Airway management in out-of-hospital cardiac arrest in Finland: current practices and outcomes

Abstract

BackgroundThough airway management methods during out-of-hospital cardiac arrest (OHCA) remain controversial, no studies on the topic from Finland have examined adherence to OHCA recommendations in real life. In response, the aim of this study was to document the interventions, success rates, and adverse events in airway management processes in OHCA, as well as to analyse survival at hospital discharge and at follow-up a year later.MethodsDuring a 6-month study period in 2010, data regarding all patients with OHCA and attempted resuscitation in southern and eastern Finland were prospectively collected. Emergency medical services (EMS) documented the airway techniques used and all adverse events related to the process. Study endpoints included the frequency of different techniques used, their success rates, methods used to verify the correct placement of the endotracheal tube, overall adverse events, and survival at hospital discharge and at follow-up a year later.ResultsA total of 614 patients were included in the study. The incidence of EMS-attempted resuscitation was determined to be 51/100,000 inhabitants per year. The final airway technique was endotracheal intubation (ETI) in 413 patients (67.3 %) and supraglottic airway device (SAD) in 188 patients (30.2 %). The overall success rate of ETI was 92.5 %, whereas that of SAD was 85.0 %. Adverse events were reported in 167 of the patients (27.2 %). Having a prehospital EMS physician on the scene (p < .001, OR 5.05, 95 % CI 2.94–8.68), having a primary shockable rhythm (p < .001, OR 5.23, 95 % CI 3.05–8.98), and being male (p = .049, OR 1.80, 95 % CI 1.00–3.22) were predictors for survival at hospital discharge.ConclusionsThis study showed acceptable ETI and SAD success rates among Finnish patients with OHCA. Adverse events related to airway management were observed in more than 25 % of patients, and overall survival was 17.8 % at hospital discharge and 14.0 % after 1 year.

33 Systematic review of the effectiveness of prehospital critical care following out-of-hospital cardiac arrest

“…Of the six observational studies included, three studies demonstrated an association between prehospital critical care and improved outcomes after OHCA. [22][23][24] The other three studies did not demonstrate any difference in patientcentred outcomes after OHCA when comparing prehospital critical care with ALS. 17,20,21 We believe that the conflicting findings can be at least partially explained by study design and the logistics of prehospital care for OHCA.…”

“…describe a highly significant association between prehospital physician presence and mid-and long-term survival. 24 However, the authors advise caution when interpreting these results. Dispatch of the prehospital physicians in this Finnish EMS frequently depended on information provided by the first EMS resources at scene.…”

“…For OHCA, the physician team might decide not to attend cases that were deemed futile, 'due to extensive time from collapse to EMS arrival, unsuccessful resuscitation efforts, and the presence of comorbidities'. 24 Targeting the limited resource of prehospital critical care to patients that will benefit is a sensible strategy. However, when it comes to researching the benefit of prehospital critical care for OHCA, it introduces confounding by indication, where patients with better prognostic factors for survival are more likely to receive prehospital critical care than those with a worse prognosis.…”

“…29 In this review, in all publications that compare prehospital critical care with ALS in the same EMS, the critical care group had better prognostic factors. 17,[21][22][23][24] While all of these publications use statistical methods to adjust for this imbalance, there is a strong possibility that unmeasured residual confounding factors bias the results in favour of prehospital critical care.…”

“…The authors point out that prehospital physicians in their study are generally attached to and admit their patients to hospitals which 'typically provide more optimal post-return of spontaneous circulation treatments, including therapeutic hypothermia and percutaneous coronary intervention', and this may be a significant confounding factor. 24 The Finnish EMS provided a three-tiered response to OHCA, with BLS and ALS-trained prehospital emergency care nurses, followed by a third tier of prehospital physicians who were specialists in anaesthesia and critical care. Prehospital physicians attended 41% of OHCA and were able to provide general anaesthesia and cardiovascular support.…”