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Cardiac arrests update from 2018
- 1. Cardiac arrests update from 2018 David Gale 9th January 2019
- 2. Outline • Airway trials • Airways2 • PART • Jabre • Paramedic2 • ILCOR updates • Other cardiac arrest studies in 2018 • Intraosseous in cardiac arrest • Hyperoxia in cardiac arrest • Intubation experience in cardiac arrest
- 3. Acknowledgements • Authors of the relevant papers • ILCOR • ANZCOR • The Bottom Line • The Resus Room
- 4. A big year for airways management in cardiac arrest • Airways 2: iGel vs ETT • PART: Laryngeal tube vs ETT • Jabra: BVM vs ETT
- 9. • Large Scale • Important clinical question • Patient focused outcome • Included non adv airway • SGA group had more adv airway • Imbalance in numbers that received an airway • Volunteers • 70% first pass success ett • Not generalisable to hospital
- 10. PART
- 11. PART- Outcomes Primary outcome Looking at 72 hour survival • LT 18.3% vs ETI 15.4% Secondary outcomes • Return of spontaneous circulation: LT 27.9% vs ETI 24.3 • Hospital survival: LT 10.8% vs ETI 8.1% • Favourable neurological status at discharge: LT 7.1% vs ETI 5.0% Crossover: LT 4.5% vs ETI 9.2% Success rates: LT 90% vs ETI 52%
- 12. JABRA
- 18. • Pragmatic • Blinding and randomisation • Important question • Good internal and external validity • Patient centred outcomes • Post ROSC care and CPR quality not controlled • Can’t generalise to early ROSC group • Loss to follow up • Not powered to detect favourable neuro outcome • Low survival rate
- 19. • Patient preferences • Few or different doses • Applicability to hospital patients • Different cohorts of patients • Survival with newer technology • IV access • Health economics
- 20. • Response to airways trials • Response to adrenaline trial • Other updates • Lignocaine in VF/VT • Magnesium • Prophylactic antiarrhythmic
- 23. Intubation experience in cardiac arrest
- 24. Take home points - Type of airway management might not matter so much - iGEL first is a reasonable strategy - Good quality CPR and early defibrillation is much more important - Implications for intubation training - Adrenaline creates more survivors with severe neurologic impairment - Lignocaine can be considered in VF/VT
Editor's Notes
- Question: In adult patients with non-traumatic out-of-hospital cardiac arrest, does a supraglottic airway device compared with tracheal intubation as the initial advanced airway management strategy, improve functional neurological outcome? Background Survival in cardiac arrest is poor, looking for ways to improve Optimal airway mx uncertain as very little high quality evidence SGA over last 10 years increased use without good evidence base, ett has been gold standard SGA is simpler and faster but may be less effective and carry high risk of aspiration
- The study multicentre, cluster randomised, UK, paramedics randomised 1:1 computer random sequence stratified by experience/distance/organisation, voluntary by paras Paramedic discretion permitted and was necessary for ethics approval, allowed crossover June 2015- Aug 2017 Exclusion: resus inappropriate, adv airway already in situ, mouth opening less than 2cm 4882 and 4407 patients respectively were included in the primary outcome analysis Well matched baseline demographics, median age 73, 36% female, median time to para arrival within one min of each other, 50% asystole/22% VF, CPR prior 63%, defib prior 3% Common: paramedics got extra training, standard airway approach with bvm and adjuncts first, etco2 used Note this is not testing a device its testing a strategy
- Primary outcome No statistical significant difference in MRS at hospital discharge or 30 days after OOHCA, adjusted risk difference of -0.6% CI -1.6-0.4% MRS divided into two groups, good and a poor Secondary outcomes There was a difference in initial ventilation success on first 2 attempts, 87.4% vs 79% p <0.001 There was a difference in unintentional loss of device 10.6% vs 5% p<0.001 No difference in survival at scene (53.7 vs 56.5%) or at discharge/30d 8% vs 8.4% No difference in aspiration 15.1% vs 14.9% No difference in ROSC 30.6% vs 28.4%
- Subgroup analysis Intervention group: Para for igel first, 82% received igel, 15% had no adv airway, 2.4% received ett first Control group: Ett with dl and bougie 2 person technique recommended, 62% ett first, 22% no airway, 14% airway first A significant number had no advanced airway, this may be due to many reasons eg by stander defib, short arrest, futility The patients without an advanced airway did significantly better and made up the majority of good survivors (20% had good outcome) 22% in ETT group and 15% in SGA group had no adv airway? Sway results? Were these patient better? Could it be that SGA is more appealing to insert? If directed to ETT first you have more patients without adv airway and high number of crossover (600 cf 166 who crossed to ett)…implication of this is that the groups are no longer the same and differential crossover. Were patients more likely to get sga if better outcome predicted, more likely to get ett if looked more sick Of the patients who did get and airway, prespecified sensitivity analysis (subset so not as reliable) In patients who received an advanced airway more patients in the SGA group had a good outcome 3.9% vs 2.6%, adjusted OR 1.57 with CI 1.18-2.07 Is this because: iGel is better Paramedics more likely to use iGel in less sick patients Scientifically this is less reliable
