Background Dynamic changes in end-tidal CO2 (EtCO2) may reflect changes in perfusion and ventilation during cardiopulmonary resuscitation. However, EtCO2 dynamics following vasopressor administration in out-of-hospital cardiac arrest (OHCA) is unknown. We sought to characterize EtCO2 variations after single dose vasopressor administration. Method We performed a secondary analysis from the Pragmatic Airway Resuscitation Trial. We summarized maximal EtCO2 values into one-minute epochs using previously validated automated signal processing. We identified vasopressor administration times using patient records and defibrillator timestamps. We studied changes in EtCO2 morphology after vasopressor administration, including time(minutes) to 15% rise above baseline, time to peak EtCO2, peak proportional change in EtCO2, and duration of EtCO2 over 15%. We compared differences in EtCO2 morphology between return-of-spontaneous circulation (ROSC) and non-ROSC using Mann-Whitney U tests. Results We included 517 patients with EtCO2 recorded during a single dose of vasopressor. 139 patients (27%) achieved ROSC. Lag time (ROSC: 1.87 min, IQR 0.88–3.38 vs. non-ROSC: 1.93 min, IQR 0.77–3.50; p = 0.177) and peak time (ROSC: 3.43 min, IQR 1.44–6.67 vs. non-ROSC: 2.70 min, IQR 1.10–4.99; p = 0.129) were not associated with ROSC. Proportional change in EtCO2 (ROSC: 43.33%, IQR 15.01–105.88 vs. non-ROSC: 24.67%, IQR 4.86–64.10; p < 0.001) and rise duration (ROSC: 4.00 min, IQR 0.50–10.00 vs. non-ROSC: 1.00 min, IQR 0.50–5.75; p < 0.001) were associated with ROSC. Conclusion Following a single dose of vasopressor, EtCO2 increased and remained elevated for longer durations in ROSC patients. EtCO2 changes after vasopressor administration may reflect progression of OHCA resuscitation.

OBJECTIVES:Neuromuscular blockade-assisted airway management is associated with harmful physiologic adverse events, such as hypoxemia, hypotension, bradycardia, and cardiac arrest. The national scope of these events in the prehospital setting is unknown. We sought to estimate the prevalence of adverse events associated with prehospital neuromuscular blockade-assisted airway management in the United States. METHODS:We conducted an observational, cross-sectional study of the 2023 National Emergency Medical Services Information System Public-Release Research Dataset. We included all adult 9-1-1 non-cardiac arrest emergency medical services activations in which neuromuscular blockade-assisted airway management was performed. The primary outcome was the prevalence of hypoxemia, hypotension, and bradycardia within 10 min of neuromuscular blocking agent administration. The secondary outcomes were the timing of adverse events relative to neuromuscular blockade, the odds of adverse events occurring based on vital signs before neuromuscular blockade, and the prevalence of EMS-witnessed cardiac arrest after NMBA administration. RESULTS:Of 54,190,579 9-1-1 emergency medical services activations, there were 11,525 (0.02%) neuromuscular blockade-assisted airway cases. Endotracheal intubation was the first technique performed in 97.5% of cases. First pass success was 80.6%. Overall, 27.5% of patients experienced at least one adverse event in the first 10 min after neuromuscular blockade. The prevalence of hypoxemia, hypotension, bradycardia, and cardiac arrest within 10 min of neuromuscular blockade were 25.0%, 15.0%, 2.7%, and 1.9%, respectively. The odds of an adverse event occurring were higher when vital signs were abnormal before neuromuscular blockade. The presence of preexisting hypoxemia increased the odds of post-neuromuscular blockade hypoxemia by 9.1 (95% CI, 7.9-10.4) and the presence of preexisting hypotension increased the odds of post-neuromuscular blockade hypotension by 16.8 (95% CI, 13.1-21.8). Half of the cases of hypoxemia and hypotension occurred within 6 min (95% CI, 6-7) and 10 min (95% CI, 9-11), respectively. CONCLUSIONS:In this national series, 1 of every 4 patients undergoing neuromuscular blockade-assisted airway management experienced a physiologic adverse event. Emergency medical services agencies that adopt this procedure should implement measures to mitigate adverse events.

