March 16, 2020

Rebellion in EM 2019: Optimal Airway Management in OHCA via Chris Hicks, MD

Traditionally, endotracheal intubation has been the gold standard for airway management in cardiac arrest. However, more recent data suggests that maybe less is more (i.e. supraglottic airways and/or bag valve mask ventilation).  The AHA guidelines have also de-emphasized airway management as the old acronym of ABC’s has now been changed to CAB’s.  In this talk from Rebellion in EM 2019, Dr. Chris Hicks, MD discusses the optimal airway management in OHCA.

Rebellion in EM 2019: Optimal Airway Management in OHCA via Chris Hicks, MD

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Tiers of Paramedics:

  • BLS – Bag Valve Mask ventilation and chest compressions, giving some basic meds
  • ALS – Same as BLS but can also start IV’s plus give more medications and intubate
  • One other tier your EMS system might have, critical care paramedics. They have ALS capabilities plus can start vasoactive drugs and manage aortic balloon pumps.

Prehospital Airway Management:

  • Should be less about specific tool and instead be about providing adequate oxygenation and ventilation
  • Focus on positioning, suction and BVM. Then once those are exhausted move to SGA and ETT

AIRWAYS-2 Trial [1]:

  • Multicenter cluster randomized clinical trial involving 1523 paramedics and 9296 patients in out of hospital cardiac arrest
  • Objective was to determine whether a supraglottic airway device (SGA) is superior to tracheal intubation (TI) as the initial advanced airway management strategy in adults with nontraumatic out-of-hospital cardiac arrest.
  • Study Results
    • Intact survival at 30 days
      • No difference between the two strategies
    • Initial ventilation success
      • Supraglottic airway superior

PART Trial [2]:

  • Cluster crossover randomized trial involving 3004 patients with out of hospital cardiac arrest
  • Study looking initial laryngeal tube insertion strategy vs intubation on 72 hour survival
    • Laryngeal tube insertion first led to statistically significant elevated survival compared to endotracheal intubation
      • Caveat that ETT placement for study had 51% first pass success much lower than other studies

OPALS Study [3]:

  • Major trauma study looking at before and after implementation from BLS toALS into 17 cities in Ontario Canada
  • 2867 total patients enrolled
    • Basic life support enrolled 1373
    • Advanced life support enrolled 1494
    • Characteristics of both arms of the study were similar for age, type of trauma and patients with GCS below 9
  • Survival did not differ overall (81.1% among patients in the advanced life-support phase v. 81.8% among those in the basic life-support phase; p = 0.65)
  • Patients with GCS below 9 had lower survival rate when in the ALS arm of the study

References:

  1. Benger JR 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. PMID: 30167701
  2. Wang HE 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. PMID: 30167699
  3. Stiell IG et al. The OPALS Major Trauma Study: Impact of Advanced Life-Support on Survival and Morbidity. CMAJ 2008. PMID: 18427089

Post Transcribed By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

 

Cite this article as: Salim Rezaie, "Rebellion in EM 2019: Optimal Airway Management in OHCA via Chris Hicks, MD", REBEL EM blog, March 16, 2020. Available at: https://rebelem.com/rebellion-in-em-2019-optimal-airway-management-in-ohca-via-chris-hicks-md/.
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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of REBEL EM
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