Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

Abstract

IntroductionThe topics reviewed by the International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force are grouped as follows: (1) airway and ventilation, (2) supporting the circulation during cardiac arrest, (3) periarrest arrhythmias, (4) cardiac arrest in special circumstances, (5) identifying reversible causes, (6) postresuscitation care, (7) prognostication, and (8) organ donation. Defibrillation topics are discussed in Part 6.The most important developments and recommendations in advanced life support (ALS) since the 2005 ILCOR review are as follows:The use of capnography to confirm and continually monitor tracheal tube placement and quality of cardiopulmonary resuscitation (CPR).More precise guidance on the control of glucose in adults with sustained return of spontaneous circulation. Blood glucose values >10 mmol L−1 (>180 mg dL−1) should be treated and hypoglycaemia, avoided.Additional evidence, albeit lower level, for the benefit of therapeutic hypothermia in comatose survivors of cardiac arrest associated initially with nonshockable rhythms.Recognition that many of the accepted predictors of poor outcome in comatose survivors of cardiac arrest are unreliable, especially if the patient has been treated with therapeutic hypothermia. There is inadequate evidence to recommend a specific approach to prognosticating poor outcome in post-cardiac arrest patients treated with therapeutic hypothermia.The recognition that adults who progress to brain death after resuscitation from out-of-hospital cardiac arrest should be considered for organ donation.The recommendation that implementation of a comprehensive, structured treatment protocol may improve survival after cardiac arrest.Airway and ventilationConsensus conference topics related to the management of airway and ventilation are categorised as (1) basic airway devices, (2) cricoid pressure, (3) advanced airway devices, (4) confirmation of advanced airway placement, (5) oxygenation, and (6) strategies for ventilation.Basic airway devicesOropharyngeal and nasopharyngeal airwaysALS/BLS-CPR&A-080B Download .pdf (.09 MB) Help with pdf files ALS/BLS-CPR&A-080BConsensus on scienceDespite frequent successful use of nasopharyngeal and oropharyngeal airways in the management of nonarrest patients, there are no published data on the use of these airway adjuncts during CPR in humans. When bag-mask ventilation was undertaken with an oral airway and compared with no oral airway, one study in anaesthetised patients demonstrated higher tidal volumes (LOE 5).1Koga K. Sata T. Kaku M. Takamoto K. Shigematsu A. Comparison of no airway device, the Guedel-type airway and the Cuffed Oropharyngeal Airway with mask ventilation during manual in-line stabilization.J Clin Anesth. 2001; 13: 6-10Abstract Full Text Full Text PDF PubMed Scopus (7) Google ScholarOne study of nasopharyngeal airways in anaesthetised patients showed that nurses inserting nasopharyngeal airways were no more likely than anaesthetists to cause nasopharyngeal trauma (LOE 5).2Chung C.H. Sum C.W. Li H.L. Cheng K.S. Tan P.C. Comparison of nasal trauma associated with nasopharyngeal airway applied by nurses and experienced anesthesiologists.Changgeng Yi Xue Za Zhi. 1999; 22: 593-597PubMed Google Scholar One study showed that the traditional methods of sizing a nasopharyngeal airway (measurement against the patient's little finger or anterior nares) do not correlate with the airway anatomy and are unreliable (LOE 5).3Roberts K. Porter K. How do you size a nasopharyngeal airway.Resuscitation. 2003; 56: 19-23Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar In one report, insertion of a nasopharyngeal airway caused some airway bleeding in 30% of cases (LOE 5).4Stoneham M.D. The nasopharyngeal airway. Assessment of position by fibreoptic laryngoscopy.Anaesthesia. 1993; 48: 575-580Crossref PubMed Google Scholar Two case reports reported inadvertent intracranial placement of a nasopharyngeal airway in patients with basal skull fractures (LOE 5).5Schade K. Borzotta A. Michaels A. Intracranial malposition of nasopharyngeal airway.J Trauma. 