similar between the groups [supraglottic airway group, 26.1% (1268/4865); tracheal intubation group, 24.5% (1072/4372); adjusted difference in proportions of patients: 1.4%, 95% confidence interval -0.6% to 3.4%], as was aspiration rate [supraglottic airway group, 15.1% (729/4824); tracheal intubation group, 14.9% (647/4337); adjusted difference in proportions of patients: 0.1%, 95% confidence interval -1.5% to 1.8%]. The longer-term outcomes were also similar between the groups (modified Rankin Scale: at 3 months, odds ratio 0.89, 95% confidence interval 0.69 to 1.14; at 6 months, odds ratio 0.91, 95% confidence interval 0.71 to 1.16). Sensitivity analyses did not alter the overall findings. There were no unexpected serious adverse events. Mean quality-adjusted life-years to 6 months were 0.03 in both groups (supraglottic airway group minus tracheal intubation group difference -0.0015, 95% confidence interval -0.0059 to 0.0028), and total costs were £157 (95% confidence interval -£270 to £583) lower in the tracheal intubation group. Although the point estimate of the incremental cost-effectiveness ratio suggested that tracheal intubation may be cost-effective, the huge uncertainty around this result indicates no evidence of a difference between groups.

LIMITATIONS

Limitations included imbalance in the number of patients in each group, caused by unequal distribution of high-enrolling paramedics; crossover between groups; and the fact that participating paramedics, who were volunteers, might not be representative of all paramedics in the UK. Findings may not be applicable to other countries.

CONCLUSION

Among patients with out-of-hospital cardiac arrest, randomisation to the supraglottic airway group compared with the tracheal intubation group did not result in a difference in outcome at 30 days. There were no notable differences in costs, outcomes and overall cost-effectiveness between the groups.

FUTURE WORK

Future work could compare alternative supraglottic airway types with tracheal intubation; include a randomised trial of bag mask ventilation versus supraglottic airways; and involve other patient populations, including children, people with trauma and people in hospital.

TRIAL REGISTRATION

This trial is registered as ISRCTN08256118.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and supported by the NIHR Comprehensive Research Networks and will be published in full in Health Technology Assessment; Vol. 26, No. 21. See the NIHR Journals Library website for further project information.

Advanced Life Support Update

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2022. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2022 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .

Effect of Early Supraglottic Airway Device Insertion on Chest Compression Fraction during Simulated Out-of-Hospital Cardiac Arrest: Randomised Controlled Trial

Early insertion of a supraglottic airway (SGA) device could improve chest compression fraction by allowing providers to perform continuous chest compressions or by shortening the interruptions needed to deliver ventilations. SGA devices do not require the same expertise as endotracheal intubation. This study aimed to determine whether the immediate insertion of an i-gel^® while providing continuous chest compressions with asynchronous ventilations could generate higher CCFs than the standard 30:2 approach using a face-mask in a simulation of out-of-hospital cardiac arrest. A multicentre, parallel, randomised, superiority, simulation study was carried out. The primary outcome was the difference in CCF during the first two minutes of resuscitation. Overall and per-cycle CCF quality of compressions and ventilations parameters were also compared. Among thirteen teams of two participants, the early insertion of an i-gel^® resulted in higher CCFs during the first two minutes (89.0% vs. 83.6%, p = 0.001). Overall and per-cycle CCF were consistently higher in the i-gel^® group, even after the 30:2 alternation had been resumed. In the i-gel^® group, ventilation parameters were enhanced, but compressions were significantly shallower (4.6 cm vs. 5.2 cm, p = 0.007). This latter issue must be addressed before clinical trials can be considered.

Association of Advanced Airway Insertion Timing and Outcomes After Out-of-Hospital Cardiac Arrest

STUDY OBJECTIVE

While often prioritized in the resuscitation of patients with out-of-hospital cardiac arrest, the optimal timing of advanced airway insertion is unknown. We evaluated the association between the timing of advanced airway (laryngeal tube and endotracheal intubation) insertion attempt and survival to hospital discharge in adult out-of-hospital cardiac arrest.

