Point-of-Care Ultrasound Use by EMS Providers in Out-of-Hospital Cardiac Arrest

Aim: Paramedics received training in point-of-care ultrasound (POCUS) to assess for cardiac contractility during management of medical out-of-hospital cardiac arrest (OHCA). The primary outcome was the percentage of adequate POCUS video acquisition and accurate video interpretation during OHCA resuscitations. Secondary outcomes included POCUS impact on patient management and resuscitation protocol adherence. Methods: A prospective, observational cohort study of paramedics was performed following a four-hour training session, which included a didactic lecture and hands-on POCUS instruction. The Prehospital Echocardiogram in Cardiac Arrest (PECA) protocol was developed and integrated into the resuscitation algorithm for medical non-shockable OHCA. The ultrasound (US) images were reviewed by a single POCUS expert investigator to determine the adequacy of the POCUS video acquisition and accuracy of the video interpretation. Change in patient management and resuscitation protocol adherence data, including end-tidal carbon dioxide (EtCO2) monitoring following advanced airway placement, adrenaline administration, and compression pauses under ten seconds, were queried from the prehospital electronic health record (EHR). Results: Captured images were deemed adequate in 42/49 (85.7%) scans and paramedic interpretation of sonography was accurate in 43/49 (87.7%) scans. The POCUS results altered patient management in 14/49 (28.6%) cases. Paramedics adhered to EtCO2 monitoring in 36/36 (100.0%) patients with an advanced airway, adrenaline administration for 38/38 (100.0%) patients, and compression pauses under ten seconds for 36/38 (94.7%) patients. Conclusion: Paramedics were able to accurately obtain and interpret cardiac POCUS videos during medical OHCA while adhering to a resuscitation protocol. These findings suggest that POCUS can be effectively integrated into paramedic protocols for medical OHCA.

The Glasgow Coma Scale: a tool to decide the need for tracheal intubation in acutely intoxicated patients?

The Glasgow Coma Scale aids decision making with regards to advanced airway management of acutely intoxicated patients. There is some evidence for lower levels of gastric aspiration when using a Glasgow Coma Scale score of eight or less to decide upon tracheal intubation, but this is not substantiated in the literature.

An Exploration and Technical Notes for Advanced Airway Management on the Ski Slope: A Simulation Experiment

Background. Skiing is a high-risk winter sport, and the rate of injury fatality is the highest compared to other winter sports. During skiing rescue, the harsh natural environments will increase the difficulty of artificial airway establishment. There has been no research focusing on the establishment of the artificial airway during skiing rescue site. This study aims to simulate the real-world scenario, calculating and comparing the operation time of different artificial airways on the cold slope, and to explore the optimal method of establishing artificial airway on the cold slope, sharing our experience, technical notes, and pitfalls we encountered, hoping to help establish a standard operating procedure in advanced airway management on the ski slope. Methods. The simulated human was placed on the cold slope with the head under the feet. Artificial airway was established by the same anesthesiologist using endotracheal intubation (endotracheal intubation group), LMA Supreme laryngeal mask (LMA group), and I-gel laryngeal mask (I-gel group). Each method was repeated 5 times, and the operation time and whether it was successful by one attempt were recorded and compared between groups. Results. Three groups of artificial airway were successful by one attempt.. The bite block dropped and drifted away for one time in the endotracheal intubation group. Operation time is 209.2 ± 32.7 seconds in the endotracheal intubation group, 72.2 ± 3.1 seconds in the LMA group, and 52.6 ± 4.2 seconds in the I-gel group. ANOVA showed that there was a significant difference in the operation time among the three groups ( p < 0.001 ). Tukey’s post hoc test showed that there were statistically significant differences between the endotracheal intubation group and the other two groups in operation time, p < 0.001 , while there was no significant difference between the LMA group and I-gel group ( p = 0.275 ). Conclusion. The artificial airway can be completed by endotracheal intubation and LMA and I-gel laryngeal mask insertion on the cold slope. Artificial airway with the I-gel laryngeal mask takes the shortest time in this study. Extra caution should be paid to slippery and drifting.

Using Lean tools to improve the efficiency of awake fibreoptic intubation setup

BackgroundAwake fibreoptic intubation is a complex advanced airway technique used by anaesthesiologists in the management of a difficult airway. The time to setup this important procedure can be significant which may dissuade its use by some providers. In our institution, the awake intubation setup process was highly variable and error prone.MethodsWe deployed Lean methods to improve the efficiency and accuracy of the awake fibreoptic intubation setup process. A 2-day improvement event with a multidisciplinary team addressed the setup process, tested solutions and created standard work documents. Twenty awake fibreoptic intubation simulations were conducted before and after the intervention to quantify gains in setup efficiency and error reduction.ResultsVariability in the setup process, including clinical locations visited, was reduced through creating a standardised process. The average time to for an awake fibreoptic intubation setup was reduced by approximately 50%, from 23 min to 11 min (p<0.001). In addition, awake fibreoptic intubation equipment set out without error increased in the postintervention simulations from 59% to 85% (p=0.003).ConclusionUsing Lean tools, we were able to make the setup of awake fibreoptic intubation not only more efficient, but also more accurate. A similar methodological approach may have value for other complex anaesthesia procedures.