- Strengths: large scale, important clinical question, patient focussed Weakness: trial population included patients that didn’t receive advanced airway Possible confounding by indication as more received SGA (confounding by indication is when an indication for something also effects the outcome) Imbalance in numbers 3400 vs 4200 with advanced airways Paramedics were volunteers, may not be representative, they were also trained more Not sure of PCI, TTM etc between groups May not be applicable in physician/paramedic groups or with other types of SGA 70% first pass success, poor, may not be representative of our population, cardiac arrest is hard Not generalisable to a hospital population More than 1/3 got no bystander CPR and only 15% received defibrillation (austalia Monash study 60% don’t get bystander CPR)
- US study, 27 ED medical services, adults with OOHCA, cluster randomised for 3-5 months, cross over allowed, open label Patients were enrolled if advanced airway anticipated which is different to airways2 which were already randomised Laryngeal tube used, different from igel, ? external validity Intubation via VL or DL, as many goes as would like, rescue technique allowed Excluded: major bleeding, major facial trauma, asphyxic cardiac arrest, pregnant, prisoners 3004 patietns
- Primary outcome Looking at 72 hour survival 18.3% vs 15.4% for lma vs ett, statistically significant, ARR 2.9% p0.04 CI 0.2-5.6%, NNT 35 Secondary - Return of spontaneous circulation: LT 27.9% vs ETI 24.3 ARR 3.6% in favour of LT (95% CI 0.3% to 6.8%; P = 0.03) - Hospital survival: LT 10.8% vs ETI 8.1% ARR 2.7% in favour of LT (95% CI 0.6% to 4.8%; P = 0.01) - Favourable neurological status at discharge: LT 7.1% vs ETI 5.0% ARR 2.1% in favour of LT (95% CI 0.3% to 3.8%; P = 0.02) Crossover: 4.5% in lt group, 9.2% in ett group Success rates: 90% LT, 52% ett Strengths: important question, complex randomisation to minimise group differences, tested strategy not device Weaknesses: crossover might mean more differences between the groups, lack of blinding, non patient centred outcome, may not be able to generalise beyond LT External validity US is going to be different to UK and AUS ETT success rates of 51% is very different to our practice A big difference is interesting and supports SGA approach but hard to externally apply Enrolment raises questions, if clinician has the discretion and knows what plan they are going to go with first, if they aren’t confident or have concerns with the approach they are more likely not to enrol and will go with basic airway manoeuvres. Not as good as airways2 from a scientific view but supports the results Adverse events (according to group allocation): More than two attempts at airway insertion LT 4.5% vs ETI 18.9% Unsuccessful initial airway insertion LT 11.8% vs ETI 44.1% Unrecognised misplacement or dislodgment LT 0.7% vs ETI 1.8% Inadequate ventilation LT 1.8% vs ETI 0.6% Pneumothoraces LT 3.5% vs ETI 7.0% Rib fractures LT 3.3% vs ETI 7.0%
- Multicentre RCT, >2000 patients, France and Belgium, 20 services and emergency physicians present Didn’t included massive aspiration prior to randomisation, pregnant or prison Allocated a strategy and allowed for rescue techniques, only stable rosc patients transported, just looking at pre rosc airway Primary outcome Survival to favourable outcome at 28 days 4.3% in BVM and 4.2% in ETT, failed to show non inferiority or inferiority ie not difference between the groups Not externally valid, most patients will have igel or ett in our service to get hands off jaw thrust and freed up but would help providers that only can do basic manoeuvres Intention to treat, 14% of BVM group get rescue advanced airway which may alter the internal validity of the study and show differences between the groups