2000; 49: 967-968Crossref PubMed Google Scholar, 6Muzzi D.A. Losasso T.J. Cucchiara R.F. Complication from a nasopharyngeal airway in a patient with a basilar skull fracture.Anesthesiology. 1991; 74: 366-368Crossref PubMed Google ScholarTreatment recommendationOropharyngeal and nasopharyngeal airways have long been used in cardiac arrest, despite never being studied in this clinical context. It is reasonable to continue to use oropharyngeal and nasopharyngeal airways when performing bag-mask ventilation in cardiac arrest, but in the presence of a known or suspected basal skull fracture an oral airway is preferred.Cricoid pressureALS-CPR&A-007B Download .pdf (.43 MB) Help with pdf files ALS-CPR&A-007BIn adults and children during ventilation and intubation, does the application and maintenance of cricoid pressure, compared to no cricoid pressure, reduce the incidence of aspiration?Consensus on scienceNo studies addressing the use of cricoid pressure during cardiac arrest were identified. All the identified studies were conducted under anaesthesia or in awake volunteers, cadavers, or manikins. (All studies are therefore LOE 5 for cardiac arrest.) Cricoid pressure in nonarrest patients may, to some extent, protect the airway from aspiration, but it may also impede ventilation or interfere with insertion of an advanced airway.The effect of cricoid presssure on gastric inflation during bag-mask ventilation was examined by two adult (LOE 17Petito S.P. Russell W.J. The prevention of gastric inflation—a neglected benefit of cricoid pressure.Anaesth Intensive Care. 1988; 16: 139-143PubMed Google Scholar; LOE 28Lawes E.G. Campbell I. Mercer D. Inflation pressure, gastric insufflation and rapid sequence induction.Br J Anaesth. 1987; 59: 315-318Crossref PubMed Google Scholar) and two paediatric studies (LOE 2).9Salem M.R. Wong A.Y. Mani M. Sellick B.A. Efficacy of cricoid pressure in preventing gastric inflation during bag-mask ventilation in pediatric patients.Anesthesiology. 1974; 40: 96-98Crossref PubMed Scopus (55) Google Scholar, 10Moynihan R.J. Brock-Utne J.G. Archer J.H. Feld L.H. Kreitzman T.R. The effect of cricoid pressure on preventing gastric insufflation in infants and children.Anesthesiology. 1993; 78: 652-656Crossref PubMed Google Scholar All showed less gastric inflation with cricoid pressure than without, although all of the studies used ventilation volumes higher than those recommended in cardiac arrest.Nine studies in nonarrest adult subjects undergoing anaesthesia showed that cricoid pressure impairs ventilation in many patients, increases peak inspiratory pressures, and causes complete obstruction in up to 50% of patients, depending on the amount of cricoid pressure (in the range of recommended effective pressure) that is applied (LOE 17Petito S.P. Russell W.J. The prevention of gastric inflation—a neglected benefit of cricoid pressure.Anaesth Intensive Care. 1988; 16: 139-143PubMed Google Scholar, 11Allman K.G. The effect of cricoid pressure application on airway patency.J Clin Anesth. 1995; 7: 197-199Abstract Full Text PDF PubMed Scopus (53) Google Scholar, 12Hartsilver E.L. Vanner R.G. Airway obstruction with cricoid pressure.Anaesthesia. 2000; 55: 208-211Crossref PubMed Scopus (100) Google Scholar, 13Hocking G. Roberts F.L. Thew M.E. Airway obstruction with cricoid pressure and lateral tilt.Anaesthesia. 2001; 56: 825-828Crossref PubMed Scopus (22) Google Scholar; LOE 214Mac G.P.J.H. Ball D.R. The effect of cricoid pressure on the cricoid cartilage and vocal cords: an endoscopic study in anaesthetised patients.Anaesthesia. 2000; 55: 263-268Crossref PubMed Scopus (65) Google Scholar; LOE 48Lawes E.G. Campbell I. Mercer D. Inflation pressure, gastric insufflation and rapid sequence induction.Br J Anaesth. 1987; 59: 315-318Crossref PubMed Google Scholar, 15Georgescu A. Miller J.N. Lecklitner M.L. The Sellick maneuver causing complete airway obstruction.Anesth Analg. 