METHODS

We performed a secondary analysis of the Pragmatic Airway Resuscitation Trial (PART), a clinical trial comparing the effects of laryngeal tube and endotracheal intubation on outcomes after adult out-of-hospital cardiac arrest. We stratified the cohort by randomized airway strategy (laryngeal tube or endotracheal intubation). Within each subset, we defined a time-dependent propensity score using patients, arrest, and emergency medical services systems characteristics. Using the propensity score, we matched each patient receiving an initial attempt of laryngeal tube or endotracheal intubation with a patient at risk of receiving laryngeal tube or endotracheal intubation attempt within the same minute.

RESULTS

Of 2,146 eligible patients, 1,091 (50.8%) and 1,055 (49.2%) were assigned to initial laryngeal tube and endotracheal intubation strategies, respectively. In the propensity score-matched cohort, timing of laryngeal tube insertion attempt was not associated with survival to hospital discharge: 0 to lesser than 5 minutes (risk ratio [RR]=1.35, 95% confidence interval [CI] 0.53 to 3.44); 5 to lesser than10 minutes (RR=1.07, 95% CI 0.66 to 1.73); 10 to lesser than 15 minutes (RR=1.17, 95% CI 0.60 to 2.31); or 15 to lesser than 20 minutes (RR=2.09, 95% CI 0.35 to 12.47) after advanced life support arrival. Timing of endotracheal intubation attempt was also not associated with survival: 0 to lesser than 5 minutes (RR=0.50, 95% CI 0.05 to 4.87); 5 to lesser than10 minutes (RR=1.20, 95% CI 0.51 to 2.81); 10 to lesser than15 minutes (RR=1.03, 95% CI 0.49 to 2.14); 15 to lesser than 20 minutes (RR=0.85, 95% CI 0.30 to 2.42); or more than/equal to 20 minutes (RR=0.71, 95% CI 0.07 to 7.14).

CONCLUSION

In the PART, timing of advanced airway insertion attempt was not associated with survival to hospital discharge.

Timing of Prehospital Advanced Airway Management for Adult Patients With Out-of-Hospital Cardiac Arrest: A Nationwide Cohort Study in Japan

Background

The timing of advanced airway management (AAM) on patient outcomes after out‐of‐hospital cardiac arrest has not been fully investigated. We evaluated the association between the timing of prehospital AAM and 1‐month survival.

Methods and Results

We conducted a secondary analysis of a prospective, nationwide, population‐based out‐of‐hospital cardiac arrest registry in Japan. We included emergency medical services–treated adult (≥18 years) out‐of‐hospital cardiac arrests from 2014 through 2017, stratified into initial shockable or nonshockable rhythms. Patients who received AAM at any minute after emergency medical services–initiated cardiopulmonary resuscitation underwent risk‐set matching with patients who were at risk of receiving AAM within the same minute using time‐dependent propensity scores. Eleven thousand three hundred six patients with AAM in shockable and 163 796 with AAM in nonshockable cohorts, respectively, underwent risk‐set matching. For shockable rhythms, the risk ratios (95% CIs) of AAM on 1‐month survival were 1.01 (0.89–1.15) between 0 and 5 minutes, 1.06 (0.98–1.15) between 5 and 10 minutes, 0.99 (0.87–1.12) between 10 and 15 minutes, 0.74 (0.59–0.92) between 15 and 20 minutes, 0.61 (0.37–1.00) between 20 and 25 minutes, and 0.73 (0.26–2.07) between 25 and 30 minutes after emergency medical services–initiated cardiopulmonary resuscitation. For nonshockable rhythms, the risk ratios of AAM were 1.12 (1.00–1.27) between 0 and 5 minutes, 1.34 (1.25–1.44) between 5 and 10 minutes, 1.39 (1.26–1.54) between 10 and 15 minutes, 1.20 (0.99–1.45) between 15 and 20 minutes, 1.18 (0.80–1.73) between 20 and 25 minutes, 0.63 (0.29–1.38) between 25 and 30 minutes, and 0.44 (0.11–1.69) after 30 minutes.

