New study: ETI versus Supraglottic Airway Insertion in OOH Cardiac Arrest

[medicsb]

Resuscitation. 2012 Jun 1. [Epub ahead of print]

Endotracheal Intubation versus Supraglottic Airway Insertion in Out-of-Hospital Cardiac Arrest.

Wang HE, Szydlo D, Stouffer J, Lin S, Carlson J, Vaillancourt C, Sears G, Verbeek R, Fowler R, Idris A, Koenig K, Christenson J, Minokadeh A, Brandt J, Rea T; the ROC Investigators.

Abstract
OBJECTIVE:

To simplify airway management and minimize cardiopulmonary resuscitation (CPR) chest compression interruptions, some emergency medical services (EMS) practitioners utilize supraglottic airway (SGA) devices instead of endotracheal intubation (ETI) as the primary airway adjunct in out-of-hospital cardiac arrest (OHCA). We compared the outcomes of patients receiving ETI with those receiving SGA following OHCA.
METHODS:

We performed a secondary analysis of data from the multicenter Resuscitation Outcomes Consortium (ROC) PRIMED trial. We studied adult non-traumatic OHCA receiving successful SGA insertion (King Laryngeal Tube, Combitube, and Laryngeal Mask Airway) or successful ETI. The primary outcome was survival to hospital discharge with satisfactory functional status (Modified Rankin Scale ≤3). Secondary outcomes included return of spontaneous circulation (ROSC), 24-hour survival, major airway or pulmonary complications (pulmonary edema, internal thoracic or abdominal injuries, acute lung injury, sepsis, and pneumonia). Using multivariable logistic regression, we studied the association between out-of-hospital airway management method (ETI vs. SGA) and OHCA outcomes, adjusting for confounders.
RESULTS:

Of 10,455 adult OHCA, 8,487 (81.2%) received ETI and 1,968 (18.8%) received SGA. Survival to hospital discharge with satisfactory functional status was: ETI 4.7%, SGA 3.9%. Compared with successful SGA, successful ETI was associated with increased survival to hospital discharge (adjusted OR 1.40; 95% CI: 1.04, 1.89), ROSC (adjusted OR 1.78; 95% CI: 1.54, 2.04) and 24-hour survival (adjusted OR 1.74; 95% CI: 1.49, 2.04). ETI was not associated with secondary airway or pulmonary complications (adjusted OR 0.84; 95% CI: 0.61, 1.16).
CONCLUSIONS:

In this secondary analysis of data from the multicenter ROC PRIMED trial, ETI was associated with improved outcomes over SGA insertion after OHCA.

 

[usalsfyre]

Wait till the BLS airway outcome data comes out..

 

[Christopher]

Wait till the BLS airway outcome data comes out..

Yeah, Dr. Fowler showed some slides at EMS Today where survival was higher when only a BVM and adjunct was used during resuscitation.

 

[medicsb]

Didn't hear about the BVM ventilation, so I looked it up. 40% improvement w/ ETI over SA, 70% improvement w/ BVM over SGA.

http://www.doctorfowler.com/www/lectures/newestofnewincpr.ppt

 

[Smash]

Ah, that clears it all up then... or something.

Honestly, the only thing that I think can be got from the vast majority of pre-hospital airway management studies is the conclusion that basic airway care done well is better than intubation done badly.

 

[Doczilla]

The system I was with moved to king tubes only for cardiac arrest in 2007. Not sure if they're still doing it . The reasoning was that providers would speed up the packaging and transport with less people trying to bogart tubes.

 

[the_negro_puppy]

The system I was with moved to king tubes only for cardiac arrest in 2007. Not sure if they're still doing it . The reasoning was that providers would speed up the packaging and transport with less people trying to bogart tubes.

Flawed reasoning. Why is the emphasis on cardiac arrest transport? Why do EMS agencies these days insist on rushing clinically dead/corpses lights and sirens to hospital when only a tiny fraction survive to discharge, not to mention trying to do effective CPR and possible de-fibrillate on the way. We generally do not transport patients in cardiac arrest, unless they arrest enroute, we achieve ROSC or other extenuating circumstances.

 

[Veneficus]

Flawed reasoning. Why is the emphasis on cardiac arrest transport? Why do EMS agencies these days insist on rushing clinically dead/corpses lights and sirens to hospital when only a tiny fraction survive to discharge, not to mention trying to do effective CPR and possible de-fibrillate on the way. We generally do not transport patients in cardiac arrest, unless they arrest enroute, we achieve ROSC or other extenuating circumstances.

Stupidity.

(I like easy questions)

 

[Christopher]

Ah, that clears it all up then... or something.

Honestly, the only thing that I think can be got from the vast majority of pre-hospital airway management studies is the conclusion that basic airway care done well is better than intubation done badly.

I'll bet it is simply that less ventilation actually occurred without an ETT or SGA in place. Less ventilation, better intrathoracic pressures. Better pressures, better survival.

 

[usalsfyre]

I was lucky enough to talk to Dr. Fowler about this a few months ago. He said the ROSC rates weren't terribly different, it was the survival to discharge neurologically intact that was.One of the theory's on this is that SGAs were concluding the internal carotids, and the ETTs were interrupting chest compressions.

 

[AnthonyM83]

I'm always curious how these stats would turn out if studies were done in some of the higher quality more well-regulated systems. If we could separate low survival rates based on people screwing up and doing skills wrong versus the skill itself by its own nature decreasing survival.

 

[Shishkabob]

Only allow ETI during compressions or during pulse checks (without delaying compressions) and allow a 1-2 attempts max. Problem solved. If you can't do ETI during compressions utilizing a bougie, skip ETI and due an SGA.




