From the articles cited above, a theme begins to emerge: Early placement of the airway, along with first-pass success, are important considerations. Practitioners must consider ROSC. Without ROSC, there really is no 72-hour or 30-day outcome at all. It is likely that the airway in the prehospital setting has something to do with ROSC. The time interval between EMS arrival and definitive airway placement is likely a key factor. In a striking secondary analysis of the ROC PRIMED data that included more than 7,000 patients, it was demonstrated that the earlier the airway is placed, the higher the likelihood there is of ROSC regardless of initial heart rhythm.⁷

In light of this data, it appears that ETI can be an appropriate EMS intervention in OHCA provided the following conditions are met: the paramedic is skilled and experienced; the endotracheal tube goes in on the first attempt without interrupting CPR or delaying defibrillation; and the airway is placed less than five minutes after EMS arrival. These conditions can exist in the real world but unfortunately may not apply for many reasons.

This leaves the emergency physician with a decision: When EMS brings in a well-ventilated OHCA patient who has an SGA in place, should they leave the iGel in or spend time replacing it with an endotracheal tube before either pronouncing the patient dead or sending the patient on to the cardiac cath lab in the case of ROSC? The case for removing the SGA may in some cases be a difficult one to make.

Dr. Miller is core faculty, EMS Fellowship at MetroHealth Medical Center, Cleveland, Ohio.

Dr. Glauser is professor of emergency medicine, Case Western Reserve University.

References

1. Dyson K, Bray JE, Smith K, et al. Paramedic Intubation Experience is Associated with Successful Tube Placement but not Cardiac Arrest Survival. Ann Emerg Med. 2017;70(3):382-390.e1.
2. Wang HE, Schmicker RH, Daya MR, 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;320(8):769-778.
3. Benger JR, Kirby K, Black S, 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;320(8):779-791.
4. Benger JR, Lazaroo MJ, Crout M, et al. Randomised trial of the i-gel supraglottic airway device versus tracheal intubation during out of hospital cardiac arrest (AIRWAYS-2): Patient outcomes at three and six months. Resuscitation. 2020;157:74-82.
5. Lyng J, Baldino KT, Braude D, et al. Prehospital supraglottic airways: an NAEMSP position statement and resource document. Prehosp Emerg Care. 2022;26(1):32-41.
6. Smida T, Menegazzi J, Crowe R, et al. A retrospective nationwide comparison of the iGel and King laryngeal tube supraglottic airways for out-of-hospital cardiac arrest resuscitation. Prehosp Emerg Care. 2023;28(2):193-199.
7. Benoit JL, McMullan JT, Wang HE, et al. Timing of advanced airway placement after witnessed out-of-hospital cardiac arrest. Prehosp Emerg Care. 2019;23(6):838-846.