1992; 74: 457-459Crossref PubMed Google Scholar, 16Ho A.M. Wong W. Ling E. Chung D.C. Tay B.A. Airway difficulties caused by improperly applied cricoid pressure.J Emerg Med. 2001; 20: 29-31Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 17Shorten G.D. Alfille P.H. Gliklich R.E. Airway obstruction following application of cricoid pressure.J Clin Anesth. 1991; 3: 403-405Abstract Full Text PDF PubMed Google Scholar).One study in anaesthetised patients determined that cricoid pressure prevents correct placement and ventilation with the laryngeal tube (LT) (LOE 1).18Asai T. Goy R.W. Liu E.H. Cricoid pressure prevents placement of the laryngeal tube and laryngeal tube-suction II.Br J Anaesth. 2007; 99: 282-285Crossref PubMed Scopus (8) Google Scholar Eight studies in anaesthetised adults showed that when cricoid pressure was used before insertion of a laryngeal mask airway (LMA), there was a reduced proportion of LMAs correctly positioned, an increased incidence of failed insertion, and impaired ventilation once the LMA had been placed (LOE 119Asai T. Barclay K. Power I. Vaughan R.S. Cricoid pressure impedes placement of the laryngeal mask airway and subsequent tracheal intubation through the mask.Br J Anaesth. 1994; 72: 47-51Crossref PubMed Google Scholar, 20Asai T. Barclay K. Power I. Vaughan R.S. Cricoid pressure impedes placement of the laryngeal mask airway.Br J Anaesth. 1995; 74: 521-525Crossref PubMed Google Scholar, 21Ansermino J.M. Blogg C.E. Cricoid pressure may prevent insertion of the laryngeal mask airway.Br J Anaesth. 1992; 69: 465-467Crossref PubMed Google Scholar, 22Aoyama K. Takenaka I. Sata T. Shigematsu A. Cricoid pressure impedes positioning and ventilation through the laryngeal mask airway.Can J Anaesth. 1996; 43: 1035-1040Crossref PubMed Google Scholar, 23Brimacombe J. White A. Berry A. Effect of cricoid pressure on ease of insertion of the laryngeal mask airway.Br J Anaesth. 1993; 71: 800-802Crossref PubMed Google Scholar; LOE 224Gabbott D.A. Sasada M.P. Laryngeal mask airway insertion using cricoid pressure and manual in-line neck stabilisation.Anaesthesia. 1995; 50: 674-676Crossref PubMed Scopus (20) Google Scholar, 25Xue F.S. Mao P. Li C.W. et al.Influence of pressure on cricoid on insertion ProSeal laryngeal mask airway and ventilation function.Zhongguo Wei Zhong Bing Ji Jiu Yi Xue. 2007; 19: 532-535PubMed Google Scholar, 26Li C.W. Xue F.S. Xu Y.C. et al.Cricoid pressure impedes insertion of, and ventilation through, the ProSeal laryngeal mask airway in anesthetized, paralyzed patients.Anesth Analg. 2007; 104 ([tables of contents]): 1195-1198Crossref PubMed Scopus (13) Google Scholar). No significant impairment to tracheal intubation was found by four LOE-1 studies performed in anaesthetised patients,27Turgeon A.F. Nicole P.C. Trepanier C.A. Marcoux S. Lessard M.R. Cricoid pressure does not increase the rate of failed intubation by direct laryngoscopy in adults.Anesthesiology. 2005; 102: 315-319Crossref PubMed Scopus (44) Google Scholar, 28McCaul C.L. Harney D. Ryan M. Moran C. Kavanagh B.P. Boylan J.F. Airway management in the lateral position: a randomized controlled trial.Anesth Analg. 2005; 101 ([table of contents]): 1221-1225Crossref PubMed Scopus (21) Google Scholar, 29Vanner R.G. Clarke P. Moore W.J. Raftery S. The effect of cricoid pressure and neck support on the view at laryngoscopy.Anaesthesia. 1997; 52: 896-900Crossref PubMed Google Scholar, 30Asai T. Murao K. Johmura S. Shingu K. Effect of cricoid pressure on the ease of fibrescope-aided tracheal intubation.Anaesthesia. 2002; 57: 909-913Crossref PubMed Scopus (18) Google Scholar while seven LOE-1 studies19Asai T. Barclay K. Power I. Vaughan R.S. Cricoid pressure impedes placement of the laryngeal mask airway and subsequent tracheal intubation through the mask.Br J Anaesth. 1994; 72: 47-51Crossref PubMed Google Scholar, 31McNelis U. Syndercombe A. Harper I. Duggan J. The effect of cricoid pressure on intubation facilitated by the gum elastic bougie.Anaesthesia. 