My agency prefers Kings first and only ETI if a King is not applicable, or once ROSC is obtained. On top of that, ETI is capped at 1 attempt max.





(Not mentioning my hatred at people more worried about success rates more than noticing a missed tube. Who cares if you miss? Just notice you missed and correct it in a timely fashion)

 

[medicsb]

I'm always curious how these stats would turn out if studies were done in some of the higher quality more well-regulated systems. If we could separate low survival rates based on people screwing up and doing skills wrong versus the skill itself by its own nature decreasing survival.

One of the confounding factors in these ROC studies is that it includes Seattle/King County Medic One. I know people like to knock them, but the data shows that they intubate very well (they average around 98% over all success) and are probably the best in North America and when it comes to cardiac arrest resuscitation, they are the service everyone else compares themselves to. I imagine if there are any outliers in these studies, a sub analysis will be done and published at some point down the line.

From the very little data available (some of which is old), the best services at intubation (arbitrarily defined as an overall success >/=95%) are Seattle/King Co., Whatcom County Medic One (WA), Boston, and a couple places in NJ (MONOC and RWJ have both at least published abstracts with intubation success numbers, and I know Virtua had a 95% success rate when they trialed RSI 12+ years ago, but that study was never published and is no longer online). I would think that Vancouver or Toronto would have a high success rate, since they have a low number of intubators, but I don't think I've come across anything. I would love to see how things similar studies would turn out at some of these services, but unfortunately, not all have the funding or drive to do research (well, mainly MICUs in NJ).

 

[Christopher]

One of the confounding factors in these ROC studies is that it includes Seattle/King County Medic One. I know people like to knock them, but the data shows that they intubate very well (they average around 98% over all success) and are probably the best in North America and when it comes to cardiac arrest resuscitation, they are the service everyone else compares themselves to. I imagine if there are any outliers in these studies, a sub analysis will be done and published at some point down the line.

From the very little data available (some of which is old), the best services at intubation (arbitrarily defined as an overall success >/=95%) are Seattle/King Co., Whatcom County Medic One (WA), Boston, and a couple places in NJ (MONOC and RWJ have both at least published abstracts with intubation success numbers, and I know Virtua had a 95% success rate when they trialed RSI 12+ years ago, but that study was never published and is no longer online). I would think that Vancouver or Toronto would have a high success rate, since they have a low number of intubators, but I don't think I've come across anything. I would love to see how things similar studies would turn out at some of these services, but unfortunately, not all have the funding or drive to do research (well, mainly MICUs in NJ).

Wake County and New Hanover County in NC both have high intubation success rates and high cardiac arrest survival to discharge rates. They also both have great STEMI D2B times as well.

I think it boils down to: if you care enough to do cardiac arrest right, you probably care enough to do intubation right. Likewise, you probably care about providing effective EMS and from there it logically follows that your system is probably high performing and bucks the trend of EMS studies.

 

[usalsfyre]

One of the confounding factors in these ROC studies is that it includes Seattle/King County Medic One. I know people like to knock them, but the data shows that they intubate very well (they average around 98% over all success) and are probably the best in North America and when it comes to cardiac arrest resuscitation, they are the service everyone else compares themselves to. I imagine if there are any outliers in these studies, a sub analysis will be done and published at some point down the line.

From the very little data available (some of which is old), the best services at intubation (arbitrarily defined as an overall success >/=95%) are Seattle/King Co., Whatcom County Medic One (WA), Boston, and a couple places in NJ (MONOC and RWJ have both at least published abstracts with intubation success numbers, and I know Virtua had a 95% success rate when they trialed RSI 12+ years ago, but that study was never published and is no longer online). I would think that Vancouver or Toronto would have a high success rate, since they have a low number of intubators, but I don't think I've come across anything. I would love to see how things similar studies would turn out at some of these services, but unfortunately, not all have the funding or drive to do research (well, mainly MICUs in NJ).

This is pretty well MORE than offset for by one of the sites in Texas. Trust me on this.

 

[Shishkabob]

This is pretty well MORE than offset for by one of the sites in Texas. Trust me on this.

Could it be the one I work for, with a near 100% first pass success rate on ETIs with established data? h34r:

 

[medicsb]

Could it be the one I work for, with a near 100% first pass success rate on ETIs with established data? h34r:

Link, please. All data I've seen indicates that first pass success outside the OR is at best around the high 80s to 90% (1st pass success for physians in the prehospital setting lower). So if your service is near 100%, share the trick so the rest of EM and EMS can get in on it.

 

[Shishkabob]

It's no secret, and is done by several agencies that I know of. Every Paramedic is required to complete an intubation on a mannequin each shift (thus causing muscle memory), then there is a maximum of 1 ETI attempt done. If you can't get it on the first try, there is no second try.

This muscle memory combined with the "I only get one shot" mentality has seen an increase in first pass success rates.



I'll have to see if I can find the link. I know where to documentation is at work, and I've seen it posted online at one of the many EMS websites, but my Google-fu has failed me thus far.

 

[usalsfyre]

Link, please. All data I've seen indicates that first pass success outside the OR is at best around the high 80s to 90% (1st pass success for physians in the prehospital setting lower). So if your service is near 100%, share the trick so the rest of EM and EMS can get in on it.

I think the poster on the wall of Linuss's shop had 96% first pass rate when I was in there a couple weeks ago. So I can confirm the data was run and presented. I know Beeson was one of the authors.

Linuss, think east, plus I don't think y'all did ROC PRIMED.

 

[medicsb]

http://gatheringofeagles.us/Presentations2008/Griswell Eagles08.pdf

Is this it?