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Out-of-Hospital Cardiac Arrest and Prehospital Intubation

Posted May 29 2013 12:00am

Worldwide, death from cardiac arrest in the out-of-hospital setting remains the leading cause of mortality. Focuses have aimed at improving bystander CPR, public access to AEDs, minimizing chest compression interruptions, and decreasing the emphasis on advanced airway management. This latter concept has become so important that the AHA/ASA have now changed their “ABC” philosophy to “CAB.” Below is the review of the literature that has changed this philosophy.


Does Prehospital Intubation Attempts Affect Survival to Hospital Discharge in Out-of-Hospital Cardiac Arrest (OHCA)?


What they did:
  • Retrospective study design at single site (Mecklenbeurg County, NC)
  • 1,142 cardiac arrests
Primary outcomes:
  • Pre-hospital return of spontaneous circulation (ROSC)
  • Survival to hospital discharge
Descriptive data:
  • 697/1142 (61%) of patients were male
  • 619/1142 (54.2%) of patients were Caucasian
  • 302/1142 (25.5%) had VF/VT arrest
  • 142/1142 (12.8%) witnessed by EMS or first responders
  • 299/1142 (26.2%) had pre-hospital ROSC
Results:
  • Pre-hospital endotracheal intubation (ETI) vs NO ETI: 25.3% vs 45.3% with pre-hospital ROSC 
  • 118/299 (39.5%) of patients with ROSC were discharged alive

Limitations:
  • ETI attempts was a self reported variable
  • Some outcome data from the hospitals was missing
Conclusions: There is a NEGATIVE association between pre-hospital ETI attempts and survival from OHCA.



Does Prehospital Intubation Attempts Affect Survival and Neurologic Outcome in Out-of-Hospital Cardiac Arrest (OHCA)?




What they did:
  • Prospective, nationwide, population-based study using all-Japan Utstein Registry
  • 649,654 adults in Japan with OHCA
Primary outcome:
  • Favorable neurological outcome 1 month after OHCA
Descriptive data:
  • 367,837/649,359 (57%) underwent BVM
  • 281,522/649,359 (43%) underwent advanced airway management
  • Overall rate of ROSC 6.5%
  • Overall rate of 1 month survival 4.7%
  • Overall rate of favorable neurologic outcome 2.2%
Results: Looking at ETI vs supraglottic airway vs BVM -
  • Favorable neurological outcome: 1.0%, 1.1%, and 2.9%, respectively
  • OR for favorable neurological outcome: 0.41, 0.38, 0.38, respectively


Limitations:
  • Observational study
  • Absence of information regarding the process of intubation
  • Japanese population only
Conclusion: In OHCA, advanced airway (ETI or supraglottic airway) was independently associated with a DECREASED neurologically favorable outcome compared to conventional BVM.



BOTTOM LINE: Pre-hospital advanced airway WORSENS survival and neurologic outcome in OHCA

Salim Rezaie, MD
( @srrezaie )
Clinical Assistant Professor of EM and IM
University of Texas Health Science Center at San Antonio

References:
  1. Hasegawa K et al. Association of Prehospital Advanced Airway Management with Neurologic Outcome and Survival in Patients with Out-of-Hospital Cardiac Arrest. JAMA 2013 Jan; 309 (3): 257 – 266. PMID: 23321764
  2. Studnek JR et al. The Association Between Prehospital endotracheal Intubation Attempts and Survival to Hospital Discharge Among Out-Of-Hospital Cardiac arrest Patients. Acad Emerg Med 2010; 17: 918 – 925. PMID: 20836771
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