2007; 62: 456-459Crossref PubMed Scopus (19) Google Scholar, 32Harry R.M. Nolan J.P. The use of cricoid pressure with the intubating laryngeal mask.Anaesthesia. 1999; 54: 656-659Crossref PubMed Scopus (38) Google Scholar, 33Noguchi T. Koga K. Shiga Y. Shigematsu A. The gum elastic bougie eases tracheal intubation while applying cricoid pressure compared to a stylet.Can J Anaesth. 2003; 50: 712-717Crossref PubMed Google Scholar, 34Asai T. Murao K. Shingu K. Cricoid pressure applied after placement of laryngeal mask impedes subsequent fibreoptic tracheal intubation through mask.Br J Anaesth. 2000; 85: 256-261Crossref PubMed Google Scholar, 35Snider D.D. Clarke D. Finucane B.T. The “BURP” maneuver worsens the glottic view when applied in combination with cricoid pressure.Can J Anaesth. 2005; 52: 100-104Crossref PubMed Google Scholar, 36Smith C.E. Boyer D. Cricoid pressure decreases ease of tracheal intubation using fibreoptic laryngoscopy (WuScope System).Can J Anaesth. 2002; 49: 614-619Crossref PubMed Google Scholar and one LOE-2 study37Heath M.L. Allagain J. Intubation through the laryngeal mask. A technique for unexpected difficult intubation.Anaesthesia. 1991; 46: 545-548Crossref PubMed Google Scholar did show impairment of intubation with increased time to intubation and decreased intubation success rates. One cadaver study demonstrated a worse laryngoscopic view with the application of cricoid pressure (LOE 5).38Levitan R.M. Kinkle W.C. Levin W.J. Everett W.W. Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy.Ann Emerg Med. 2006; 47: 548-555Abstract Full Text Full Text PDF PubMed Scopus (30) Google ScholarTwenty-one manikin studies demonstrated that many providers applied less cricoid pressure than has been shown to be effective (in cadaver studies) whereas many other providers applied more pressure than has been shown to be necessary (and far in excess of the amount of pressure shown to impede ventilation) (LOE 5).39Domuracki K.J. Moule C.J. Owen H. Kostandoff G. Plummer J.L. Learning on a simulator does transfer to clinical practice.Resuscitation. 2009; 80: 346-349Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 40Beavers R.A. Moos D.D. Cuddeford J.D. Analysis of the application of cricoid pressure: implications for the clinician.J Perianesth Nurs. 2009; 24: 92-102Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 41Meek T. Gittins N. Duggan J.E. Cricoid pressure: knowledge and performance amongst anaesthetic assistants.Anaesthesia. 1999; 54: 59-62Crossref PubMed Scopus (62) Google Scholar, 42May P. Trethewy C. Practice makes perfect? Evaluation of cricoid pressure task training for use within the algorithm for rapid sequence induction in critical care.Emerg Med Australas. 2007; 19: 207-212Crossref PubMed Scopus (4) Google Scholar, 43Clark R.K. Trethewy C.E. Assessment of cricoid pressure application by emergency department staff.Emerg Med Australas. 2005; 17: 376-381Crossref PubMed Google Scholar, 44Kopka A. Robinson D. The 50 ml syringe training aid should be utilized immediately before cricoid pressure application.Eur J Emerg Med. 2005; 12: 155-158Crossref PubMed Google Scholar, 45Flucker C.J. Hart E. Weisz M. Griffiths R. Ruth M. The 50-millilitre syringe as an inexpensive training aid in the application of cricoid pressure.Eur J Anaesthesiol. 2000; 17: 443-447PubMed Google Scholar, 46Lawes E.G. Cricoid pressure with or without the “cricoid yoke”.Br J Anaesth. 1986; 58: 1376-1379Crossref PubMed Google Scholar, 47Shimabukuro A. Kawatani M. Nagao N. Inoue Y. Hayashida M. Hikawa Y. Training in application of cricoid pressure.Masui. 2006; 55: 742-744PubMed Google Scholar, 48Schmidt A. Akeson J. Practice and knowledge of cricoid pressure in southern Sweden.Acta Anaesthesiol Scand. 2001; 45: 1210-1214Crossref PubMed Scopus (17) Google Scholar, 49Patten S.P. Educating nurses about correct application of cricoid pressure.AORN J. 2006; 84: 449-461Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 50Ashurst N. Rout C.C. Rocke D.A. Gouws E. Use of a mechanical simulator for training in applying cricoid pressure.Br J Anaesth. 