Join us in our latest Pre-Hospital and Transport Medicine Journal Club, where we take a look at the most recent and relevant literature pertaining to the use of IOs in out-of-hospital cardiac arrest, as well as the impact that pre-hospital intubation has with regards to ROSC success post resuscitative thoracotomy in individuals afflicted by out-of-hospital cardiac arrest secondary to penetrating trauma.
Tibial & Humeral IOs in Out-of-Hospital Cardiac Arrest
Background and Objectives
Expeditious administration of ACLS medications (e.g. epinephrine and antiarrhythmics) may be associated with improved patient outcomes. Peripheral intravenous (PIV) catheterization is the gold standard for medication administration but is slower and more difficult to place than an intraosseous (IO) needle. Limited studies suggest tibial IO (TIO) use is associated with lower survival compared to PIV in out-of-hospital cardiac arrest (OHCA). This study sought to determine the association between first vascular access using PIV, TIO, and humeral IO (HIO) and return of spontaneous circulation (ROSC) at emergency department (ED) arrival.
Methods
This was a retrospective secondary analysis of an American (Portland, OR) cardiac arrest registry using multivariable logistic regression adjusted for potential confounders.
| Population: | Adult patients with non-traumatic OHCA resuscitated by participating emergency medical services (EMS) agencies. |
| Intervention(s): | Initial vascular access strategy using either TIO or HIO. |
| Comparison: | Initial vascular access strategy using PIV. |
| Outcome(s): | ROSC (palpable pulse) at ED arrival.
Secondary outcomes included survival to hospital admission, survival to discharge, and survival with good neurologic recovery, defined as a Cerebral Performance Category (CPC) = 1 or 2. |
Results
First access attempts using TIO or HIO were associated with lower odds of ROSC at ED arrival (adjusted ORs 0.79, 95% CI 0.64-0.98, and 0.75, 95% CI 0.60-0.93, respectively) compared to using PIV first. In stratified analysis, these associations remained for patients with shockable rhythms, but not those with pulseless electrical activity (PEA) or asystole. Overall, there was no difference in adjusted odds of survival to hospital admission, survival to discharge, and survival with good neurologic recovery, but for the subgroup of patients with shockable rhythms, TIO or HIO were associated with lower odds of survival to discharge and survival with good neurologic recovery compared to PIV.
Authors’ Conclusions
“TIO or HIO as first access strategies in OHCA were associated with lower odds of ROSC at ED arrival compared to PIV”.
Limitations
This was a retrospective observational study conducted in a single urban setting with multiple residual confounders and missing data.
Bottom Line
In patients with out-of-hospital cardiac arrest, an initial vascular access strategy using intraosseous access is associated with poorer patient outcomes compared to using peripheral intravenous access. Intraosseous access should be reserved as a rescue strategy when peripheral intravenous access is not feasible or unsuccessful.
Citation
Cameron Benner, Jonathan Jui, Matthew R. Neth, Ritu Sahni, Kathryn Thompson, Jeffrey Smith, Craig Newgard, Mohamud R. Daya & Joshua R. Lupton (28 Nov 2023): Outcomes with Tibial and Humeral Intraosseous Access Compared to Peripheral Intravenous Access in Out-of-Hospital Cardiac Arrest, Prehospital Emergency Care, DOI: 10.1080/10903127.2023.2286621
Impact of Out-of-Hospital Time & Prehospital Intubation on ROSC after Resuscitative Thoracotomy
Background and Objectives
Patients receiving resuscitative thoracotomy for traumatic cardiac arrest have a very low survival rates. In the general trauma population, longer prehospital times are associated with increased mortality. In addition to delaying transport, intubation with positive pressure ventilation may be detrimental to hemodynamically unstable patients for pathophysiologic reasons. Narrowing the selection of patients for resuscitative thoracotomy may improve outcomes. This study sought to determine the association between prehospital intubation and out-of-hospital time, and ROSC and survival in patients with traumatic cardiac arrest requiring resuscitative thoracotomy.
Methods
This was a retrospective cohort study of all trauma activations at two Canadian (Toronto, ON) level-one trauma centres using univariate logistic regression analysis.
| Population: | Trauma patients with absent vital signs on scene, during transport, or in the trauma bay who underwent resuscitative thoracotomy in the ED or in the operating room within 60 min of hospital arrival. |
| Exposure/Intervention(s): | (1) Out-of-hospital time (OOHT), defined as EMS on-scene arrival to hospital arrival in minutes.
(2) Any prehospital intubation attempt. |
| Comparison: | No prehospital intubation attempts (for 2nd intervention above). |
| Outcome(s): | ROSC following resuscitative thoracotomy.
Secondary outcome was survival to hospital discharge. |
Results
There was no association between OOHT time and ROSC or survival to hospital discharge (ORs 1.00, 95% CI 0.97-1.03, and 0.99, 95% CI 0.94-10.5, respectively). Generally, the odds of ROSC for patients with attempted intubation were lower, but this was not statistically significant (OR 0.62, 95% CI 0.33-1.15). Within the (planned) subgroup of patients with penetrating trauma, odds of ROSC when intubation was attempted were reduced (OR 0.39, 95% CI 0.19-0.82, p=0.01). Additionally, the odds of ROSC were lower in patients without prehospital signs of life (SOL) compared to those with prehospital SOL present (OR 0.32, 95% CI 0.15-0.67, p<0.01).
Authors’ Conclusions
“There was a significant association between prehospital intubation and lower likelihoods of ROSC in the penetrating TCA population requiring RT, as well as with the absence of prehospital SOL in all patients. OOHT did not appear to significantly impact ROSC or survival”.
Limitations
This was a retrospective observational study conducted in a single urban setting. Survival following resuscitative thoracotomy is generally very low affecting statistical analysis and ability to control for confounding variables. Data around actual nonperfusion time was limited.
Bottom Line
For patients undergoing resuscitative thoracotomy for cardiac arrest secondary to penetrating trauma, prehospital intubation is associated with a lower probability of return of spontaneous with a trend towards decreased survival. Basic airway interventions should be emphasized over definitive airway control and positive pressure ventilation for critically ill penetrating trauma patients.
Citation
Nada Radulovic, Morgan Hillier, Rosane Nisenbaum, Linda Turner & Brodie Nolan (28 Nov 2023): The Impact of Out-of-Hospital Time and Prehospital Intubation on Return of Spontaneous Circulation following Resuscitative Thoracotomy in Traumatic Cardiac Arrest, Prehospital Emergency Care, DOI: 10.1080/10903127.2023.2285390
If you enjoyed this content and would like to learn more about recent updates in pre-hospital medicine, make sure to check-out our other journal club recaps, by clicking HERE.