Perception and success rate of using advanced airway management by hospital-based paramedics in the Kingdom of Saudi Arabia

Objective: The study aimed to measure the success rate of pre-hospital tracheal intubation (TI) and supraglottic airway devices (SADs) performed by paramedics for adult patients and to assess the perception of paramedics of advanced airway management.Method: The study consisted of two phases: phase 1 was a retrospective analysis to assess the TI and SADs’ success rates when applied by paramedics for adult patients aged >14 years from 2012 to 2017, and phase 2 was a distributed questionnaire to assess paramedics’ perception of advanced airway management.Result: In phase 1, 24 patients met our inclusion criteria. Sixteen (67%) patients had TI, of whom five had failed TI but then were successfully managed using SADs. The TI success rate was 69% from the first two attempts compared to SADs (100% from first attempt). In phase 2, 63/90 (70%) paramedics responded to the questionnaire, of whom 60 (95%) completed it. Forty-eight (80%) paramedics classified themselves to be moderately or very competent with advanced airway management. However, most of them (80%) performed only 1‐5 TIs or SADs a year.Conclusion: Hospital-based paramedics (i.e. paramedics who are working at hospitals and not in the ambulance service, and who mostly respond to small restricted areas in Saudi Arabia) handled few patients requiring advanced airway management and had a higher competency level with SADs than with TI. The study findings could be impacted by the low sample size. Future research is needed on the success rate and impact on outcomes of using pre-hospital advanced airway management, and on the challenges of mechanical ventilation use during interfacility transfer.

Respiratory adverse events associated with deep propofol sedation during upper gastrointestinal procedures in children

Background/Aims: Upper airway stimulation with endoscopes and pH-impedance probes during deep propofol sedation confers unknown risk for associated respiratory adverse airway events. This report quantifies frequencies of such events and airway rescue interventions associated with Esophagogastroduodenoscopies (EGD) and multi-channel intraluminal acid detection impedance probe (MIIP) placements. Methods: This was a prospective observational study regarding occurrence of adverse respiratory events in 42 children undergoing propofol sedated EGDs and MIIP placements: Group 1. (n=21 EGDs), Group2 (n=21 EGDs before MIIP), Group 3. (n=21 during MIIP). Results: All procedures were successfully completed using deep propofol sedation. Respiratory events were transient and associated with no morbidity or mortality. Nearly half of each group experienced a respiratory event. “Partial airway obstruction” during 42 EGDs occurred in 28.6% and responded to simple airway interventions. “Complete airway obstruction” occurred during 1/42 EGDs and 2/21 MIIPs. Throughout MIIP placement, endoscopic visualization of the glottis was maintained and unnecessary stimulation of the glottis was avoided; nonetheless, complete airway obstruction occurred in 2/21. Advanced airway rescue maneuvers were not required in either instance. Conclusions: Respiratory adverse events commonly occurred during EGDs and MIIP placements. All events were successfully rescued by simple airway interventions.

Abstract 11488: Ventilation Rate and Sustained Return of Spontaneous Circulation in In-Hospital Cardiac Arrest: Is More Better?

Introduction: Current consensus holds that CPR must balance chest compressions and ventilation rate (VR), with a low VR being essential for venous return and cardiac output. AHA guidelines recommend a VR of 10 ventilations per minute (vpm) after advanced airway placement. We sought to examine VR adherence and its impact on end-tidal CO 2 (ETCO 2 ) and ROSC >20 minutes. Methods: This is a retrospective analysis of data from AWARE II, a multicenter prospective observational study of adult in-hospital cardiac arrest (IHCA) outcomes at 14 US and UK sites. Inclusion criteria were: 1) adult patient in CA, 2) advanced airway already in place or placed during the CA, and 3) at least one minute of VR and ETCO 2 data available after removal of the last minute of CPR in subjects achieving ROSC (due to the rise of ETCO 2 just prior to ROSC). Results: A total of 563 subjects were enrolled in the parent study. Of these, 225 had ETCO 2 and VR tracings available, and 201 had sufficient data for inclusion. Mean age was 69.3 (range 18-100), patients were 63.7% male, and 16.4% had a shockable initial rhythm. A total of 116 subjects (57.7%) achieved ROSC, which was sustained in 76 (37.8%), leading to survival to hospital discharge with favorable neurological outcomes in 9 (4.5%). Mean VR was 16.3 vpm, with 171 (85.1%) subjects being ventilated in excess of guidelines; only 16 (8.0%) subjects received 8-10 vpm. Higher VR had a weak but significant association with increased mean ETCO 2 (linear R 2 = 0.11, p < 1x10 -6 ) and sustained ROSC (OR 1.05; 95% CI: 1.01-1.11; p = 0.02). Patients with sustained ROSC had a significantly higher VR at 17.7 vpm than those without sustained ROSC at 15.6 vpm (p = 0.007). Patients receiving a VR close to AHA guidelines (6-12 vpm) had a significantly lower rate of sustained ROSC (26.1%, n = 46) than patients receiving >12 vpm (42.0%, n = 148) (OR 2.30; 95% CI: 1.08-4.89; p = 0.031 using a multivariate model including patient age, shockable initial rhythm, known cardiac disease, witnessed IHCA, and use of mechanical compressions). Conclusions: VR within AHA guidelines is rare during IHCA. However, ventilation in excess of current guidelines may increase rates of sustained ROSC, an essential predicate to survival. AHA guidelines on VR in CPR with an advanced airway may not yet be optimized.

