Difficult intubation and outcome after out-of-hospital cardiac arrest: a registry-based analysis

Abstract

BackgroundAirway management during resuscitation attempts is pivotal for treating hypoxia, and endotracheal intubation is the standard procedure. This German Resuscitation Registry analysis investigates the influence of airway management on primary outcomes after out-of-hospital cardiac arrest, in a physician-based emergency system.MethodsA total of 8512 patients recorded in the German Resuscitation Registry (2007–2011) were analyzed. The Return of Spontaneous Circulation After Cardiac Arrest (RACA) score was used to compare observed return of spontaneous circulation (ROSC) rates with the ROSC predicted by the score and to analyze factors influencing the primary outcome. Patients were classified into three groups: difficult intubation, impossible intubation, and a control group with normal airways.ResultsThe observed ROSC matched the predicted ROSC in the group with difficult airways. The impossible intubation group had lower ROSC rates (31.3 % vs. 40.5 %; P < 0.05). Impossible intubation was more frequent in men (OR 2.28; 95 % CI, 1.43–3.63; P = 0.001), young patients (OR 2.18; 95 % CI, 1.26–3.76; P = 0.005) and those with trauma (OR 2.22; 95 % CI, 1.01–4.85; P = 0.046). Fewer impossible intubations were reported when the emergency physicians were anesthesiologists (OR 0.65; 95 % CI, 0.44–0.96; P = 0.028). If a supraglottic airway device was not used in the impossible intubation group, the observed ROSC (18.0 %; 95 % CI, 7.4–28.6 %) was poorer than predicted (38.2 %) (P < 0.05).ConclusionsOutcomes after resuscitation attempts are poorer when endotracheal intubation is not possible. Predictive factors for impossible intubation are male gender, younger age, and trauma. Supraglottic airway devices should be used at an early stage whenever these negative factors are present.Electronic supplementary materialThe online version of this article (doi:10.1186/s13049-015-0124-0) contains supplementary material, which is available to authorized users.

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival

“…Limited published data are available on unsuccessful intubation in the global in-hospital setting. However, data from the emergency department 37 and out-of-hospital setting 38 indicate that failed intubation is associated with poor outcomes. Because these patients were classified as having no intubation in the GWTG-R registry, this would potentially bias the results toward the null and therefore probably cannot explain the findings reported herein.…”

External validation of the ROSC after cardiac arrest (RACA) score in a physician staffed emergency medical service system

“…In a previously published study RACA score was used to compare predicted and observed non-traumatic out-of-hospital cardiac arrest ROSC rates over three 5-year time periods in the EMS of Bonn, Germany, showing lower than observed ROSC rates in all time periods [20]. It was also used in another German study to compare ROSC rates in out-of-hospital cardiac arrest patients with difficult or unsuccessful intubations where predicted and observed ROSC rates were similar in the group of difficult intubations, while the unsuccessful intubation group had lower than predicted ROSC rates [21]. ROSC rate was higher than predicted by the RACA score in a study comparing seven different centres in Germany when used as one part of EMS quality assessment [22].…”

Development and validation of an interpretable prehospital return of spontaneous circulation (P-ROSC) score for patients with out-of-hospital cardiac arrest using machine learning: A retrospective study

“…Instead, by providing a predicted ROSC rate, the score has the potential of identifying weak points in the 'chain of survival', enabling comparison of studies conducted in different communities and cohorts, serving as a 'quality indicator' of varying resuscitation strategies and EMS systems. In two European studies, the RACA score was applied to assess the impact of airway management on ROSC rate, 9 and to evaluate the effect of resuscitation staffing. 10 …”