Commentary to intubation strategy in cardiac arrest victims

Abstract

Grier and Thomas seek to convince the reader that their preference for tracheal intubation in cardiac arrest is justified, whilst at the same time admitting that there is no evidence to support it. In addition, the proposal they make to provide a skilled practitioner working within a specialised team at every out of hospital cardiac arrest is impractical. The best approach to airway management during cardiac arrest is unknown, and the source of considerable controversy [1]. Views range from no airway management (compression-only CPR) to tracheal intubation, and in the absence of high quality randomised trials it is possible to find observational and anecdotal evidence that will support almost any belief. There are only two interventions that are proven to be effective in adult non-traumatic cardiac arrest (which makes up >90% of cardiac arrest cases): high quality continuous chest compressions and defibrillation where appropriate [2]. It is therefore essential that any airway management strategy does not interfere with these, yet tracheal intubation has been shown to be associated with long pauses in chest compressions [3], and where experienced practitioners attempt intubation but fail a return of spontaneous circulation (ROSC) is significantly delayed [4]. In the early stages of adult cardiac arrest not attributable to hypoxia there is a compelling argument for ignoring the airway entirely [5]. This, coupled with increased acceptability, is the main reason for advocating “compression only CPR” for bystanders who witness cardiac arrest, pending emergency medical services (EMS) arrival [6]. For EMS it may be reasonable to provide oxygenation through some form of assisted ventilation, however the best available evidence (meta-analysis of observational data) strongly supports basic airway management (bag-mask ventilation) alone [7]. This may be because it is the “safest” approach for EMS to take, and interrupts chest compressions least. One of the most intriguing possibilities is that the best results are achieved by those with minimal training, who are obliged to concentrate on chest compressions, defibrillation and bag mask ventilation because this is all that is available to