Clinical trials are essential for generating evidence-based knowledge to support clinical practice. In the prehospital setting, particular challenges exist in clinical trial design that have a large impact on the quality of the results, including the appropriate and systematic allocation of assigned treatment arm. The Pediatric Prehospital Airway Resuscitation Trial is a multicenter clinical trial evaluating different paramedic airway management strategies on critically ill and injured children in the prehospital setting. The trial assigns airway management strategy using odd-even day pseudo-randomization, which pragmatically balances the rigor of a statistical design that minimizes bias with the complexities of operationalizing a clinical trial in the prehospital setting. We describe the development of 2 technologies to aid in treatment assignment adherence during the trial: (1) a quick response code-linked web application, and (2) a self-contained portable reminder device. These technologies offer novel approaches to support treatment allocation in acute care clinical trials.

Rationale & Objective Acute kidney injury (AKI) frequently complicates acute heart failure (HF), yet predictors of HF-associated AKI remain poorly defined. We examined whether urinary biomarkers of tubular health, measured years before HF hospitalization predict subsequent AKI risk. Study Design Case-control study Setting & Participants Adults ≥45 years in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study hospitalized for acute heart failure (HF). We compared 400 acute kidney injury (AKI) cases with 419 frequency-matched non-AKI controls. Exposures Biomarkers of tubular function (alpha-1 microglobulin [A1M], uromodulin [UMOD], epidermal growth factor [EGF]) and injury (kidney injury molecule-1 [KIM-1]). Outcomes AKI, defined as a serum creatinine rise ≥0.3 mg/dL during HF admission. Analytical Approach Logistic regression adjusted for demographics, comorbidities, urine creatinine, time to HF, eGFR and albuminuria. Results Median time was 5.6 years from baseline to HF. AKI cases exhibited higher A1M and lower UMOD and EGF than non-AKI controls. Higher EGF was strongly associated with lower AKI risk (OR for 4th vs. 1st quartile: 0.27, 95% CI 0.16–0.46), persisting after adjustment for eGFR and albuminuria (OR 0.49, 95% CI 0.27–0.91). Continuous EGF analysis showed a similar trend but was not significant in fully adjusted models (OR per 2-fold increase: 0.89, 95% CI 0.77–1.04). No other biomarkers independently predicted AKI. Limitations Extended time from baseline to HF hospitalization. Conclusions Higher urinary EGF, measured years before HF, is associated with lower risk of AKI during HF hospitalization. Tubular health may be associated with resilience against HF-related kidney injury.

Well-conducted clinical trials are essential to developing our evidence base for medical care. However, the regulatory guidelines and differing operations surrounding clinical trials can be daunting and difficult for new investigators. New investigators often find themselves trying to learn clinical trial management on the go, as this aspect of research is not routinely taught in medical school or residency. To address this problem, this article explains clinical trial startup, including the regulatory and operational aspects of investigator-initiated trials, multicenter trials, and different funding sources (government, foundation, and industry). We also include tables of over 30 common acronyms used in clinical trial operations and discuss common research infrastructure and protocols. The goal of this article is to collate study startup knowledge and materials in one place to build the emergency medicine pipeline of clinical trialists and researchers.