Abstract 8883: Pre-hospital Physician’s Presence and Neurological Outcome Among Patients Performed Pre-hospital Advanced Airway Management: A Nationwide Multicenter Observational Study in Japan (the Japanese Association for Acute Medicine-out-of-Hospital Cardiac Arrest Registry)

Purpose: Using the out-of-hospital cardiac arrest (OHCA) registry in Japan, we evaluated the effectiveness of pre-hospital advanced airway management under physicians’ presence after adjusting in-hospital treatments. Methods: This was a multicenter cohort study. We registered all consecutive OHCA patients in Japan who, from 1 June 2014 through 31 December 2017, were transported to institutions participating in the Japanese Association for Acute Medicine OHCA Registry. We included OHCA patients performed pre-hospital advanced airway management, who were ≥18 years of age with medical etiology and who received resuscitation from emergency medical services (EMS) personnel and medical professionals in hospitals. The primary outcome was one-month favorable neurological survival.We estimated the propensity score by fitting a logistic regression model that was adjusted for several variables before the arrival of EMS personnel and/ or pre-hospital physician. A multivariable logistic regression analysis in propensity score-matched patients was used to adjust confounders including extracorporeal membrane oxygenation, percutaneous coronary intervention, intra-aortic balloon pumping, and targeted temperature management. Results: We analyzed 9,672 patients. Among them, 2.3% (N = 218) had a neurologically favorable outcome. The adjusted odds ratio (AOR) of pre-hospital advanced airway management under physicians’ presence compared with their absence for primary outcome was 0.96 (95% confidence interval (CI): 0.61-1.51). Among first documented non-shockable cardiac rhythm, the AOR was 3.10 (95% CI: 1.05-10.77). Among first documented shockable cardiac rhythm, the AOR was 0.90 (95% CI: 0.53-1.53). Conclusion: In Japan, pre-hospital advanced airway management under physicians’ presence was not associated with one-month favorable neurological survival among patients with first documented shockable cardiac rhythm, whereas it was associated with a neurologically favorable outcome among patients with first documented non-shockable cardiac rhythm.

Abstract 11045: Pre-Hospital Airway for Out-of-Hospital Cardiac Arrest: A Nationwide Multicenter Study

Introduction: This study investigated whether use of pre-hospital advanced airway management (AAM) is associated with improved survival of adults with out-of hospital cardiac arrest (OHCA) compared to conventional bag-valve-mask ventilation (BVM). Method: The study subjects were derived from Korean Cardiac Arrest Research Consortium (KoCARC), a multi-center OHCA registry of Korea. Patients who underwent AAM or BVM using supraglottic airway, oropharyngeal airway, or endotracheal intubation were compared. The differences in baseline clinical characteristics were adjusted using propensity scoring matching (PSM) or inverse probability of treatment weighting (IPTW). The primary outcome was 30-day survival with neurologically favorable status of cerebral performance category ≤2. The outcome was also compared according to the duration of low-flow time. Results: Of 9,616 patients enrolled, (median age = 71, male sex = 65%) there were 7,583 AAM and 2,033 BVM patients. The unadjusted survival to with neurologically favorable status was lower in AAM compared to BVM (HR = 1.27, 95% confidence interval (CI) = 1.20 - 1.34, p<0.001). However, there was no significant difference of survival to with neurologically favorable status between AAM and BVM after PSM or ITPW-adjusted comparisons (p>0.05, all). This finding was consistent irrespective of duration of low-flow time. Conclusion: In this nationwide real-world data of out-of hospital cardiac arrest study, prehospital advanced airway management compared to bag-and-mask ventilation did not result in an improved clinical outcome at 30 days.