- Should this change practice These papers need to be looked at in totality ? Need to filling missing piece of the puzzle sga vs bvm, now more equipoise Implications of training and maintaining ett skills, this needs to stay in the skill set : too hard for theatres, dilution with more icps, may be different for different areas Provides reassurance that the move towards igel is not harmful How does this affect post rosc care and timing of intubation Overall take home point Airway may not matter, lots of patients had no adv airway and did well Hard to justify ETT as first line approach iGel achieves the same primary outcome, is more likely to ventilate, does not increase regurg/aspiration, is used more commonly by paramedics, if you ask them to use igel they are more likely to use it than ett, crossover suggest igel more applicable (position, single person) and depending on your interpretation may have better outcomes when looking at sensitivity analysis ETT can’t be thrown away, eg choking patients or failed sga, how do we train for this? How do we train paramedics BLS rules, airway shouldn’t detract from this (Ett needs bandwidth, equipment and personel), disadvantage may be nothing to do with tube and everything to do with distraction from bls/defib. Ie which is more harmful rather than which is more beneficial
- Adrenaline in cardiac arrest has potential beneficial effects by increasing the aortic diastolic pressure and thus increasing coronary blood flow; however harmful effects have also been hypothesised. These include increased myocardial oxygen demand, and platelet activation leading to thrombosis and impaired microvascular flow potentially increasing cerebral ischaemia. There has been conflicting evidence as to whether epinephrine (adrenaline) is beneficial or not. 9 observational studies showed increased ROSC without improved long term survival, 50% had a reduction in favourable neurologic outcome in those that survived suggesting adrenaline may not help long term favourable neurologic outcome. Study 16 years old, NHS, excluded asthma and anaphylaxis, excluded those already received adrenaline/pregnant/trauma, double blinded 8000 patients Primary: survival at 30 days Secondary: favourable neurologic outcome at different time points up to 3 months
- Similar baseline characteristics Age: 69.7 (Epinephrine) vs. 69.8 (Placebo) Male: 65.0% vs. 64.6% Initial Cardiac Rhythm: Shockable: 19.2% vs. 18.7% VF: 17.8% vs. 17.1% VT: 0.6% vs. 0.5% Non-shockable: 78.4% vs. 79.5%, Asystole: 53.2 % vs. 54.9%, PEA: 23.8% vs. 23.4% Cause : Medical: 91.1% vs. 92.3%, Traumatic: 1.6% vs. 1.4%, Drowning: 0.2% vs. 0.3%, Drug Overdose: 1.8% vs. 1.8%, Electrocution: 0 vs. <0.1%, Asphyxia: 2.9% vs. 2.0%, Missing Data: 2.3% vs. 2.1% Witness Unwitnessed: 37.3% vs. 37.6%, Bystander: 50.1% vs. 49.2%, Paramedic: 11.3% vs. 11.8%, Missing Data: 1.3% vs. 1.4% CPR - Bystander: 59.3% vs. 58.7%, Paramedic 11.3% vs. 11.8%, Missing Data: 1.7% vs. 2.1% Time frames for key events also similar Median interval between emergency call and ambulance arrival: 6.7 min (Epinephrine) vs. 6.6 min (Placebo) Median interval between emergency call and administration of trial agent: 21.5 min vs. 21.1 min Mean interval between ambulance arrival and departure: 50.1 min vs. 44.5 min Mean interval between ambulance departure and hospital arrival:12.9 min vs. 12.4 min Medial interval between initiation and cessation of ALS: 47.5 min vs. 43.1 min Mean of 4.9 drug doses given in epinephrine group vs. 5.1 in placebo 5% received amiodarone in epinephrine group vs. 9.2% in placebo 3980 shocks after randomisation in epinephrine group vs. 3962 in placebo Initial Response to Resuscitation - Transported to hospital in 50.8% in epinephrine group vs. 30.7% in placebo - Of those transported 15.3% of epinephrine group not declared dead in emergency room vs. 7.3% in placebo group Rates of concurrent pre-hospital treatments (IV or IO access, supraglottic airway device, endotracheal tube) similar
- PRIMARY: Primary outcome adrenaline had a significantly higher survival at 30days 3.2 vs 2.4, NNT 112 to prevent one death, ARR 0.89 CI 0.17-0.16 SECONDARY: No significant difference in favourable neurologic outcome 2.2 vs 1.9, higher likelihood of disability in those that achieved rosc in adrenaline 31% vs 17.8% ROSC 36.3 vs 11% rosc rate in adrenaline group Shock vs no shock Sub group of presenting rhythm showed no difference in shock vs non shock, would have thought pea might do better with adrenaline but wasn’t born out. Only observational data exists in good for pea/asystole and bad for VF/VT
- Survival rates at various time points were significantly better in the Epinephrine group. Length of stay in ICU and hospital did not differ Neurological outcomes were possibly worse in the Epinephrine group when categorised into binomial ‘favourable’ and ‘non-favourable’ there was no statistically significant difference When assessing the number who survived with severe neurological deficit, the difference was statistically significant with worse outcome in the Epinephrine group The pre-hospital use of epinephrine in patients with OOHCA resulted in a significantly higher rate of survival at 30 days when compared to a placebo There was no significant difference between groups with regards to a favourable neurological outcome More survivors in the epinephrine group had severe neurological impairment.
