Clinical paperImpact of prehospital airway interventions on outcome in cardiac arrest following drowning: A study from the CARES Surveillance Group
Introduction
Drowning results in more than 360,000 deaths worldwide, $173 million in injury costs in the U.S. annually, and is the 3rd leading cause of unintentional injury death worldwide.1, 2 Prior studies have examined which factors may impact outcomes in drowning patients and some factors include submersion times, earlier EMS arrival with a median of 11 min compared to 21 min, and witnessed status as well as patient characteristics associated with poor outcomes, such as male sex and self-pay insurance.3, 4, 5, 6, 7 Additional studies have focused on Emergency Department-specific predictors of safe discharge in pediatric patients, a population at risk for adverse outcomes in drowning worldwide.8, 9 However, less is known about airway interventions and drowning outcomes in the prehospital environment.
Given the need to correct hypoxemia in drowning, understanding EMS airway interventions and their impact on patient outcomes is crucial to improving care of drowning patients. When examining outcomes of all cardiac arrest patients regardless of etiology, comparisons of advanced airways, supraglottic airway devices (SGA), and bag valve masks (BVM) have shown conflicting results.10, 11, 12, 13 In one case report, a drowning patient was unable to be adequately ventilated with an i-Gel so the crew removed the device and resumed BVM with improvement in chest rise; however, return of spontaneous circulation (ROSC) did not occur.14 One possible explanation for the failure of the SGA device is that higher pressures are required to ventilate drowning patients leading to leakage around the device, though other explanations are possible for the inability to produce chest rise in this particular case. Given the uncertain impact of one type of SGA on drowning patients, further studies will need to determine which airway intervention will improve outcomes and if certain devices and device classes are superior to others.
This study describes the demographics of drowning patients suffering from cardiac arrest and the respective airway management they received. It further evaluates whether patient outcomes differ by airway management method in a large national cohort of drowning patients in the Cardiac Arrest Registry to Enhance Survival (CARES) dataset. More specifically, the aim of this investigation is to determine if advanced airway maneuvers will improve survival to hospital admission as well as survival to hospital discharge and favorable neurological outcomes at discharge.
Section snippets
Methods
The CARES database was developed in 2004 as part of a collaboration between Emory University and the Centers for Disease Control and Prevention to improve outcomes in out-of-hospital-cardiac arrest (OHCA). The CARES database includes data from 28 state-wide registries and from 45 communities in 14 additional states. Its catchment area includes more than 135 million people served by over 1800 Emergency Medical Service (EMS) agencies and more than 2200 hospitals. Participating programs enter
Results
From 2013 to 2018, there were 2416 CARES patients of drowning etiology, of which 28 received an unspecified advanced airway or an advanced airway besides SGA or ETT. Of the remaining 2388 patients, 70.44% (95% CI 68.57–72.23) were male, 41.79% (95% CI 39.83–43.78) were white, and 58.79% (95% CI 56.81–60.75) had a cardiac arrest in a public location. Airway management type was significantly associated with each covariate except gender (Table 1). Airway management type was also significantly
Discussion
The majority of drowning patients (92.13%) in the CARES database had non-shockable rhythms, consistent with the presumed significant hypoxic etiology of the arrest. Just under half (48.70%) received BVM for airway management, and significant differences between airway management types were found when assessing survival to hospital admission and survival to hospital discharge. The SGA group had significantly lower odds of survival to hospital admission compared to ETT, as well as significantly
Limitations
The study of OHCA is difficult as limitations arise in the timing of interventions, the order of airway interventions, the likelihood that patients will remain in arrest due to the initial severe insult, and the impact that the level and skill of the responding providers will have on outcomes. In the CARES database, the order of airway interventions is not recorded, and patients undergoing airway management procedures in cardiac arrest will likely have more than one type of airway intervention,
Conclusion
As correcting hypoxemia is essential in drowning patients, this study attempted to discern the most effective prehospital airway strategy to improve outcomes. In this cohort of drowning patients in cardiac arrest that did not attain sustained ROSC after only BVM, the use of an SGA was associated with statistically significantly lower odds of survival to hospital admission as well as discharge, compared to the use of ETT and BVM, respectively. Odds of survival to hospital discharge with good
Conflict of interest
None.
CRediT authorship contribution statement
Kevin M. Ryan: Conceptualization, Methodology, Formal analysis, Writing - original draft, Writing - review & editing, Project administration. Matthew D. Bui: Conceptualization, Formal analysis, Writing - original draft, Writing - review & editing. Julianne N. Dugas: Conceptualization, Methodology, Formal analysis, Data curation, Writing - original draft, Writing - review & editing, Visualization. Ivan Zvonar: Writing - original draft, Writing - review & editing. Joshua M. Tobin:
Acknowledgments
The authors would like to acknowledge and thank all of the CARES participating sites. A complete list of sites can be found at: https://mycares.net/sitepages/map.jsp
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