Conclusions

In this observational study, the timing of AAM was not statistically associated with improved 1‐month survival for shockable rhythms, but AAM within 15 minutes after emergency medical services–initiated cardiopulmonary resuscitation was associated with improved 1‐month survival for nonshockable rhythms.

Airway management during in-hospital cardiac arrest in adults: UK national survey and interview study with anaesthetic and intensive care trainees

BACKGROUND

The optimal airway management strategy for in-hospital cardiac arrest is unknown.

METHODS

An online survey and telephone interviews with anaesthetic and intensive care trainee doctors identified by the United Kingdom Research and Audit Federation of Trainees. Questions explored in-hospital cardiac arrest frequency, grade and specialty of those attending, proportion of patients receiving advanced airway management, airway strategies immediately available, and views on a randomised trial of airway management strategies during in-hospital cardiac arrest.

RESULTS

Completed surveys were received from 128 hospital sites (76% response rate). Adult in-hospital cardiac arrests were attended by anaesthesia staff at 40 sites (31%), intensive care staff at 37 sites (29%) and a combination of specialties at 51 sites (40%). The majority (123/128, 96%) of respondents reported immediate access to both tracheal intubation and supraglottic airways. A bag-mask technique was used 'very frequently' or 'frequently' during in-hospital cardiac arrest by 111/128 (87%) of respondents, followed by supraglottic airways (101/128, 79%) and tracheal intubation (69/128, 54%). The majority (60/100, 60%) of respondents estimated that ≤30% of in-hospital cardiac arrest patients undergo tracheal intubation, while 34 (34%) estimated this to be between 31% and 70%. Most respondents (102/128, 80%) would be 'likely' or 'very likely' to recruit future patients to a trial of alternative airway management strategies during in-hospital cardiac arrest. Interview data identified several barriers and facilitators to conducting research on airway management in in-hospital cardiac arrest.

CONCLUSIONS

There is variation in airway management strategies for adult in-hospital cardiac arrest across the UK. Most respondents would be willing to take part in a randomised trial of airway management during in-hospital cardiac arrest.

Fewer tracheal intubation attempts are associated with improved neurologically intact survival following out-of-hospital cardiac arrest

BACKGROUND

International guidelines emphasize advanced airway management during out-of-hospital cardiac arrest (OHCA). We hypothesized that increasing endotracheal intubation attempts during OHCA were associated with a lower likelihood of favorable neurologic survival at discharge.

METHODS

This retrospective, observational cohort evaluated the relationship between number of intubation attempts and favorable neurologic survival among non-traumatic OHCA patients receiving cardiopulmonary resuscitation (CPR) from January 1, 2015-June 30, 2019 in a large urban emergency medical services (EMS) system. Favorable neurologic status at hospital discharge was defined as a Cerebral Performance Category score of 1 or 2. Multivariable logistic regression, adjusted for age, sex, witness status, bystander CPR, initial rhythm, and time of EMS arrival, was performed using the number of attempts as a continuous variable.

RESULTS

Over 54 months, 1205 patients were included. Intubation attempts per case were 1 = 757(63%), 2 = 279(23%), 3 = 116(10%), ≥4 = 49(4%), and missing/unknown in 4(<1%). The mean (SD) time interval from paramedic arrival to intubation increased with the number of attempts: 1 = 4.9(2.4) min, 2 = 8.0(2.9) min, 3 = 10.9(3.3) min, and ≥4 = 15.5(4.4) min. Final advanced airway techniques employed were endotracheal intubation (97%), supraglottic devices (3%), and cricothyrotomy (<1%). Favorable neurologic outcome declined with each additional attempt: 11% with 1 attempt, 4% with 2 attempts, 3% with 3 attempts, and 2% with 4 or more attempts (AOR = 0.41, 95% CI 0.25-0.68).