- Strengths - pragmatic, good blinding and randomisation, important question, good internal and external validity, patient centred outcomes, Weaknesses CPR quality/post ROSC care not controlled: given blinding unlikely to affect performance bias Can’t generalise to early ROSC group There was significant loss to follow-up for the secondary outcomes 20 (18.2%) in the placebo group and 29 (18.2%) in the epinephrine group were lost at 3 months, attrition bias if there are differences in the groups lost to follow up… ie what if more placebo had sev neuro def For the survivors, there was a difference in the rate of unfavourable neurological outcome at hospital discharge (epinephrine 31.0% vs placebo 17.8%) and at 3 months (16.3% vs 14.9%), so what is the best time frame to study neurological outcomes - Is this because patients with unfavourable are dying before 3 months, what is the best time point to assess? Not powered to find statistically significant favourable neurologic outcome, ? Larger trial would have been different Lower survival rate than would be expected, probably because patients get rosc before enrolement so this would select worse patients, particularly in shockable rhythm
- Patient preferences: 95% said long term survival without brain damage most important rather than surviving at all, how do we consider individual preferences On average patients got 5 adrenaline, would you consider stopping earlier? Can this be applied to in hospital? Different patients/aetiology/survival rates/response time/personnel Doesn’t explain different groups/patients/aetiology who may benefit from adrenaline Will adrenaline be helpful in survival to ecmo and change outcomes that way? What about different doses? Could iv access and adrenaline vs no iv access and no adrenaline affect outcomes, less cpr interruption Lingering health economics questions: survival to hospital/ICU/organ donation/DC Where to now CPR and adrenaline much more important, confusion about treatment shouldn’t interfere with CPR/adrenaline and protocols should be followed without discussion! Await ilcor updates Need more public conversation about whats important and this is what should drive change Enhancing community response, bystander CPR and defib When things are being done serial not parallel, adrenaline can move down the list without worsening outcomes significantly
- New model for ILCOR recommendations, continuous evidence evaluation processes. ANZIC guidelines not yet changed Adrenaline: The study did not demonstrate improved long-term survival with good neurologic function. The optimal dose and timing of epinephrine during cardiac arrest remain important knowledge gaps. Moving forward, the ILCOR ALS Task Force will evaluate the results of this important study and determine if the current ILCOR treatment recommendations for epinephrine during CPR should be modified. Airways: 2015 ILCOR Treatment Recommendation: We suggest using either an SGA or tracheal tube as the initial advanced airway during CPR (weak recommendation, very low-quality evidence) for cardiac arrest in any setting. The Task Force will combine the findings from these trials with those from previously published trials to generate an updated consensus on science and treatment recommendation. Lignocaine: amiodarone OR lignocaine may be consider for VF/pVT that is unresponsive to defibrillation. 2015 said amiodarone may be considered. Magnesium: The routine use of magnesium for cardiac arrest is not recommended in adult patients (same as 2015) Magnesium may be considered for torsades de pointes (ie, polymorphic VT associated with long QT interval) (Class IIb, LOE C-LD). The wording of this recommendation is consistent with the AHA’s 2010 ACLS guidelines. Post rosc care prophylactic antiarrhythmic: 2018 recommendations: insufficient evidence to support or refute the routine use of lidocaine early (within the first hour) after ROSC. In the absence of contraindications, the prophylactic use of lidocaine may be considered in specific circumstances (such as during emergency medical services transport) when treatment of recurrent VF/pVT might prove to be challenging (Class IIb, LOE C-LD).
