EMS World

DEC 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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Page 58 of 83

58 DECEMBER 2018 | EMSWORLD.com EVIDENCE-BASED MEDICINE group who actually had it attempted than there were patients who received intu- bation in the ETI group. In other words, more patients in the ETI group had either no air way attempted or an SGA placed in v i o l ati o n of th e p roto co l . B e n ge r suspects this may have been because paramedics felt they were more likely to succeed with the SGA. A sensitivit y analysis was also done in this trial based on the device patients actually received (a s opposed to the intention-to -treat approach of the primar y analysis). This sensitivity analysis looked only at those who had an air way attempted. It found more sur vival in the i-gel group (3.9%) than in the ETI group (2.6%), a significant difference. AIRWAYS-2 had a small number of patients who had CPR performance data available. When compression quality was included in the analysis, there was still no difference in sur vival between i-gel and ETI. This suggests, in this trial at least, compressions were not being interrupted to intubate. There were several interesting ancil- lar y finding s to this study. There wa s more unintentional tube dislodgement and regurgitation after air way placement seen with the i-gel than the ETI. There was no difference in the groups' rates of aspiration pneumonitis, however. My bottom line on this study is that a strateg y of either SGA or ETI a s the initial air way in cardiac arres t is rea- sonable. In fact, when taken together with the PART study, I think that is the main takeaway. If your system doesn't or can't field an oversight, training, and QI program to assure high-performance air way management with ETI, your car- diac arrest patients will most likely do better if you adopt an SGA strateg y. I also wrote a deeper dive on this trial for the FOAMfrat blog: w w w.foamfrat.com/ single-post/2018/09/19/iGel-Faces-Off- Against-ETI-AIRWAYS-2-w-Jeff-Jar vis. Epinephrine in Cardiac Arrest The PARAMEDIC trial (for Prehospital Assessment of the Role of Adrenaline: M e a su rin g th e Ef fe c tive n es s of D ru g Administration In Cardiac Arrest) is a won- derful study for two main reasons. First, that's an awesome acronym, and it was probably worth doing the study just for that. Next, it was a well-done study that aimed to answer a ver y important ques- tion that has eluded definitive answer for years: Does epinephrine improve out- comes in cardiac arrest? 3 Though epinephrine given ever y 3–5 minutes is one of the most fundamental tenets of ACLS, there is little evidence to suppor t it. Whether it is given at 1 mg, 3 mg, or 5 mg, we have yet to show improved neurologically intact sur vival in a prospective study. We have, however, prett y conclusively shown it increases rates of return of spontaneous circu- lation (ROSC) and sur vival to hospital admission. While this may seem like a good thing, if we are only getting pulses back on patients who never wake up or live with devastating disabilit y, we are not really doing those patients any good. With this dearth of information in mind, the U.K. National Health Ser vice funded this large s tud y. It wa s a multicenter study of five NHS ambulance systems that, prospectively and in a double-blind- ed fashion, randomized adult patients with all causes of out-of-hospital car- diac arrest to get either epinephrine 1 mg or normal saline ever y 3–5 minutes. The actual method used for blinding was bril- liant: Researchers prepared special study boxes that contained 10 prefilled 10 ml syringes. These syringes contained 1 mg of either epinephrine or normal saline. Patients would be randomized to a group when the medic opened the box. Because epinephrine is known to be ef fective in anaphylaxis and asthma, patients who ar re s ted w ith th e s e con ditions were excluded from the trial. There were 8,014 patient s enrolled (4,015 getting epi, 3,999 placebo). The Does epinephrine improve post-cardiac arrest outcomes? A large U.K. study sought answers.

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