CONCLUSIONS

Increasing number of intubation attempts during OHCA resuscitation was associated with lower likelihood of favorable neurologic outcome.

Association between time to advanced airway management and neurologically favourable survival during out-of-hospital cardiac arrest

BACKGROUND

Advanced airway management (AAM) is commonly performed as part of advanced life support. However, there is controversy about the association between the timing of AAM and outcomes after out-of-hospital cardiac arrest (OHCA). This study aimed to determine whether time to AAM is associated with outcomes after OHCA.

METHODS

This was a nationwide population-based observational study using the Japanese government-led registry of OHCA. Adults who experienced OHCA and received AAM by EMS personnel in the prehospital setting from 2014 to 2017 were included. Multivariable logistic regression models were used to assess the associations between time to AAM (defined as time in minutes from emergency call to the first successful AAM) and outcomes after OHCA. Then, associations between early (≤ 20 min) vs. delayed (> 20 min) AAM and outcomes after OHCA were examined using propensity score-matched analyses. The primary outcome was one-month neurologically favourable survival.

RESULTS

A total of 164,223 patients (median [IQR] age, 80 [69-86] years; 57.7% male) were included. The median time to AAM was 17 min (IQR, 14-22). Longer time to AAM was significantly associated with a decreased chance of one-month neurologically favourable survival (multivariable adjusted OR per minute delay, 0.90 [95% CI, 0.90-0.91]). In the propensity score-matched cohort, compared with early AAM, delayed AAM was associated with a decreased chance of one-month neurologically favourable survival (516 of 50,997 [1.0%] vs. 226 of 50,997 [0.4%]; RR, 0.44; 95% CI, 0.37-0.51; NNT, 176).

CONCLUSIONS

Delay in AAM was associated with a decreased chance of one-month neurologically favourable survival among patients with OHCA.

[Adult advanced life support]

These European Resuscitation Council Advanced Life Support guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.

Early endotracheal intubation improves neurological outcome following witnessed out-of-hospital cardiac arrest in Japan: a population-based observational study

Aim

It is unclear whether endotracheal intubation in the prehospital setting improves outcomes following out-of-hospital cardiac arrest. The purpose of this study was to evaluate the association between endotracheal intubation time (time from patient contact to endotracheal intubation) and favorable neurological outcomes on out-of-hospital cardiac arrest.

Methods

We extracted patients who underwent endotracheal intubation on the scene from a nationwide out-of-hospital cardiac arrest database registered between 2014 and 2017 in Japan. We included 14,969 witnessed and intubated adult out-of-hospital cardiac arrest cases. Patients were divided into Shockable (n = 1,102) and Non-shockable (n = 13,867) cohorts. We first drew the logistic curve due to predicting the association between endotracheal intubation time and favorable neurological outcome defined as Cerebral Performance Category (CPC) 1 or 2. Secondary, multivariable logistic regressions were used to estimate the association between the endotracheal intubation time (1-min unit increase), CPC 1 or 2.

Results

The logistic curve for CPC 1 or 2 showed similar shapes and indicated a decreasing outcome over time. From the results of multivariable logistic regression, in the Shockable cohort, endotracheal intubation time delay was correlated with decreasing favorable outcomes: CPC 1 or 2 (adjusted odds ratio, 0.89; 95% confidence interval, 0.82-0.87). Results were the same for the Non-shockable cohort: CPC 1 or 2 (adjusted odds ratio, 0.94; 95% confidence interval, 0.89-0.99).

Conclusion

Early endotracheal intubation was correlated with favorable neurological outcome. Training for intubation skills and improving protocols are needed for carrying out early endotracheal intubation.

European Resuscitation Council Guidelines 2021: Adult advanced life support

These European Resuscitation Council Advanced Life Support guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.

