Clinical evaluation of the use of laryngeal tube versus laryngeal mask airway for out-of-hospital cardiac arrest by paramedics in Singapore

INTRODUCTION@#It remains unclear which advanced airway device has better placement success and fewer adverse events in out-of-hospital cardiac arrests (OHCAs). This study aimed to evaluate the efficacy of the VBM laryngeal tube (LT) against the laryngeal mask airway (LMA) in OHCAs managed by emergency ambulances in Singapore.@*METHODS@#This was a real-world, prospective, cluster-randomised crossover study. All OHCA patients above 13 years of age who were suitable for resuscitation were randomised to receive either LT or LMA. The primary outcome was placement success. Per-protocol analysis was performed, and the association between outcomes and airway device group was compared using multivariate binomial logistic regression analysis.@*RESULTS@#Of 965 patients with OHCAs from March 2016 to January 2018, 905 met the inclusion criteria, of whom 502 (55.5%) were randomised to receive LT while 403 (44.5%) were randomised to receive LMA. Only 174 patients in the LT group actually received the device owing to noncompliance. Placement success rate for LT was lower than for LMA (adjusted odds ratio [OR] 0.52, 95% confidence interval [CI] 0.31-0.90). Complications were more likely when using LT (OR 2.82,0 95% CI 1.64-4.86). Adjusted OR for prehospital return of spontaneous circulation (ROSC) was similar in both groups. A modified intention-to-treat analysis showed similar outcomes to the per-protocol analysis between the groups.@*CONCLUSION@#LT was associated with poorer placement success and higher complication rates than LMA. The likelihood of prehospital ROSC was similar between the two groups. Familiarity bias and a low compliance rate to LT were the main limitations of this study.

Comparison of inhalational methoxyflurane (Penthrox®) and intramuscular tramadol for prehospital analgesia

INTRODUCTION@#Treatment of pain is an important component of prehospital care. Inhalational analgesia agents have attractive strengths, but there is a paucity of studies comparing these with more conventional agents. We aimed to compare inhalational methoxyflurane and intramuscular (IM) tramadol as first-contact analgesia in the Singapore national ambulance service.@*METHODS@#Ambulances were randomised to carry either methoxyflurane or IM tramadol for the first six months and crossed over to the other arm after six months. Patients aged ≥ 16 years, with acute pain arising from musculoskeletal trauma with Numerical Rating Scale (NRS) score ≥ 3 were enrolled. Variables included NRS reduction, time variables, adverse effects, Ramsay Sedation Scores, and patient and paramedic satisfaction scores on a Likert scale.@*RESULTS@#A total of 369 patients were enrolled into this study, but 26 patients were excluded due to missing data. The methoxyflurane arm had a shorter median time taken from arrival at the scene to drug administration (9.0 [interquartile range 6.0-14.0] minutes vs. 11.0 [interquartile range 8.0-15.0] minutes). For patients who achieved reduction in NRS ≥ 3 within 20 minutes, those in the methoxyflurane arm took a shorter time. However, the methoxyflurane (46.7%) arm experienced lower proportion of patients not achieving NRS reduction ≥ 3 when compared to the tramadol (71.6%) arm after over 20 minutes. The methoxyflurane arm had significantly higher paramedic and patient satisfaction scores.@*CONCLUSION@#For the doses of medication used in this implementation study, methoxyflurane was superior in efficacy, speed of onset and administration, but had more minor adverse effects when compared to IM tramadol.