1996; 77: 468-472Crossref PubMed Google Scholar, 51Meek T. Vincent A. Duggan J.E. Cricoid pressure: can protective force be sustained?.Br J Anaesth. 1998; 80: 672-674Crossref PubMed Google Scholar, 52Koziol C.A. Cuddeford J.D. Moos D.D. Assessing the force generated with application of cricoid pressure.AORN J. 2000; 72 (30): 1018-1028Abstract Full Text Full Text PDF PubMed Google Scholar, 53Howells T.H. Chamney A.R. Wraight W.J. Simons R.S. The application of cricoid pressure. An assessment and a survey of its practice.Anaesthesia. 1983; 38: 457-460PubMed Google Scholar, 54Clayton T.J. Vanner R.G. A novel method of measuring cricoid force.Anaesthesia. 2002; 57: 326-329Crossref PubMed Scopus (24) Google Scholar, 55Owen H. Follows V. Reynolds K.J. Burgess G. Plummer J. Learning to apply effective cricoid pressure using a part task trainer.Anaesthesia. 2002; 57: 1098-1101Crossref PubMed Scopus (28) Google Scholar, 56Kopka A. Crawford J. Cricoid pressure: a simple, yet effective biofeedback trainer.Eur J Anaesthesiol. 2004; 21: 443-447PubMed Google Scholar, 57Walton S. Pearce A. Auditing the application of cricoid pressure.Anaesthesia. 2000; 55: 1028-1029Crossref PubMed Scopus (10) Google Scholar, 58Quigley P. Jeffrey P. Cricoid pressure: assessment of performance and effect of training in emergency department staff.Emerg Med Australas. 2007; 19: 218-222Crossref PubMed Scopus (9) Google Scholar, 59Herman N.L. Carter B. Van Decar T.K. Cricoid pressure: teaching the recommended level.Anesth Analg. 1996; 83: 859-863PubMed Google Scholar Four of those studies determined that performance can be improved with training (although many cricoid pressure applications following training remain outside recommended effective pressures).54Clayton T.J. Vanner R.G. A novel method of measuring cricoid force.Anaesthesia. 2002; 57: 326-329Crossref PubMed Scopus (24) Google Scholar, 55Owen H. Follows V. Reynolds K.J. Burgess G. Plummer J. Learning to apply effective cricoid pressure using a part task trainer.Anaesthesia. 2002; 57: 1098-1101Crossref PubMed Scopus (28) Google Scholar, 56Kopka A. Crawford J. Cricoid pressure: a simple, yet effective biofeedback trainer.Eur J Anaesthesiol. 2004; 21: 443-447PubMed Google Scholar, 59Herman N.L. Carter B. Van Decar T.K. Cricoid pressure: teaching the recommended level.Anesth Analg. 1996; 83: 859-863PubMed Google Scholar No study examined if cricoid pressure performance to the required standard could be maintained beyond the immediate post-training period.Cricoid pressure prevented movement of liquid from the oesophagus into the pharynx in 5 cadaver studies (LOE 5)60Fanning G.L. The efficacy of cricoid pressure in preventing regurgitation of gastric contents.Anesthesiology. 1970; 32: 553-555Crossref PubMed Google Scholar, 61Salem M.R. Wong A.Y. Fizzotti G.F. Efficacy of cricoid pressure in preventing aspiration of gastric contents in paediatric patients.Br J Anaesth. 1972; 44: 401-404Crossref PubMed Scopus (34) Google Scholar, 62Vanner R.G. Pryle B.J. Regurgitation and oesophageal rupture with cricoid pressure: a cadaver study.Anaesthesia. 1992; 47: 732-735Crossref PubMed Google Scholar, 63Strang T.I. Does the laryngeal mask airway compromise cricoid pressure?.Anaesthesia. 1992; 47: 829-831Crossref PubMed Scopus (23) Google Scholar, 64Salem M.R. Joseph N.J. Heyman H.J. Belani B. Paulissian R. Ferrara T.P. Cricoid compression is effective in obliterating the esophageal lumen in the presence of a nasogastric tube.Anesthesiology. 1985; 63: 443-446Crossref PubMed Google Scholar; however, in 1 LOE-2 study65Fenton P.M. Reynolds F. Life-saving or ineffective? An observational study of the use of cricoid pressure and maternal outcome in an African setting.Int J Obstet Anesth. 2009; 18: 106-110Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar of 4891 obstetric patients undergoing anaesthesia, no significant difference was observed in regurgitation rates between patients who received cricoid pressure and those who did not. There are case reports where prevention of aspiration is ascribed to the application of cricoid pressure (LOE 4)66Neelakanta G. Cricoid pressure is effective in preventing esophageal regurgitation.Anesthesiology. 