Effect on Chest Compression Fraction of Continuous Manual Compressions with Asynchronous Ventilations Using an i-gel® versus 30:2 Approach during Simulated Out-of-Hospital Cardiac Arrest: Protocol for a Manikin Multicenter Randomized Controlled Trial

The optimal airway management strategy during cardiopulmonary resuscitation is uncertain. In the case of out-of-hospital cardiac arrest, a high chest compression fraction is paramount to obtain the return of spontaneous circulation and improve survival and neurological outcomes. To improve this fraction, providing continuous chest compressions should be more effective than using the conventional 30:2 ratio. Airway management should, however, be adapted, since face-mask ventilation can hardly be carried out while continuous compressions are administered. The early insertion of a supraglottic device could therefore improve the chest compression fraction by allowing ventilation while maintaining compressions. This is a protocol for a multicenter, parallel, randomized simulation study. Depending on randomization, each team made up of paramedics and emergency medical technicians will manage the 10-min scenario according either to the standard approach (30 compressions with two face-mask ventilations) or to the experimental approach (continuous manual compressions with early insertion of an i-gel® supraglottic device to deliver asynchronous ventilations). The primary outcome will be the chest compression fraction during the first two minutes of cardiopulmonary resuscitation. Secondary outcomes will be chest compression fraction (per cycle and overall), compressions and ventilations quality, time to first shock and to first ventilation, user satisfaction, and providers' self-assessed cognitive load.

Resuscitation highlights in 2020

BACKGROUND

This review is the latest in a series of regular annual reviews undertaken by the editors and aims to highlight some of the key papers published in Resuscitation during 2020. The number of papers submitted to the Journal in 2020 increased by 25% on the previous year.MethodsHand-searching by the editors of all papers published in Resuscitation during 2020. Papers were selected based on then general interest and novelty and were categorised into general themes.ResultsA total of 103 papers were selected for brief mention in this review.ConclusionsResuscitation science continues to evolve rapidly and incorporate all links in the chain of survival.

The limitations of evidence: increasing data and increasing doubt in the treatment of cardiac arrest

PURPOSE OF REVIEW

Cardiac arrest is one of the most challenging disease processes to study with clinical trials due to the emergent and unpredictable nature of these events and complexity of the patient population. In recent years, there has been a major push to complete more large, multicentre trials. In many cases, however, there remains little certainty on what treatments are most efficacious, in spite of the recent increase in evidence. This review was undertaken to address some of the unique barriers to address answering research questions in cardiac arrest with clinical trials.

RECENT FINDINGS

Multiple examples of trials that have failed to reach definitive conclusions, and potential reasons for this, are discussed.

SUMMARY

Trials on multiple major cardiac arrest interventions, including temperature management, drugs during cardiopulmonary resuscitation (CPR) and airway management, now have high-quality randomized trials, but significant questions on efficacy and best practices remain. Common pitfalls and reasons for this are explored, including heterogeneity of patients and providers, variability in exact interventions studied, delay in starting research interventions and lack of consistency across systems in decision making around appropriateness for resuscitation.

Performance of the laryngeal tube for airway management during cardiopulmonary resuscitation

INTRODUCTION

Sudden cardiac arrest is one of the leading causes of death in Europe and the whole world. Effective chest compressions and advanced airway management have been shown to improve survival rates. Supraglottic airway devices such as the laryngeal tube (LT) are a well-known strategy for patients with cardiac arrest during both basic (BLS) and advanced life support (ALS). This systematic literature review aimed to summarize current data for using the LT when performing BLS and ALS.

EVIDENCE ACQUISITION

Recent data on the use of the LT during cardiopulmonary resuscitation (CPR) was gathered by using the Medline database and a specific search strategy. Terms were used in various order and combinations without time restrictions. A total of N.=1005 studies were identified and screened by two experienced anesthesiologists/emergency physicians independently. Altogether, data of N.=19 relevant papers were identified and included in the analysis.

