So what should we do for the airway based on the results from these 12,000 total patients? Although there is more than enough room for debate, it seems the least favorable position would be to support prehospital ETI. ETI cannot conclusively be shown to result in harm compared to SGA, but it is challenging to consider it the best strategy.
Explore This Issue
ACEP Now: Vol 37 – No 10 – October 2018A better question may be whether any advanced airway is routinely necessary. A small trial in France could not reach a conclusion regarding the utility of ETI compared to bag-valve-mask ventilation even though that trial utilized physicians for airway procedures in the prehospital setting.4
I believe the current evidence favors conserving limited health care resources by omitting epinephrine and using primarily SGA, if any airway is even needed. However, it would be just as reasonable for a medical director to draw up protocols using both epinephrine and ETI as it would be to omit both. At the end of the day, we are a little closer to definitive answers, but we have many new questions.
References
- Perkins GD, Ji C, Deakin CD, et al. A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Engl J Med. 2018;379(8):711-721.
- 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.
- 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.
- Jabre P, Penaloza A, Pinero D, et al. Effect of bag-mask ventilation vs endotracheal intubation during cardiopulmonary resuscitation on neurological outcome after out-of-hospital cardiorespiratory arrest: a randomized clinical trial. JAMA. 2018;319(8):779-787.
Pages: 1 2 3 | Single Page
2 Responses to “Studies Test Common Cardiac-Arrest Advanced Life Support Practices”
October 28, 2018
William ReedRegarding the PARAMEDIC2 trial reviewed by Dr. Radecki.
First, love the Princess Bride reference.
Second, I would respectively offer another interpretation of the study.
The study shows that epinephrine in OHCA will likely not improve “neuro-intact” survival if:
1. Your EMS agency does not give the drug earlier than a median of 14.8 minutes after arrival.
And,
2. Your EMS agency has a very low overall survival rate for OHCA (1/5th that of the great state of Oregon’s – 2017 CARES data).
Close, but no cigar.
Repeating this study in the US with EMS agencies with a CPR fraction greater than 90% and who give Epi early (less than 10 minutes after EMS arrival) would help better define the utility of this drug in OHCA.
Respectfully submitted “as you wish.”
WJR
November 1, 2018
Ryan RadeckiThanks for the comment, William.
I agree with all your points.
Generalizability of a study is always of concern – if a study’s population and practices do not reflect your own, it limits the applicability to your setting. It blurs the line between practice-defining and hypothesis-generating, as you note, where either a subgroup analysis may be more informative, or another type of trial altogether.
Cheers,
Ryan