Welcome to our annual review of the best articles from the finishing year.

This will be a weekly (or so..) appointment with the top (or so…) articles of 2017 divided by topic and chosen by me.

Here is the best (for me) about:

 Advanced Life Support

Here are the best 2017 articles:

• Cardiocerebral and cardiopulmonary resuscitation – 2017 update
• Ventilation rate in adults with a tracheal tube during cardiopulmonary resuscitation: a systematic review
• Favorable neurocognitive outcome with low tidal volume ventilation after cardiac arrest
• Improving CPR Performance
• Association of Mechanical Cardiopulmonary Resuscitation Device Use With Cardiac Arrest Outcomes
• Safety of mechanical chest compression devices AutoPulse and LUCAS in cardiac arrest: a randomized clinical trial for non-inferiority
• Conventional versus chest-compression-only cardiopulmonary resuscitation by bystanders for children with out-of-hospital cardiac arrest
• Post-admission outcomes of participants in the PARAMEDIC trial: a cluster randomised trial of mechanical or manual chest compressions
• Pre-hospital Supraglottic Airway was Associated with Good Neurological Outcome in Cardiac Arrest Victims Especially Who Received Prolonged Cardiopulmonary Resuscitation.
• Cardiac Arrest and Mortality Related to Intubation Procedure in Critically Ill Adult Patients: A Multicenter Cohort Study
• Out-of-hospital airway management during manual compression or automated chest compression devices
• Paramedic Intubation Experience Is Associated With Successful Tube Placement but Not Cardiac Arrest Survival
• Cardiac Arrest and Mortality Related to Intubation Procedure in Critically Ill Adult
  Patients: A Multicenter Cohort Study
• Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival
• Whether to Intubate During Cardiopulmonary Resuscitation
• A multicenter prospective randomized study comparing the efficacy of escalating higher biphasic versus low biphasic energy defibrillations in patients presenting with cardiac arrest in the in-hospital environment
• Double sequential defibrillation for refractory ventricular fibrillation
• Comparative effectiveness of antiarrhythmics for out-of-hospital cardiac arrest: A systematic review and network meta-analysis
• Antiarrhythmics in Cardiac Arrest: A Systematic Review and Meta-Analysis
• Antiarrhythmic drugs for out-of-hospital cardiac arrest with refractory ventricular
  fibrillation
• A retrospective study of Pulseless Electrical Activity, Bedside ultrasound identifies
  interventions during resuscitation associated with improved survival to hospital admission. A REASON Study.
• Rebellions of the Heart: The End of Amiodarone
• Emergent coronary angiography post arrest–Do observational studies provide enough evidence for strong recommendations?
• Distance to invasive heart centre, performance of acute coronary angiography, and angioplasty and associated outcome in out-of-hospital cardiac arrest: a nationwide study
• Post-resuscitation arterial oxygen and carbon dioxide and outcomes after out-of-hospital cardiac arrest.
• The effect of 50% compared to 100% inspired oxygen fraction on brain oxygenation and post cardiac arrest mitochondrial function in experimental cardiac arrest
• Prehospital cooling to improve successful targeted temperature management after cardiac arrest: A randomized controlled trial
• Targeted Temperature Management After Cardiac Arrest: Systematic Review and Meta-analyses
• Targeted Temperature Management for 48 vs 24 Hours and Neurologic Outcome After Out-of-Hospital Cardiac Arrest A Randomized Clinical Trial

My take home messages:

Pathophysiological bases in experimental swine models

• In a swine model following primary cardiac arrest the respiration continues at least for 1 minute. and after that Gasping starts lasting for another minute.
• In a swine model following primary cardiac arrest the blood shifts from high pressure compartment (arteries) to low pressure compartment (veins). 
• In a swine model the PaO2 following primary cardiac untreated VF arrests PaO2 results 70 mmHg after 9 min with a saturation of 93% and decrease at 44 mmHg with a saturation of 61% after 14 min of CPR. In this period airway management with possible interruption of chest compressions and starting positive pressure ventilation (with decreased return to the thorax end depression of cardiac output) is not mandatory due to the low cost/beneficial ratio and the potential detrimental effect. 

Chest compressions

• Chest compressione only CPR is associated with worst outcome in children under 8 yers. Always perform chest compression/ventilation (ratio 15:2) in children <8 years of age (only exception if the cardiac arrest is due to primitive cardiac causes). 
• Chest compressione only CPR can be a valuable option in adult witnessed VF/pulseless VT primary cardiac arrest (delayed airway management and passive O2 administration is reasonable).
• Mechanical chest compression (MCC) is the future of CPR. They still do not demonstrated evident superiority in terms of outcome respect to manual chest compressions, but are evidently not inferior with a similar rate of life treating lesions. For sure MCC avoid variability in quality and allows good quality CC during transport. 

