The clinical significance of a failed initial intubation attempt during emergency department resuscitation of out-of-hospital cardiac arrest patients

Abstract

Objective: Advanced airway management is one of the fundamental skills of advanced cardiac life support (ACLS). A failed initial intubation attempt (FIIA) is common and has shown to be associated with adverse events. We analysed the association between FIIA and the overall effectiveness of ACLS.

Methods: Using emergency department (ED) out-of-hospital cardiac arrest (OHCA) registry data from 2008 to 2012, non-traumatic ED-resuscitated adult OHCA patients on whom endotracheal intubation was initially tried were identified. Prehospital and demographic factors and patient outcomes were retrieved from the registry. The presence of a FIIA was determined by reviewing nurse-documented CPR records. The primary outcome was achieving a return of spontaneous circulation (ROSC). The secondary outcomes were time to ROSC and the ROSC rate during the first 30min of ED resuscitation.

Results: The study population (n=512) was divided into two groups based on the presence of a FIIA (N=77). Both groups were comparable without significant differences in demographic or prehospital factors. In the FIIA group, the unadjusted and adjusted odds ratios (ORs) for achieving a ROSC were 0.50 (95% confidence interval [CI], 0.31-0.81) and 0.40 (95% CI, 0.23-0.71), respectively. Multivariable median regression analysis revealed that FIIA was associated with an average delay of 3min in the time to ROSC (3.08; 95% CI, 0.08-5.80). Competing risk regression analysis revealed a significantly slower ROSC rate during the first 15min (adjusted subhazard ratio, 0.52; 95% CI, 0.35-0.79) in the FIIA group.

Conclusion: FIIA is an independent risk factor for the decreased effectiveness of ACLS.

Keywords: Advanced cardiac life support; Airway management; Intubation; Out-of-hospital cardiac arrest; Resuscitation.