2003; 99: 242Crossref PubMed Google Scholar, 67Swayne P. Greenslade G.L. Emergency intubation through the laryngeal mask airway. The effective application of cricoid pressure.Anaesthesia. 1994; 49: 696-697Crossref PubMed Scopus (7) Google Scholar, 68Sellick B.A. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia.Lancet. 1961; 2: 404-406Abstract PubMed Google Scholar and other case reports documenting that aspiration occurs despite the application of cricoid pressure (LOE 4).69Kluger M.T. Short T.G. Aspiration during anaesthesia: a review of 133 cases from the Australian Anaesthetic Incident Monitoring Study (AIMS).Anaesthesia. 1999; 54: 19-26Crossref PubMed Scopus (96) Google Scholar, 70Schwartz D.E. Matthay M.A. Cohen N.H. Death and other complications of emergency airway management in critically ill adults. A prospective investigation of 297 tracheal intubations.Anesthesiology. 1995; 82: 367-376Crossref PubMed Scopus (254) Google Scholar, 71Thibodeau L.G. Verdile V.P. Bartfield J.M. Incidence of aspiration after urgent intubation.Am J Emerg Med. 1997; 15: 562-565Abstract Full Text PDF PubMed Scopus (27) Google Scholar, 72Whittington R.M. Robinson J.S. Thompson J.M. Prevention of fatal aspiration syndrome.Lancet. 1979; 2: 630-631Abstract PubMed Google Scholar, 73Williamson R. Cricoid pressure.Can J Anaesth. 1989; 36: 601PubMed Google ScholarTreatment recommendationThe routine use of cricoid pressure to prevent aspiration in cardiac arrest is not recommended. If cricoid pressure is used during cardiac arrest, the pressure should be adjusted, relaxed, or released if it impedes ventilation or placement of an advanced airway.Knowledge gapsFuture research should address whether cricoid pressure prevents regurgitation and aspiration, the pressure required to be effective, and effectiveness trials evaluating if it can be done well by responders to a cardiac arrest.Advanced airway devicesThe tracheal tube was once considered the optimal method of managing the airway during cardiac arrest. There is considerable evidence that without adequate training or ongoing skills maintenance, the incidence of failed intubations and complications, such as unrecognised oesophageal intubation or unrecognised dislodgement, is unacceptably high.74Bradley J.S. Billows G.L. Olinger M.L. Boha S.P. Cordell W.H. Nelson D.R. Prehospital oral endotracheal intubation by rural basic emergency medical technicians.Ann Emerg Med. 1998; 32: 26-32Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 75Sayre M.R. Sakles J.C. Mistler A.F. Evans J.L. Kramer A.T. Pancioli A.M. Field trial of endotracheal intubation by basic EMTs.Ann Emerg Med. 1998; 31: 228-233Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar, 76Katz S.H. Falk J.L. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.Ann Emerg Med. 2001; 37: 32-37Abstract Full Text Full Text PDF PubMed Scopus (299) Google Scholar, 77Jones J.H. Murphy M.P. Dickson R.L. Somerville G.G. Brizendine E.J. Emergency physician-verified out-of-hospital intubation: miss rates by paramedics.Acad Emerg Med. 2004; 11: 707-709PubMed Google Scholar, 78Wirtz D.D. Ortiz C. Newman D.H. Zhitomirsky I. Unrecognized misplacement of endotracheal tubes by ground prehospital providers.Prehosp Emerg Care. 2007; 11: 213-218Crossref PubMed Scopus (36) Google Scholar, 79Timmermann A. Russo S.G. Eich C. et al.The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians.Anesth Analg. 