- Intraosseous vascular access is associated with lower survival in patients with OOHCA Secondary analysis of previously collected database in the states, 6 centres, huge data set Excluded either failed IO or IV or had both an IV/IO, only looked at initial IV or IO patients Primary: favourable neurologic outcome MDR <4 Looked at AED use, timing, bystander etc at baseline 13000 oohca included, only 660 received IO, massively weighted towards IV IO had a 1.5% advantage, IV had 7.6% advantage Multivariate regression, IO associated with poorly outcome, 0.24 with CI 0.12-0.46 (odds of IO have good outcome 24% that of IV) Should we be throwing IO in the bin? 6% difference seems to be too large and unusual just for IO especially given the drugs used in cardiac arrest aren’t necessarily that import Especially if the finding from the resuscitology paper puplished earlier this year Makes you think about those patients that are getting IO High stress environment more likely to reach for IO IV might be done in patients that aren’t so bad and have decent vascular ? less sick (if you can have this in cardiac arrest) No matter how much statistics you do its difficult to balance the groups Shockable in IV 26% vs 14% in IO, witnessed in 41% vs 35%, IV had higher rates of hypothermia and pci. Stats can account for some of these but not the decisions that were made for these patients, paramedics or docs are seeing something the numbers don’t and going for IO instead Reasonable to try IV first otherwise go for IO Resucutiology: drugs more likely to reach the heart significantly faster when delivered through a humeral IO than brachieal vein
- Hyperoxia Association between intra and post arrest hyperoxia on mortality in adults with cardiac arrest, resuscitation, patel, systematic review Intra-arrest not just post arrest 2000-2015, adults, pao2 recorded, mortality end point, in hospital and prehospital looked at 40000 patients, 16 observational studies, 119-12000 patients included, very different study weighting Only 2 studies looked at intra-arrest, approx. 300 patients 4 studies abg in an hour, 1 study in 4 hours, 8 studies in 24 hours…. Not at the point of rosc so not necessarily that relevant Varying definitions for hyperoxia: 300mmhg seems to be standard Outcome: intra-arrest, hyperoxia showed lower mortality, OR 0.25, CI don’t cross 1 (significant), for post arrest hyperoxia is bad OR 1.34, not statistically significant Intraarrest hyperoxia good, post arrest bad Titrate down when stable to reach normoxia Intra-arrest evidence not good enough to change practice but it does show we shouldn’t mess around with oxygen during arrest and focus on the resuscitation however likely more evidence to come with hyperoxia All observation, so many potential confounders, timing of hyperoxia not measured so not able to apply to your practice, huge changes to resus care during 2000-2015 so likely too many other confounders impossible to draw out from retrospective and observational data
- Resuscitation, Sin Young Kim et al, how much experience do rescuers require to achieve successful tracheal intubation during cardiopulmonary resuscitation Prior studies suggest around 100 intubations to get core skills then approx. 1 per month ED residents, adult, direct, cardiac arrest patients, south korea, retrospective data collected prospectively Randomly assigned to cpr or ett, data from cctv from arrest and ecg data which helps assess interprutption timing Main outcomes: qualified Ett intubation in 60sec, highly qualified 30s without complications, secondary: first pass success and hands of chest time Time is entering mouth to bag ventilation time 255 patients in total, 162 excluded either VL used, DNR or previously placed airway, 110 attempts for 93 patients (small) First pass success is 68%, 11 from 110 were oesophageal (high, ? not reflective of practice) For 80% of qualified ett without complication it would require 137 intubations, to get to 90% 157 intubations, for highly qualified it would require 220 intubations and for 90% 243 Strengths Good registry, prospective, video and timings used, reasonable methodology, internal validity reasonable Weakness Single centre, external validity, huge number removed ? VL and difficult airways, only 11 clinicians used, only 110 patients (small patient, small clinician), can’t really generalise this, doesn’t really change practice Training and competence needs to be on the radar