Ventilation

• Lower Tidal volumes following OHCA is independently associated with favourable neurocognitive outcome
• Weak evidences demonstrate that the ideal rate for ventilation of intubated patients  during CPR is 10/min

Airway management

• There is not beneficial effect on outcome with early intubation in Cardiac Arrest (CA). 
• Privilege High Quality CPR and Defibrillation (if needed).
• Use Supraglottic Airway Devices (SAD) in first part (15 min) of resuscitation 
• If Mechanical Chest Compressions is used, to optimise ventilation with SAD, use 30:2 ratio (because the intrathoracic pressure generated during MCC overrules that generated from SAD and impaires ventilation).
• In prolonged Cardiac Arrest management converting SAD to Endotracheal Tube can be considered.
• Experience provider only can perform endotracheal intubation in CA. They have a better chance of first passage rate, without interruption in chest compressions. First pass success rate is positively associated to survival and good neurological outcome.

Defibrillation

• Escalating bilevel energy (150-200-360 Joule) is associated with more efficacy in termination of shock resistant VF/pulselessVT cardiac arrest
• Dual Sequential Defibrillation is feasible and safe. Although the evidences on its beneficial effect on outcome are still lacking it has to be considered in case of CA with refractory shockable rhythm. 

Antiarrhythmics drugs

• There has been no conclusive evidence that any antiarrhythmic agents improve rates of ROSC, survival to admission, survival to discharge or neurological outcomes.

Ultrasound

• Ultrasound in PEA is a key tool to detect CA causes improving survivival.

Post Resuscitation Care

• In post resuscitation phase avoid any arterial oxygen and carbon dioxide abnormality because are associated to increased mortality.
• Centralisation of resuscitated patients toward an acute PCI/CABG capable Center  is associated to better outcome.

Targeted Temperature Management

• Prehospital cooling does not improve faster in-hospital target temperature achieving and due to its costs is not recommended.

If you are interested on a daily update about the best emergency medicine literature follow me on Facebook, Twitter or give your like to MEDEST Facebook page.

Welcome to our annual review of the best articles from the past year.

This will be a weekly (or so..) appointment with the top (or so…) articles of 2017 divided by topic and chosen by me.

At the end of the post I will also mention some take home points as summary of the evidences emerged from the articles. 

And now here is the best (for me) about:

 Airway management

Here are the best articles of the past year about Airway Management:

• Cardiac Arrest and Mortality Related to Intubation Procedure in Critically Ill Adult Patients: A Multicenter Cohort Study
• Apneic oxygenation reduces the incidence of hypoxemia during emergency intubation: A systematic review and meta-analysis
• Intubation using apnoeic oxygenation to prevent desaturation: A systematic review and meta-analysis
• Effectiveness of Apneic Oxygenation During Intubation: A Systematic Review and Meta-analysis
• A prospective, randomised trial of pre-oxygenation strategies available in the pre-hospital environment
• Maintenance of Oxygenation during Rapid Sequence Intubation in the Emergency Department
• Direct Versus Video Laryngoscopy for Prehospital Intubation: A Systematic Review and Meta-analysis
• Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review
• Prehospital Intubation is Associated with Favorable Outcomes and Lower Mortality in ProTECT IIIP
• The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis
• Pre-hospital Supraglottic Airway was Associated with Good Neurological Outcome in Cardiac Arrest Victims Especially Who Received Prolonged Cardiopulmonary Resuscitation.
• The effectiveness of rapid sequence intubation (RSI) versus non-RSI in emergency department: an analysis of multicenter prospective observational study
• Avoidance versus use of neuromuscular blocking agents for improving conditions during tracheal intubation or direct laryngoscopy in adults and adolescents (Cochrane review)
• The Impact of Prehospital Intubation With and Without Sedation on Outcome in Trauma Patients With a GCS of 8 or Less
• Rocuronium vs. succinylcholine for rapid sequence intubation: a Cochrane systematic review
• Effect of patient weight on first pass success and neuromuscular blocking agent dosing for rapid sequence intubation in the emergency department
• Cuffed vs. uncuffed tracheal tubes in children: a randomised controlled trial comparing leak, tidal volume and complications
• Managing Initial Mechanical Ventilation in the Emergency Department
• The myth of the difficult airway: airway management revisited
• Strategies for the prevention of airway complications – a narrative review
• Airway Management in Trauma

My take home messages about airway management:

1. Risk factors for intubation related cardiac arrest are: overweight or obesity, age more than 75 years old, low SBP prior to intubation, hypoxemia prior to intubation, and absence of preoxygenation before intubation procedure.
2. Preoxygenation is crucial (at least 2 minutes), before paralysing, to extend safe apnea time.
3. Use apneic oxygenation during intubation attempts.
4. Tracheal intubation is good in the hands of very well skilled professionals. Otherwise can improve mortality rate.
5. Supraglottic devices perform well in cardiac arrest and are a valuable option for airway management. 
6. Videolaryngoscopy improve glottic view but need training to improve first pass success.
7. Always use paralytics when intubating a non cardiac arrest patient. It improves the chances fo first pass success.
8. Rocuronium and Succynocholine are both valuable options for paralysis in airway management. 
9. Dose Succynocholine, and other depolarising neuromuscular blockade drugs, based on actual body weight. Dose Rocuronium or Vecuronium based on ideal body weight.
10. Use cuffed tracheal tubes even in paediatric patients. They perform well and  complications rate is the same. 
11. The difficult airway is a myth. It’s not  a matter of technique but of decision making.

If you are interested on a daily update about the best emergency medicine literature follow me on Facebook, Twitter or give your like to MEDEST Facebook page.