EMS World

NOV 2018

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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THE TRIP REPORT: TURNING RESEARCH INTO PRACTICE 18 NOVEMBER 2018 | EMSWORLD.com I t's not often we see articles dedicated to EMS in the top medical journals. When one of them publishes a manu- script discussing prehospital care, we should all know about it. This month we discuss a JAMA manuscript that's not only interesting but has the potential to change the way we care for victims of out-of-hos- pital cardiac arrest. This study compared laryngeal tube inser- tion to endotracheal tube insertion. The out- come of interest was 72-hour survival follow- ing out-of-hospital cardiac arrest (OHCA). Past studies have compared alternatives to endotracheal intubation (ETI), and many have reported better outcomes with ETI. However, many of these were also observa- tional studies. Randomized trials represent a higher level of evidence than observational studies. The study we review this month is a randomized trial. In fact, it's a multicenter cluster-crossover randomized trial. This means they used multiple EMS agencies in their study (multicenter). Typically random- ization is done at the patient level; however, for this study the agencies were randomized in groups (clusters) to use either laryngeal tubes (LT) or ETI during OHCA. After a pre- determined amount of time, the agencies would switch from one intervention to the other (crossover). There were 27 EMS agencies included. These were associated with U.S. Resuscita- tion Outcomes Consortium (ROC) sites. The ROC is a multicenter network established to conduct OHCA clinical trials. This study was the ROC Pragmatic Airway Resuscitation Outcome Trial (PART). These 27 agencies were split into 13 groups that were random- ized to initially use laryngeal tubes or ETI dur- ing OHCA. They switched interventions after either 3 or 5 months, and crossover could be assigned more than once. The authors did not indicate which specific laryngeal tube was evaluated in this study; however, they noted they only evaluated the LT "because it is the most commonly used supraglottic airway in the United States." The study protocol allowed agencies to use neuromuscular blocking agents or video laryngoscopy, but agencies were only per- mitted to use either LT or ETI for the initial intubation efforts. If the initial effort was unsuccessful, they were then permitted to use any available airway technique, including the other study intervention, other supraglot- tic airways, cricothyroidotomy, etc. It is important to note that the study did not prescribe what clinical care was deliv- ered at the receiving hospitals. In situations where more than just the EMS agency par- ticipating in the study was present on scene, providers from the first-arriving unit deter- mined what treatment was assigned. Besides survival to 72 hours after OHCA, the authors also evaluated secondary out- comes such as return of spontaneous cir- culation, survival to hospital discharge, and favorable neurologic status at discharge. Last month we discussed an intention- to-treat analysis, and the authors here uti- lized this same method for their main data analysis. In short, intention-to-treat analyses evaluate data based on what intervention was supposed to be delivered under the ini- tial randomization, rather than evaluating what intervention was actually delivered. The authors also conducted a per-protocol analysis, which removed cases that were out of compliance with their assigned airway group. Cases where only BVM was utilized were considered compliant. They also con- ducted an as-treated analysis that looked specifically at LT vs. ETI. Results Patients were enrolled in the trial from December 1, 2015 to November 4, 2017. There were 3,004 patients enrolled: 1,505 Which was linked with better 72-hour survival? By Antonio R. Fernandez, PhD, NRP, FAHA LT performed better than ETI in every measure reported. Look for research podcasts based on the topics featured in this column at www.emsworld.com/pcrf-podcasts REVIEWED THIS MONTH 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. Authors: Wang HE, Schmicker RH, Daya MR, et al. Published in: JAMA, 2018; 320(8): 769–78. Laryngeal vs. Endotracheal Tubes After OHCA

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