Mounting evidence against intubating cardiac arrest patients...

[island emt]

I still have a set of mast trousers in my museum Doc.

Back in the day every trauma pt got them put on and half of them got inflated.

Why???

because the current science from Vietnam showed they worked.

[rock_shoes]

This is a valid question. They identify in the study abstract that SGAs have been used prehospitally there since 1991. ETI was then introduced for some practitioners in 2004, with a 62 hour didactic component, and 30 tubes in the OR. They discuss whether this is adequate training in the discussion, and state that it exceeds "national curriculum requirements" in the US (apparently only 5 tubes?), and in the UK (25). They quote a study that I haven't read, suggesting that 20 OR tubes are the sort of minimum number to hit a 90% success rate for paramedics. I find this numbers to be a little suspect, but I haven't bothered to actually read the sources, so I should probably reserve comment.

This just wasn't described, which I think was a problem with ROC-PRIMED as well. They also seem unclear on whether some of the SGA group are patients whom they initially attempted to intubate with ETT, and then went to SGA as a rescue. Obviously these patients may have been exposed to greater and more numerous periods of interrupted CPR than a primary SGA group.

This is possible. The BVM only group showed a more rapid ROSC versus the advanced airway group. I don't think that the difference was statistically significant, but if there's a group of rapid ROSC, high risk for survival patients hidden amongst a bunch of noise it could skew things.

In pigs. The very limited evidence suggests that it impairs cerebral circulation in pigs. The only evidence of detriment in humans is the post hoc analysis of ROC-PRIMED, an analysis that's contradicted by this much larger, more recent study, which shows an equal detriment to both.

If anyone wants a copy, pm me with an email, and I might be able to point you in the right direction.

Correct with regard to the pig study and ROC-PRIMED. It's enough to warrant study specific to the issue though don't you think? Currently working in a service that is a huge supporter of the various ROC studies has given me some insight into this and honestly ROC is very well run overall. There are some inconsistencies like any study but the efforts behind it are both genuine and effective overall.

[systemet]

Correct with regard to the pig study and ROC-PRIMED. It's enough to warrant study specific to the issue though don't you think? Currently working in a service that is a huge supporter of the various ROC studies has given me some insight into this and honestly ROC is very well run overall. There are some inconsistencies like any study but the efforts behind it are both genuine and effective overall.

I agree that the issue is worthy of further study. While Hasegawa et al. suggests that there's detriment to both ETT and SGA, an issue that may relate directly to ventilation technique, it would be good to see a prospective trial that attempts to control for some of the potential confounders that were present here and in ROC-PRIMED. It would be nice to compare a planned primary SGA versus primary ETT versus primary BVM -- rather than selecting patients by the final airway technique employed. It would be nice to look at hand-on percentages, etc.

There is a study going on in the UK currently, that's about to stop enrollment that might answer some of these questions: http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=11962

It's a randomised comparison of iGel versus LMA versus current practice (which I think is ETT). They're due to close on the 28th, and have n =>500 right now. This may answer some questions regarding any harm with SGAs, unless that harm is specific to a given device, i.e. for some reason the King or Combitube cause detriment but the LMA or iGel don't.

Nothing I've said should be taken as being negative about the excellent work the ROC is doing. The ROC-PRIMED study did an excellent job of evaluating the usefulness of impedence threshold devices (ITDs), and comparing a short period of CPR (30-90s) before defibrillation versus a longer period (3 min). It's great that they decided afterwards to look at the difference in outcome between SGA and ETT patients -- but this wasn't what the study was designed to do, and as a result the design was suboptimal for answering that particular question. I think that's to be expected. Hopefully the UK study will answer some of these questions.

[mikeymedic1984]

This is not an old school vs new school or vet versus rookie argument. You could make the same argument that CPR is not useful in out of hospital cardiac arrest, because very little is useful in out of hospital cardiac arrest. Yes, you may see ups and downs in ROSC, but survivability is still about the same. All I am saying is don't pin your hopes on whatever the new "study" says. I base the validity of "scientific studies" on their "OUTCOMES". When the outcome does not change, you have to wonder how valid the research was; but I will give credit to the scientist in that there are way more variables to consider in pre-hospital cardiac arrest, that are way out of there control.

But I will take the bet; everyone throw away your laryngoscopes, let's take a look at "YOUR" data in 2/2014 to see how many more arrest patients survived in your jurisdiction than in 2012 ? I will buy lunch if I lose.