2007; 104: 619-623Crossref PubMed Scopus (138) Google Scholar Prolonged attempts at tracheal intubation are harmful if associated with interruption of chest compressions because this will compromise coronary and cerebral perfusion. Alternatives to the tracheal tube that have been studied during CPR include the bag-mask and supraglottic airway devices, such as the laryngeal mask airway, oesophageal–tracheal combitube and laryngeal tube, among others. Studies comparing supraglottic airway to tracheal intubation have generally compared insertion time and ventilation success rates. No study has shown an effect of the method of ventilation on survival. There are no data to support the routine use of any specific approach to airway management during cardiac arrest. The quality of CPR with various advanced airways was not included in the review for 2010. The best technique depends on the precise circumstances of the cardiac arrest, local guidelines, training facilities, and the competence of the rescuer.Timing of advanced airway placementALS-SAM-062A Download .pdf (.04 MB) Help with pdf files ALS-SAM-062AIn adult cardiac arrest (prehospital or in-hospital), does an alternate timing for advanced airway insertion (e.g., early or delayed), as opposed to standard care (standard position in algorithm), improve outcome (e.g., return of spontaneous circulation [ROSC], survival)?Consensus on scienceOne registry study evaluated the impact of timing of advanced airway placement during 25,006 in-hospital cardiac arrests (LOE 2).80Wong M.L. Carey S. Mader T.J. Wang H.E. Time to invasive airway placement and resuscitation outcomes after inhospital cardiopulmonary arrest.Resuscitation. 2010; 81: 182-186Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar In this study, earlier time to invasive airway (<5 min) was associated with no improvement in ROSC but improved 24-h survival (NNT = 48). In an urban out-of-hospital setting, intubation in <12 min was associated with better survival than intubation ≥13 min.81Shy B.D. Rea T.D. Becker L.J. Eisenberg M.S. Time to intubation and survival in prehospital cardiac arrest.Prehosp Emerg Care. 2004; 8: 394-399Crossref PubMed Scopus (0) Google Scholar In an out-of-hospital urban and rural setting, patients intubated during resuscitation had better survival than patients not intubated;82Jennings P.A. Cameron P. Walker T. Bernard S. Smith K. Out-of-hospital cardiac arrest in Victoria: rural and urban outcomes.Med J Aust. 2006; 185: 135-139PubMed Google Scholar whereas in an in-hospital setting, patients requiring intubation during CPR had worse survival.83Dumot J.A. Burval D.J. Sprung J. et al.Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of “limited” resuscitations.Arch Intern Med. 2001; 161: 1751-1758Crossref PubMed Google Scholar A recent study found that delayed tracheal intubation bundled with passive oxygen delivery and minimally interrupted chest compressions was associated with improved neurologically intact survival after out-of-hospital cardiac arrest in patients with adult, witnessed, ventricular fibrillation (VF)/ventricular tachycardia (VT).84Bobrow B.J. Ewy G.A. Clark L. et al.Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest.Ann Emerg Med. 2009; 54: 656e1-662e1Google Scholar The independent contribution of the timing of the advanced airway was not available in the study.Treatment recommendationThere is inadequate evidence to define the optimal timing of advanced airway placement during cardiac arrest.Knowledge gapsTo advance the science in this area we need to define what is “early” and what is “delayed” placement of advanced airways, the superiority of advanced airways over simple bag-mask ventilation, and whether there is any significant difference between the advanced airway types.Advanced airway versus ventilation with bag-maskALS/BLS-CPR&A-088A, ALS/BLS-CPR&A-088B Download .pdf (.32 MB) Help with pdf files ALS/BLS-CPR&A-088A Download .pdf (.08 MB) Help with pdf files ALS/BLS-CPR&A-088BIn adult cardiac arrest (prehospital, out-of-hospital cardiac arrest [OHCA], in-hospital cardiac arrest [IHCA]), does the use of supraglottic devices, compared with bag-mask alone for airway management, improve any outcomes (e.g., increase ventilation, increase oxygenation, reduce hands-off time, allow for continuous compressions, and/or improve survival)?Consensus on scienceA retrospective case series (LOE 4) comparing a laryngeal mask air