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Why First-Pass Success Matters in Arrest

August 27, 2021

Written by Nickolas Srica

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An increasing number of intubation attempts by EMS was independently associated with worsened odds of survival to hospital discharge with favorable neurologic outcome among patients treated for out-of-hospital cardiac arrest (OHCA).

Why does this matter?
Advanced airway management is an essential component of the management of OHCA and continues to be emphasized in international resuscitation guidelines, though the optimal strategy for this airway management is not well-defined. For those who elect to perform endotracheal intubation, is an increasing number of intubation attempts associated with a lower likelihood of patient survival to discharge with a favorable neurologic status? 

No pressure or anything, but looks like the first time’s the charm…
This was a retrospective, observational cohort study evaluating patients who were treated by the Seattle Fire Department for non-traumatic OHCA who received one or more laryngoscopy attempts during their resuscitation by EMS ALS providers. An attempt was counted anytime the laryngoscope blade was introduced past the teeth and concluded when it was removed from the mouth. The primary outcome was favorable neurologic status at hospital discharge defined as a Cerebral Performance Category (CPC) score of 1 (mild or no deficit) or 2 (moderate disability), with secondary outcomes of ROSC, survival to hospital admission, and survival to hospital discharge. 1,205 patients met inclusion criteria, with 63% being intubated on the first attempt and 86% by the second attempt; 97% of the airways that were completed were endotracheal intubations. The mean (SD) time from ALS arrival to advanced airway completion increased with number of attempts: 1 = 4.9 (2.4) min, 2 = 8.0 (2.9) min, 3 = 10.9 (3.3) min, and >/= 4 = 15.5 (4.4) min. Only 11% of patients survived to hospital discharge, with only 8% total surviving to discharge with a favorable neurologic outcome. In a multivariable adjusted model, the relative odds of surviving to hospital discharge with a favorable neurologic outcome decreased by 59% for every subsequent intubation attempt (adjusted OR 0.41, 95%CI 0.25-0.68). The secondary outcomes including survival to hospital admission, survival to hospital discharge, and ROSC similarly declined as intubation attempts increased. It’s important to again note this was all direct laryngoscopy performed by the EMS providers in this study, and it further illustrates the importance of optimizing your chances of first pass success during endotracheal intubation. Perhaps more standardized utilization of video laryngoscopy or a bougie might be worth considering. Also, if that supraglottic airway is ventilating/oxygenating in the field, it’s probably worth leaving in place until hospital arrival.

Fewer Tracheal Intubation Attempts are Associated with Improved Neurologically Intact Survival following Out-of-Hospital Cardiac Arrest. Resuscitation. 2021 July. doi: 10.1016/j.resuscitation.2021.07.001

What are your thoughts?