Edited February 12, 2013 by mikeymedic1984

[ERDoc]

This is not an old school vs new school or vet versus rookie argument. You could make the same argument that CPR is not useful in out of hospital cardiac arrest, because very little is useful in out of hospital cardiac arrest. Yes, you may see ups and downs in ROSC, but survivability is still about the same. All I am saying is don't pin your hopes on whatever the new "study" says. I base the validity of "scientific studies" on their "OUTCOMES". When the outcome does not change, you have to wonder how valid the research was; but I will give credit to the scientist in that there are way more variables to consider in pre-hospital cardiac arrest, that are way out of there control.

But I will take the bet; everyone throw away your laryngoscopes, let's take a look at "YOUR" data in 2/2014 to see how many more arrest patients survived in your jurisdiction than in 2012 ? I will buy lunch if I lose.

I don't think you value studies on their outcomes (nor understand how scientific research works) because if you did your view would be much different. There is a growing body of evidence that outcomes (your word) are worse for prehospital cardiac arrests that have some sort of advanced airway. About the only thing that has been shown to be useful in cardiac arrest is CPR (despite your feelings otherwise). Cardiac arrest without CPR survivability=0%. Cardiac arrest with CPR survivability=about 3%. According to the AHA, there are 383,000 OHSCA in the US alone. So, we go from having 0 survivors to 11500 survivors (with variable neurological outcomes).

I would welcome a study looking at the differences in outcomes comparing prehospital cardiac arrests who had advanced airways versus those who didn't and were just bagged versus those who just received 15L NRB. I know where I would put my money based on the literature that is already available.

[Spock]

I would emphasize what others have already pointed out: you have to read the entire article before reaching any decision and what happens in Japan does not automatically apply to any other country. Good compressions and early defibrillation are the two most important interventions in cardiac arrest management. Airway management is not high on the list.

[Bieber]

Oh Lord, to be young and gullible again. Scientific studies are no more unbiased than what you politicians tell you. Studies are funded by someone, and often the outcome of the study slants towards whatever drug or technology that the company that donated the money wanted it to produce (not always, but often). AHA has put out numerous scientific studies over the years (I have been at this almost 30), changing the ACLS drugs to whatever was deemed to be the drug of choice after the last ACLS book expired. Guess what, cardiac arrest survival rates have not changed any despite all of those expert scientific studies and STATISTICS that suggested that the old way was stupid and that the new way will save everyone.

ACLS has to change the curriculum every few years to sell more books to us, and that is all this is about. In a controlled setting like an OR, and for a short period of time, a supraglottic airway is sufficient, but in the field, the ETT is king. And to correct the rookie who stated that vomit in the airway is due to over inflating the stomach, I have worked two arrests at buffet restaurants this year (2013) where the vomit was in the airway before CPR was started, not to mention the numerous GSWs to the face (or other facial/head trauma) that put tons of blood in the airway.

Young is good. Naive is good. Naivity is the fountain from which novel ideas flow, unimpeded by the blockage of bitterness and inflexibility. As far as gullible goes, I think the greater harm here is to be gullible enough to really believe that single-digit survival rates are the best we can do, and that's exactly what we're getting out of tubes and drugs. That is the old way. It's time to try something new, something radical, and something which maybe, just maybe, will give us some real, dramatic increases in survivability.

As far as anecdote... well, I don't really have much use for it, nor do I think many others on these forums do. I think that's why most people who come to these forums are attracted to them. Because at the heart of it, they come here seeking more than what they're finding in the EMS community today. Something more than the anecdote-filled, unscientific dogma and catch-phrase-filled culture that proliferates our industry...

It's awesome that you're passionate about something, but at the end of the day, don't you want cardiac arrest survival and survival to discharge neurologically intact and with a good quality of life post-discharge to be something routine and not just a "handful in a career" type of deal? At the end of the day, most people who die die with good reason... they're old and infirm beyond what is compatible with life. But for some, we have a real chance at returning productive life to folks. Why squander that with unproven treatments like epinephrine, intubation, and transport of active-arrests? If we just start from the bottom, from the very basis of science, that nothing is true until it is proven, and work our way up from there, we will accomplish a million times more and uncover the truth to so much more than we will trying to insist on the veracity of something that (paradoxically) is proving very difficult to prove: that ETI is beneficial.

What do we know works? I mean really KNOW, backed by irrefutable evidence? That chest compressions and defibrillation increases survivability.

What do we NOT know works? What does NOT have irrefutable or unquestionable evidence? PPV, ETI, drugs.

What do we know DOESN'T work? What has been discounted, disproven, etc? Transporting active arrests.

Even you have to admit that there is a lot of questions surrounding the true benefit of ETI, when you start quantifying and qualifying it. Should we be routinely practicing that which has not been irrefutably proven true? Or should we strike it out and go with what we KNOW, and treat everything else as "in need of testing" until proof of benefit appears?