EVIDENCE SYNTHESIS

Using the LT showed fast and easy placement with high success rates (76% to 94%) and was associated with higher short-term survival as compared to other strategies for initial airway management (2.2% vs. 1.4%). Quality of CPR such as chest compression fraction (CCF) before and after LT-insertion is improved (75% vs. 59%). For long-term survival, the LT showed lower survival rates.

CONCLUSIONS

Especially as initial device of airway management (for inexperienced staff), the use of a LT is easy and results in a fast insertion. The advantages of the LT as compared to bag mask ventilation and endotracheal intubation are inhomogeneous in recent literature.

Optimizing airway management and ventilation during prehospital advanced life support in out-of-hospital cardiac arrest: A narrative review

Airway management and ventilation are essential components of cardiopulmonary resuscitation to achieve oxygen delivery in order to prevent hypoxic injury and increase the chance of survival. Weighing the relative benefits and downsides, the best approach is a staged strategy; start with a focus on high-quality chest compressions and defibrillation, then optimize mask ventilation while preparing for advanced airway management with a supraglottic airway device. Endotracheal intubation can still be indicated, but has the largest downsides of all advanced airway techniques. Whichever stage of airway management, ventilation and chest compression quality should be closely monitored. Capnography has many advantages and should be used routinely. Optimizing ventilation strategies, harmonizing ventilation with mechanical chest compression devices, and implementation in complex and stressful environments are challenges we need to face through collaborative innovation, research, and implementation.

Cardiac arrest: An interdisciplinary scoping review of the literature from 2019

Objectives

The Interdisciplinary Cardiac Arrest Research Review (ICARE) group was formed in 2018 to conduct a systematic annual search of peer-reviewed literature relevant to cardiac arrest. Now in its second year, the goals of the review are to illustrate best practices in research and help reduce compartmentalization of knowledge by disseminating clinically relevant advances in the field of cardiac arrest across disciplines.

Methods

An electronic search of PubMed using keywords related to cardiac arrest was conducted. Title and abstracts retrieved by these searches were screened for relevance, classified by article type (original research or review), and sorted into 7 categories. Screened manuscripts underwent standardized scoring of overall methodological quality and impact on the categorized fields of study by reviewer teams lead by a subject-matter expert editor. Articles scoring higher than 99 percentiles by category-type were selected for full critique. Systematic differences between editors’ and reviewers’ scores were assessed using Wilcoxon signed-rank test.

Results

A total of 3348 articles were identified on initial search; of these, 1364 were scored after screening for relevance and deduplication, and forty-five underwent full critique. Epidemiology & Public Health represented 24% of fully reviewed articles with Prehospital Resuscitation, Technology & Care, and In-Hospital Resuscitation & Post-Arrest Care Categories both representing 20% of fully reviewed articles. There were no significant differences between editor and reviewer scoring.

Conclusions

The sheer number of articles screened is a testament to the need for an accessible source calling attention to high-quality and impactful research and serving as a high-yield reference for clinicians and scientists seeking to follow the ever-growing body of cardiac arrest-related literature. This will promote further development of the unique and interdisciplinary field of cardiac arrest medicine.

Translation from animal studies of novel pharmacological therapies to clinical trials in cardiac arrest: A systematic review

BACKGROUND

There is a lack of new promising therapies to improve the dismal outcomes from cardiac arrest. The objectives of this study were: (1) To identify novel pharmacological therapies investigated in experimental animal studies and (2) to identify pharmacological therapies translated from experimental animal studies to clinical trials.

METHODS

PubMed was searched to first identify relevant experimental cardiac arrest animal models published within the last 20 years. Based on this, a list of interventions was created and a second search was performed to identify clinical trials testing one of these interventions. Data extraction was performed using standardised data extraction forms.

