Rebellion in EM 2019: Optimal Airway Management in OHCA via Chris Hicks, MD
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Tiers of Paramedics:
- BLS – Bag Valve Mask ventilation and chest compressions, giving some basic meds
- ALS – Same as BLS but can also start IV’s plus give more medications and intubate
- One other tier your EMS system might have, critical care paramedics. They have ALS capabilities plus can start vasoactive drugs and manage aortic balloon pumps.
Prehospital Airway Management:
- Should be less about specific tool and instead be about providing adequate oxygenation and ventilation
- Focus on positioning, suction and BVM. Then once those are exhausted move to SGA and ETT
AIRWAYS-2 Trial [1]:
- Multicenter cluster randomized clinical trial involving 1523 paramedics and 9296 patients in out of hospital cardiac arrest
- Objective was to determine whether a supraglottic airway device (SGA) is superior to tracheal intubation (TI) as the initial advanced airway management strategy in adults with nontraumatic out-of-hospital cardiac arrest.
- Study Results
- Intact survival at 30 days
- No difference between the two strategies
- Initial ventilation success
- Supraglottic airway superior
- Intact survival at 30 days
PART Trial [2]:
- Cluster crossover randomized trial involving 3004 patients with out of hospital cardiac arrest
- Study looking initial laryngeal tube insertion strategy vs intubation on 72 hour survival
- Laryngeal tube insertion first led to statistically significant elevated survival compared to endotracheal intubation
- Caveat that ETT placement for study had 51% first pass success much lower than other studies
- Laryngeal tube insertion first led to statistically significant elevated survival compared to endotracheal intubation
OPALS Study [3]:
- Major trauma study looking at before and after implementation from BLS toALS into 17 cities in Ontario Canada
- 2867 total patients enrolled
- Basic life support enrolled 1373
- Advanced life support enrolled 1494
- Characteristics of both arms of the study were similar for age, type of trauma and patients with GCS below 9
- Survival did not differ overall (81.1% among patients in the advanced life-support phase v. 81.8% among those in the basic life-support phase; p = 0.65)
- Patients with GCS below 9 had lower survival rate when in the ALS arm of the study
References:
- Benger JR et al. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During OUt-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA 2018. PMID: 30167701
- Wang HE et al. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults with Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA 2018. PMID: 30167699
- Stiell IG et al. The OPALS Major Trauma Study: Impact of Advanced Life-Support on Survival and Morbidity. CMAJ 2008. PMID: 18427089
Post Transcribed By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)
Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)
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