Prehospital Airway Management: A Systematic Review.

Objective: To assess comparative benefits and harms across three airway management approaches (bag valve mask [BVM], supraglottic airway [SGA], and endotracheal intubation [ETI]) used by prehospital emergency medical services (EMS) to treat patients with trauma, cardiac arrest, or medical emergencies, and how they differ based on techniques and devices, EMS personnel and patient characteristics. Data sources: We searched electronic citation databases (Ovid® MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus®) from 1990 to September 2020. Review methods: We followed Agency for Healthcare Research and Quality Effective Health Care Program Methods guidance. Outcomes included mortality, neurological function, return of spontaneous circulation (ROSC), and successful advanced airway insertion. Meta-analyses using profile-likelihood random effects models were conducted, with analyses stratified by study design, emergency type, and age. Results: We included 99 studies involving 630,397 patients. We found few differences in primary outcomes across airway management approaches. For survival, there was no difference for BVM versus ETI or SGA in adult and pediatric patients with cardiac arrest or trauma. For neurological function, there was no difference for BVM versus ETI and SGA versus ETI in pediatric patients with cardiac arrest. There was no difference in BVM versus ETI in adults with cardiac arrest, but improved neurological function with BVM or ETI versus SGA. There was no difference in ROSC for patients with cardiac arrest for BVM versus ETI or SGA in adults and pediatrics, or SGA versus ETI in pediatrics. There was higher frequency of ROSC in adults with SGA versus ETI. For successful advanced airway insertion, there was higher first-pass success with SGA versus ETI for all patients except adult medical patients (no difference), and no difference in overall success using SGA versus ETI in adults. Conclusions: The currently available evidence does not indicate benefits of more invasive airway approaches based on survival, neurological function, ROSC, or successful airway insertion. Strength of evidence was low or moderate; most included studies were observational. This supports the need for high-quality randomized controlled trials to advance clinical practice and EMS education and policy, and improve patient-centered outcomes.

Development of the PTSD-Repository: A Publicly Available Repository of Randomized Controlled Trials for Posttraumatic Stress Disorder.

Given the extensive research on posttraumatic stress disorder (PTSD) treatment, a single, updatable repository of data from PTSD treatment studies would be useful for clinical, research, and policy stakeholders. To meet this need, we established a preliminary dataset of abstracted PTSD trial data, which serve as the basis for the PTSD Trials Standardized Data Repository (PTSD-Repository), maintained by the National Center for PTSD (NCPTSD). We followed systematic review methods to identify published randomized controlled trials (RCTs) of PTSD interventions. We consulted with a panel of experts to determine a priori inclusion criteria, ensure that we captured all relevant studies, and identify variables for abstraction. We searched multiple databases for materials published from 1980 to 2018 and reviewed reference lists of relevant systematic reviews and clinical practice guidelines. In total, 318 RCTs of PTSD interventions that enrolled almost 25,000 participants were included. We abstracted 337 variables across all studies, including study, participant, and intervention characteristics as well as results. In the present paper, we describe our methods and define data elements included in the data tables. We explain coding challenges, identify inconsistencies in reporting across study types, and discuss ways stakeholders can use PTSD-Repository data to enhance research, education, and policy. The abstracted data are currently publicly available on the NCPTSD website and can be used for future systematic reviews and identifying research gaps and as an information resource for clinicians, patients, and family members.

Out-of-hospital Circulatory Measures to Identify Patients With Serious Injury: A Systematic Review.

OBJECTIVE: The objective was to systematically identify and summarize out-of-hospital measures of circulatory compromise as diagnostic predictors of serious injury, focusing on measures usable by emergency medical services to inform field triage decisions. METHODS: We searched Ovid MEDLINE, CINAHL, and the Cochrane databases from 1996 through August 2017 for published literature on individual circulatory measures in trauma. We reviewed reference lists of included articles for additional relevant citations. Measures of diagnostic accuracy included sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). Indicators of serious injury included resource need, serious anatomic injury, and mortality. We pooled estimates when data permitted. RESULTS: We identified 114 articles, reporting results of 111 studies. Measures included systolic blood pressure (sBP), heart rate (HR), shock index (SI), lactate, base deficit, and HR variability. Pooled out-of-hospital sensitivity estimates were sBP < 90 mm Hg = 19% (95% confidence interval [CI] = 12% to 29%), HR ≥ 110 beats/min = 28% (95% CI = 20% to 37%), SI > 0.9 = 37% (95% CI = 22% to 56%), and lactate > 2.0 mmol/L = 74% (95% CI = 48% to 90%). Pooled specificity estimates were sBP < 90 mm Hg = 95% (95% CI = 91% to 97%), HR ≥ 110 beats/min = 85% (95% CI = 74% to 91%), SI > 0.9 = 85% (95% CI = 72% to 92%), and lactate > 2.0 mmol/L = 62% (95% CI = 51% to 72%). Pooled AUROCs included sBP = 0.67 (95% CI = 0.58 to 0.75), HR = 0.67 (95% CI = 0.56 to 0.79), SI = 0.72 (95% CI = 0.66 to 0.77), and lactate = 0.77 (95% CI = 0.67 to 0.82). Strength of evidence was low to moderate. CONCLUSIONS: Out-of-hospital circulatory measures are associated with poor to fair discrimination for identifying trauma patients with serious injuries. Many seriously injured patients have normal circulatory measures (low sensitivity), but when present, the measures are highly specific for identifying patients with serious injuries.

Out-of-hospital Respiratory Measures to Identify Patients With Serious Injury: A Systematic Review.

OBJECTIVES: The objective was to systematically review the published literature on the diagnostic accuracy of out-of-hospital respiratory measures for identifying patients with serious injury, focusing on measures feasible for field triage by emergency medical services personnel. METHODS: We searched Ovid MEDLINE, CINAHL, and the Cochrane databases from January 1, 1996, through August 31, 2017. We included studies on the diagnostic accuracy (sensitivity, specificity, and area under the receiver operating characteristic curve [AUROC]) for all respiratory measures used to identify patients with serious injury (resource use, serious anatomic injury, and mortality). We assessed studies for risk of bias and strength of evidence (SOE). We performed meta-analysis for measures with sufficient data. RESULTS: We identified 46 articles reporting results of 44 studies. Out-of-hospital respiratory measures included respiratory rate, pulse oximetry, and airway support. Meta-analysis was only possible for respiratory rate, which demonstrated a pooled sensitivity for serious injury of 13% (95% confidence interval [CI] = 5 to 29, I2  = 97.8%), specificity of 96% (95% CI = 83 to 99, I2  = 99.6%), and AUROC of 0.70 (95% CI = 0.66 to 0.79, I2  = 16.6%). For oxygen saturation, sensitivity ranged from 13% to 63%; specificity, 85% to 99%; and AUROC, 0.53 to 0.76. Need for airway support had a sensitivity of 8% to 53% and specificity of 61% to 100%; studies did not report AUROC. Across respiratory measures, the SOE was low. Other respiratory measures (pH, end-tidal carbon dioxide [CO2 ], and sublingual partial pressure of CO2 ) were reported only in emergency department studies. CONCLUSIONS: Data on the accuracy of out-of-hospital respiratory measures for field triage are limited and of low quality. Based on available research, respiratory rate, oxygen saturation, and need for airway intervention all have low sensitivity, high specificity, and poor to fair discrimination for identifying seriously injured patients.