BACKGROUND:Exhaled end-tidal carbon dioxide (EtCO2) trajectory is associated with out-of-hospital cardiac arrest (OHCA) outcomes. However, the minimum EtCO2 monitoring duration needed to discriminate return of spontaneous circulation (ROSC) from non-ROSC remains unknown. We sought to determine the EtCO2 trajectory observation time required to differentiate ROSC from non-ROSC patients. METHODS:We performed a secondary analysis of the cluster-randomized Pragmatic Airway Resuscitation Trial (PART), which assessed endotracheal intubation or laryngeal tube strategies in OHCA resuscitation. We summarized mean EtCO2 in 1-minute epochs over the resuscitation. Cases were stratified a priori by: (1) witnessed versus unwitnessed status, and (2) initial EtCO2: low (≤30 mm Hg), moderate (31-49), and high (≥50). Within each stratum, group-based trajectory modeling (GBTM) was used to identify latent EtCO2 trajectory classes, and patients were categorized into an upward or downward trajectory. To balance trajectory groups on baseline characteristics including age, sex, race, initial rhythm, location, and bystander CPR, we applied inverse probability of treatment weighting. We fit weighted pooled logistic regression models to estimate risk ratios (RRs) for ROSC comparing upward versus downward EtCO2 trajectories. Within each stratum, we identified the earliest minute when CIs between upward versus downward EtCO2 trajectories no longer overlapped. RESULTS:EtCO2 data were available for 1168 patients: 452 (38.6%) witnessed and 716 (61.1%) unwitnessed. Patients were predominantly men (63.5%), with a median age of 65 years (Q1, Q3: 53-75), majority White race (51.3%), and presenting in a nonpublic setting (85.4%). Overall ROSC was 18.2%: 30.5% of witnessed and 10.5% of unwitnessed. Among witnessed arrests, 95% CI for upward versus downward EtCO2 trajectories no longer overlapped at 8 minutes for low initial EtCO2 (RR, 3.06; 95% CI, 1.49, 6.71), 12 minutes for moderate EtCO2 (RR, 1.95; 95% CI, 1.23, 3.48), and 21 minutes for high EtCO2 (RR, 2.12; 95% CI, 1.30, 3.73). Among unwitnessed arrests, nonoverlapping CIs were first observed at 7 minutes (RR, 3.56; 95% CI, 1.53, 10.37). CONCLUSIONS:Depending on witness status and initial EtCO2, between 7 and 21 minutes of monitoring are needed to reliably differentiate upward from downward EtCO2 trajectories during OHCA resuscitation. Dynamic EtCO2 trajectory monitoring may provide early prognostic information to guide resuscitation.

OBJECTIVES:Injury mechanisms play a critical role in determining the need for advanced airway management during prehospital trauma care. While prior studies have examined airway interventions in the context of physiological compromise or specific clinical conditions, few have evaluated how airway device use varies across trauma mechanisms (e.g., falls, motor vehicle collisions). Understanding which injury types are most associated with airway placement, and which airway devices are most commonly used, can help emergency medical service (EMS) clinicians anticipate airway needs and inform trauma system preparedness. METHODS:We analyzed 2023 data from the National Emergency Medical Services Information System (NEMSIS) to evaluate 9-1-1 trauma activations with documented advanced airway device placement (endotracheal intubation [ETI], supraglottic airway [SGA], and cricothyrotomy [Cric]). Injury causes were categorized based on clinically relevant categories derived from the 20 most common ICD-10 trauma codes. Airway use was described by patient age, sex, urbanicity, incident location, EMS system response, scene, and transport times. Age-stratified airway use rates (per/1,000 trauma activations) were calculated for pediatric (≤15), adult (16-64), and geriatric (≥65) patients. RESULTS:Among 5,716,650 trauma activations in 2023, 18,628 (3.6 per/1,000) involved advanced airway placement: ETI-only (13,452; 72.2%), SGA-only (3,544; 19.0%), Cric-only (110; 0.6%), and multiple airways (1,522; 8.2%). Patients were primarily male (75.0%) with a median age of 48 years (IQR: 30-66), found in urban areas (81.2%), on street/highway (40.0%) locations, with over half experiencing out-of-hospital cardiac arrest (55.8%). Falls (29.0%) and motor vehicle collisions (MVCs) (21.0%) accounted for the largest frequency of airway placements, while firearm-related injuries (51.9/1,000) and motorcycle accidents (16.1/1,000) had the highest airway use rates across all age groups. Cricothyrotomy was most commonly performed in firearm-related trauma (39.1%). Among patients with scene and transport times <60 min, median scene and transport times differed across airway types. CONCLUSIONS:Advanced airway placement occurred in approximately 4 of every 1,000 EMS trauma activations. While falls and MVCs were the most frequent injury types, firearm-related injuries and motorcycle accidents had the highest incidence of airway use. These findings highlight high-risk scenarios for airway intervention and may inform EMS training, triage, and airway preparedness strategies.