RESULTS

We identified 415 animal studies testing 190 different pharmacological interventions. The most commonly tested interventions were classified as vasopressors, anaesthetics/gases, or interventions aimed at molecular targets. We found 43 clinical trials testing 26 different interventions identified in the animal studies. Of these, 13 trials reported positive findings and 30 trials reported neutral findings with regards to the primary endpoint. No study showed harm of the intervention. Some interventions tested in human clinical trials, had previously been tested in animal studies without a positive effect on outcomes. A large number of animal studies was performed after publication of a clinical trial.

CONCLUSION

Numerous different pharmacological interventions have been tested in experimental animal models. Despite this only a limited number of these interventions have advanced to clinical trials, however several of the clinical trials tested interventions that were first tested in experimental animal models.

Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.

Hands-On Times, Adherence to Recommendations and Variance in Execution among Three Different CPR Algorithms: A Prospective Randomized Single-Blind Simulator-Based Trial

Background: Alternative cardiopulmonary resuscitation (CPR) algorithms, introduced to improve outcomes after cardiac arrest, have so far not been compared in randomized trials with established CPR guidelines. Methods: 286 physician teams were confronted with simulated cardiac arrests and randomly allocated to one of three versions of a CPR algorithm: (1) current International Liaison Committee on Resuscitation (ILCOR) guidelines (“ILCOR”), (2) the cardiocerebral resuscitation (“CCR”) protocol (3 cycles of 200 uninterrupted chest compressions with no ventilation), or (3) a local interpretation of the current guidelines (“Arnsberg“, immediate insertion of a supraglottic airway and cycles of 200 uninterrupted chest compressions). The primary endpoint was percentage of hands-on time. Results: Median percentage of hands-on time was 88 (interquartile range (IQR) 6) in “ILCOR” teams, 90 (IQR 5) in “CCR” teams (p = 0.001 vs. “ILCOR”), and 89 (IQR 4) in “Arnsberg” teams (p = 0.032 vs. “ILCOR”; p = 0.10 vs. “CCR”). “ILCOR” teams delivered fewer chest compressions and deviated more from allocated targets than “CCR” and “Arnsberg” teams. “CCR” teams demonstrated the least within-team and between-team variance. Conclusions: Compared to current ILCOR guidelines, two alternative CPR algorithms advocating cycles of uninterrupted chest compressions resulted in very similar hands-on times, fewer deviations from targets, and less within-team and between-team variance in execution.

Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.

Updates in Cardiac Arrest Resuscitation

There are approximately 350,000 out-of-hospital cardiac arrests and 200,000 in-hospital cardiac arrests annually in the United States, with survival rates of approximately 5% to 10% and 24%, respectively. The critical factors that have an impact on cardiac arrest survival include prompt recognition and activation of prehospital care, early cardiopulmonary resuscitation, and rapid defibrillation. Advanced life support protocols are continually refined to optimize intracardiac arrest management and improve survival with favorable neurologic outcome. This article focuses on current treatment recommendations for adult nontraumatic cardiac arrest, with emphasis on the latest evidence and controversies regarding intracardiac arrest management.

Effects of Bag Mask Ventilation and Advanced Airway Management on Adherence to Ventilation Recommendations and Chest Compression Fraction: A Prospective Randomized Simulator-Based Trial

The role of advanced airway management (AAM) in cardiopulmonary resuscitation (CPR) is currently debated as observational studies reported better outcomes after bag-mask ventilation (BMV), and the only prospective randomized trial was inconclusive. Adherence to CPR guidelines ventilation recommendations is unknown and difficult to assess in clinical trials. This study compared AAM and BMV with regard to adherence to ventilation recommendations and chest compression fractions in simulated cardiac arrests. A total of 154 teams of 3–4 physicians were randomized to perform CPR with resuscitation equipment restricting airway management to BMV only or equipment allowing for all forms of AAM. BMV teams ventilated 6 ± 6/min and AAM teams 19 ± 8/min (range 3–42/min; p < 0.0001 vs. BMV). 68/78 BMV teams and 23/71 AAM teams adhered to the ventilation recommendations (p < 0.0001). BMV teams had lower compression fractions than AAM teams (78 ± 7% vs. 86 ± 6%, p < 0.0001) resulting entirely from higher no-flow times for ventilation (9 ± 4% vs. 3 ± 3 %; p < 0.0001). Compared to BMV, AAM leads to significant hyperventilation and lower adherence to ventilation recommendations but favourable compression fractions. The cumulative effect of deviations from ventilation recommendations has the potential to blur findings in clinical trials.

