Pre-hospital ETT vs. Laryngeal Airway in Cardiac Arrest Endovascular vs. Thrombolytic Therapy in Proximal Ischemic Stroke
This month we will be exploring a few topics of interest. The first two articles attempt to address the following PICO: P: In out of hospital cardiac arrest patients. I:Are supra-glottic airway devices C: Compared to endotracheal tubes O: Associated with better outcomes(success rates, survival to hosp D/C, etc.) As is the case with most resuscitation data, the quality of available studies has been poor with mostly observational data, small numbers of patients and a host of confounders. Although most of us consider ETT the “definitive” airway, success rates in inexperienced hands particularly in the prehospital environment is poor and ET placement also tends to disrupt effective CPR. Two large RCT’s that attempt to address these questions were recently published in JAMA. One is a “pragmatic” cluster crossover study from Texas that included over 3000 patients and the other was an RCT from England that included over 9000 patients. Do these large RCT’s provided sufficient unbiased data that warrants revisiting prehospital endotracheal intubation in the cardiac arrest victim?
Our second topic is a meta-analysis of RCT’s and registry data from Canada that looks at approaches to stroke management including endovascular thrombectomy alone, thrombolytics plus thrombectomy and thrombolytics alone. If direct thrombectomy was immediately available (STEMI-like) in the proximal occlusion stroke alert patient, would we expect better outcomes and less hemorrhagic complications?
Wang et al, 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.JAMA. 2018 Aug 28;320(8):769-778.
Benger JR et al, Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018 Aug 28;320(8):779-791.
Phan K et al, Direct endovascular thrombectomy and bridging strategies for acute ischemic stroke: a network meta-analysis. J Neurointerv Surg. 2018 Oct 5.