• Airway management and out-of-hospital cardiac arrest outcome in the CARES registry

    by Alan Batt. Last modified: 01/03/14

    airwaymngt

    Summary

    • Retrospective cohort review
    • 10,691 Out-of Hospital Cardiac Arrests (OHCA)
      • 5591 received endotracheal intubation (ETI)
      • 3110 received supraglottic airway (SGA)
      • 1929 received no advanced airway
    • Unadjusted neurologically-intact survival was: ETI 5.4%, SGA 5.2%, no advanced airway 18.6%
    • ETI achieved higher sustained ROSC, survival to hospital admission, hospital survival and hospital discharge with good neurologic outcome than SGA
    • Patients receiving no advanced airway attained higher survival to hospital admission, hospital survival and hospital discharge with good neurologic outcome than either ETI or SGA patients.

    The results of this registry review should be considered with caution – it is a retrospective cohort review of registry findings that did not take into account all confounding variables in its conclusions. Retrospective cohort studies cannot show a temporal relationship (i.e. cause & effect) – only display that one group was exposed to an intervention that resulted in better outcome. Errors due to confounding and bias are more common in retrospective studies than in prospective studies.

    Some examples of why this study is limited in its conclusions include:

    • Documenting airway data was optional in the CARES registry so results are not representative of entire population
    • Witnessed versus unwitnessed arrests not discriminated overall – early ROSC (associated with higher survival rates) may not require advanced airway management
    • Concluding neurologically intact survival and discharge from hospital to be related to airway management without analysing impact of further interventions such as PCI rates, therapeutic hypothermia, ICD insertion etc.

     
    McMullan J1, Gerecht R2, Bonomo J2, Robb R3, McNally B3, Donnelly J4, Wang HE4; CARES Surveillance Group. Airway management and out-of-hospital cardiac arrest outcome in the CARES registry. Resuscitation. 2014 Feb 18. PMID: 24561079.

    Abstract

    Background

    Optimal out of hospital cardiac arrest (OHCA) airway management strategies remain unclear. We compared OHCA outcomes between patients receiving endotracheal intubation (ETI) versus supraglottic airway (SGA), and between patients receiving [ETI or SGA] and those receiving no advanced airway.

    Methods

    We studied adult OHCA in the Cardiac Arrest Registry to Enhance Survival (CARES). Primary exposures were ETI, SGA, or no advanced prehospital airway placed. Primary outcomes were sustained ROSC, survival to hospital admission, survival to hospital discharge, and neurologically-intact survival to hospital discharge (cerebral performance category 1-2). Propensity scores characterized the probability of receiving ETI, SGA, or no advanced airway. We adjusted for Utstein confounders. Multivariable random effects regression accounted for clustering by EMS agency. We compared outcomes between (1) ETI vs. SGA, and (2) [no advanced airway] vs. [ETI or SGA].

    Results

    Of 10,691 OHCA, 5591 received ETI, 3110 SGA, and 1929 had no advanced airway. Unadjusted neurologically-intact survival was: ETI 5.4%, SGA 5.2%, no advanced airway 18.6%. Compared with SGA, ETI achieved higher sustained ROSC (OR 1.35; 95%CI 1.19-1.54), survival to hospital admission (1.36; 1.19-1.55), hospital survival (1.41; 1.14-1.76) and hospital discharge with good neurologic outcome (1.44; 1.10-1.88). Compared with [ETI or SGA], patients receiving no advanced airway attained higher survival to hospital admission (1.31; 1.16-1.49), hospital survival (2.96; 2.50-3.51) and hospital discharge with good neurologic outcome (4.24; 3.46-5.20).

    Conclusions

    In CARES, survival was higher among OHCA receiving ETI than those receiving SGA, and for patients who received no advanced airway than those receiving ETI or SGA.

    References

     
    1.

    McMullan J1, Gerecht R2, Bonomo J2, Robb R3, McNally B3, Donnelly J4, Wang HE4; CARES Surveillance Group. Airway management and out-of-hospital cardiac arrest outcome in the CARES registry. Resuscitation. 2014 Feb 18. PMID: 24561079.

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    Alan Batt

    Alan Batt

    Paramedic, educator, researcher
    Alan is a critical care paramedic, paramedic educator and prehospital researcher, currently working around the world as an educator and researcher. He has previously worked and studied across Europe, North America and the Middle East. He holds a Graduate Certificate in Intensive Care Paramedic Studies, and an MSc in Critical Care. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education.

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