Airway management during in-hospital cardiac arrest: An international, multicentre, retrospective, observational cohort study

AIM

To determine the type of airway devices used during in-hospital cardiac arrest (IHCA) resuscitation attempts.

METHODS

International multicentre retrospective observational study of in-patients aged over 18 years who received chest compressions for cardiac arrest from April 2016 to September 2018. Patients were identified from resuscitation registries and rapid response system databases. Data were collected through review of resuscitation records and hospital notes. Airway devices used during cardiac arrest were recorded as basic (adjuncts or bag-mask), or advanced, including supraglottic airway devices, tracheal tubes or tracheostomies. Descriptive statistics and multivariable regression modelling were used for data analysis.

RESULTS

The final analysis included 598 patients. No airway management occurred in 36 (6%), basic airway device use occurred at any time in 562 (94%), basic airway device use without an advanced airway device in 182 (30%), tracheal intubation in 301 (50%), supraglottic airway in 102 (17%), and tracheostomy in 1 (0.2%). There was significant variation in airway device use between centres. The intubation rate ranged between 21% and 90% while supraglottic airway use varied between 1% and 45%. The choice of tracheal intubation vs. supraglottic airway as the second advanced airway device was not associated with immediate survival from the resuscitation attempt (odds ratio 0.81; 95% confidence interval 0.35-1.8).

CONCLUSION

There is wide variation in airway device use during resuscitation after IHCA. Only half of patients are intubated before return of spontaneous circulation and many are managed without an advanced airway. Further investigation is needed to determine optimal airway device management strategies during resuscitation following IHCA.

2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.

Comparison of Different Intubation Methods in Difficult Airways during Simulated Cardiopulmonary Resuscitation with Continuous Chest Compression: A Randomized Cross-Over Manikin Trial

Introduction

Airway management is one of key elements of resuscitation. Endotracheal intubation is still considered the gold standard for airway management during resuscitation.

Aim

The aim of the study was to compare success rates and intubation time of different endotracheal intubation methods during emergency intubation with difficult airways in the conditions of cardiopulmonary resuscitation in a standardized manikin model.

Methods

The study was designed as a prospective, randomized, cross-over simulation study. It involved 46 paramedics with at least 5 years of experience in Emergency Medical Service. The participants performed endotracheal intubation under difficult airway conditions during continuous chest compression, implemented with the LUCAS3 chest compression system. Three methods of tracheal intubation were applied: (1) standard Macintosh laryngoscope without a bougie stylet; (2) standard laryngoscope and a standard bougie stylet; (3) standard laryngoscope and a new bougie stylet.

Results

The overall intubation success rate was 100% in the standard bougie and new bougie groups and lower (86.9%) when no bougie stylet was used (P=0.028). The intubation success rate with the 1^st attempt equalled 91.3% for the new bougie group, 73.9% for standard bougie, and only 23.9% in the no-bougie group. The median intubation time was shortest in the new bougie group, where it amounted to 29 s (interquartile range [IQR]: 25-38); the time equalled 38s (IQR:31-44.5) in the standard bougie group and 47.5s (IQR:36-58) in the no-bougie group. The ease of use was lowest in the no-bougie group (85, IQR:63-88), average in the standard bougie group (44, IQR:30-51), and highest in the new bougie stylet group (32, IQR:19-41).

Conclusion

In this manikin-based study, paramedics were able to perform endotracheal intubation with higher efficacy and in a shorter time using the new bougie stylet as compared with the standard bougie stylet.