Confirmatory methods for endotracheal tube placement in out-of-hospital settings: A systematic review of the literature.

Background: Confirming proper placement of an endotracheal tube (ETT) is important, as accidental misplacements may occur and lead to critical injuries, potentially leading to adverse outcomes. Multiple methods are available for determining the correct ETT placement in prehospital care. Objective: To assess the accuracy and reliability of the different methods used to confirm endotracheal intubation in prehospital settings. Methods: A comprehensive literature search was performed in the MEDLINE, EMBASE, Scopus, and Web of Science databases for studies that were published between 1-June-1992 and 12-June-2022 using a combination of predetermined search terms. Studies that met the inclusion criteria were included and assessed for risk of bias using "Risk of Bias in Non-randomized Studies of Intervention" tool. Results: Of the 1016 identified studies, nine met the inclusion criteria. Capnography and point-of-care ultrasound showed high sensitivity and specificity rates when applied to confirm ETT placement in prehospital care. Other methods including capnometry, colorimetric detectors, ODDs, and auscultation showed varied sensitivity and specificity. Patient comorbidities and device failure contributed to decreased accuracy rates in prehospital care. Capnography was less reliable in distinguishing between endotracheal intubation and right main stem intubation, which is known as a complication in out-of-hospital endotracheal intubation. Point-of-care ultrasound was more accurate and reliable in detecting oesophageal and endobronchial misplacements. ETCO2 monitors, i.e., capnometry and colorimetric detectors, were less reliable in patients with low perfusion states. Conclusion: This systematic review showed that there is no single method with 100% accuracy in confirming the correct ETT placement and detecting the occurrence of accidental oesophageal or endobronchial misplacements in prehospital care. Further studies with a larger sample size are needed to assess the accuracy of multiple confirmatory methods in prehospital settings.

Variability in patient selection criteria across extracorporeal cardiopulmonary resuscitation (ECPR) systems: A systematic review.

BACKGROUND: Across the world, many systems have implemented extracorporeal cardiopulmonary resuscitation (ECPR) as a potential treatment strategy for patients in refractory cardiac arrest. To date, there are no universally accepted criteria for patient selection for ECPR. We conducted a systematic review to explore the variability in patient eligibility criteria for ECPR across systems. METHODS: We searched the Cochrane Library(Wiley), EMBASE(OVID), and MEDLINE ALL (OVID) databases from inception to 5th February-2024 for all studies that described an ECPR system and where the system eligibility criteria was described. A combination of predetermined search terms was used to identify relevant articles. We conducted forward and backward citation tracking to identify any further relevant articles. RESULTS: Our search identified 12,503 articles of which 167 articles were found to be potentially eligible. Seventy-seven articles were further excluded as they described the same ECPR system as another study. We finally included 90 studies describing a total of 93 ECPR systems. The eligibility criteria for ECPR differed among the included systems. Across systems, ECPR eligibility criteria included age (n=75, 80.7%), arrest witnessed status (n=64, 68.8%), any initial rhythm (n=55, 59.1%), and bystander CPR (n=33, 35.5%). Within criteria, we observed marked variability. The age cut-off varied from 50 to 80 years, with the most common age cut-off being 75 years and 18 (19.3%) systems having no cut-off. Whilst most systems limited ECPR to shockable rhythms (n=28,30.1%), some systems included shockable rhythms and/or PEA only (n=10,10.8%). CONCLUSION: We observed marked variability across systems in the eligibility criteria for potential ECPR patients. There is a need for further work to identify the optimum ECPR selection criteria. REVIEW REGISTRATION: PROSPERO (CRD42023451109).

Perception and success rate of using advanced airway management by hospital-based paramedics in the Kingdom of Saudi Arabia.

OBJECTIVE: The study aimed to measure the success rate of pre-hospital tracheal intubation (TI) and supraglottic airway devices (SADs) performed by paramedics for adult patients and to assess the perception of paramedics of advanced airway management. METHOD: The study consisted of two phases: phase 1 was a retrospective analysis to assess the TI and SADs' success rates when applied by paramedics for adult patients aged >14 years from 2012 to 2017, and phase 2 was a distributed questionnaire to assess paramedics' perception of advanced airway management. RESULT: In phase 1, 24 patients met our inclusion criteria. Sixteen (67%) patients had TI, of whom five had failed TI but then were successfully managed using SADs. The TI success rate was 69% from the first two attempts compared to SADs (100% from first attempt). In phase 2, 63/90 (70%) paramedics responded to the questionnaire, of whom 60 (95%) completed it. Forty-eight (80%) paramedics classified themselves to be moderately or very competent with advanced airway management. However, most of them (80%) performed only 1-5 TIs or SADs a year. CONCLUSION: Hospital-based paramedics (i.e. paramedics who are working at hospitals and not in the ambulance service, and who mostly respond to small restricted areas in Saudi Arabia) handled few patients requiring advanced airway management and had a higher competency level with SADs than with TI. The study findings could be impacted by the low sample size. Future research is needed on the success rate and impact on outcomes of using pre-hospital advanced airway management, and on the challenges of mechanical ventilation use during interfacility transfer.