Background:Pediatric out-of-hospital cardiac arrests (pOHCA) are low frequency, high acuity events for Emergency Medical Services (EMS). The survival rate is low, with only 10% of children surviving, and few survivors having favorable neurologic outcomes. Optimal prehospital management of pOHCA includes rapid epinephrine administration, yet factors contributing to its administration are not well understood. Objective:Our study objective was to evaluate the frequency of epinephrine administration in pOHCA. Our secondary objective was to characterize the demographic and clinical characteristics associated with epinephrine administration in pediatric OHCA in the United States. Methods:In this retrospective, observational study, we analyzed data from the National Emergency Medical Services Information System (NEMSIS) dataset for the year 2021. We identified pediatric patients ages ≥1 day-old to <18 years-old from "9-1-1" activations that were treated by advanced life support (ALS) clinicians. OHCA events were identified by performance of cardiopulmonary resuscitation (CPR) or defibrillation. We used descriptive statistics to evaluate the frequency of epinephrine administration and assess demographic and clinical characteristics in this population. Multivariable logistic regression model was utilized to find characteristics associated with epinephrine administration. Results:In 2021, 8495 pOHCA events (median [IQR] age: 3.0 [0.3-13.0] years; 58.5% males) were managed by an ALS unit in the United States. Two out of every five (40.2%) pOHCA events did not receive epinephrine. Epinephrine use was more common in younger age groups (1 day-1 year OR, 1.25 [95% CI, 1.07-1.46]; 1-5 years OR, 1.19 [95% CI, 1.00-1.38]; 6-12 years OR, 1.59 [95% CI, 1.24-1.79]; referent: 13-17 years), urban population settings (OR, 2.06 [95% CI: 1.79-2.38]), incidents with scene time >10 min (OR, 1.41, [95% CI, 1.25-1.60]), advanced airway attempt(OR 8.33, [95% CI, 7.33-9.47]), and in those receiving defibrillation (OR 1.95, [95% CI, 1.61-2.37]). Odds of epinephrine administration were lower in public settings (OR 0.55, [95% CI, 0.47-0.65]) and in females (OR 0.83, [95% CI, 0.73-0.93]). Conclusion:Epinephrine is not given in 2 of every 5 pOHCA events. Longer scene time and additional resuscitation interventions were associated with epinephrine administration. The low rate of administration has implications for further research and reforms in the prehospital care of critically ill children.

Introduction Supraglottic airways (SGA) are common advanced airway devices for out-of-hospital cardiac arrest (OHCA) that are simpler to place than endotracheal tubes. Little is known about SGA placement by emergency medical technicians (EMTs). We sought to evaluate SGA placement by EMTs for OHCA. Methods We retrospectively studied the 2019-2023 NEMSIS database. We included adult OHCAs with SGA insertion on first airway attempt. We stratified encounters by the credentials of the provider placing the SGA: EMTs and paramedics. We evaluated the change in SGAs placed by EMTs over time using Cochran-Armitage tests and the number of Emergency Medical Services (EMS) agencies with EMT-placed SGAs over time, and we evaluated regional variation. Using mixed-model logistic regression and compared to paramedics, we evaluated the association between EMT-placed SGAs and first-pass success. Results SGA placement occurred in 189,307 OHCAs: 41,035 (21.7%) placed by EMTs, 148,272 (78.3%) placed by paramedics. EMT placed SGAs increased from 3,140 (20.6%) in 2019 to 10,371 (23.3%) in 2023 (p<0.01). The number of EMS agencies with EMT-placed SGAs also increased from 664 (38.0%) in 2019 to 1,525 (51.7%) in 2023. The regions with the highest proportions of EMT placed SGAs were West North Central (38.9%), East North Central (31.4%), and Mountain (25.0%). First-pass success (SGA) was slightly lower for EMTs (93.7% v 94.3% for paramedics, aOR 0.93 [0.89-0.98]). Conclusion The proportion of SGAs placed by EMTs and the proportion of EMS agencies with EMT-placed SGAs have increased over time. The FPS rate was similar between EMT and paramedic-placed SGAs.

Background While prompt defibrillation is a key intervention in out-of-hospital cardiac arrest (OHCA), it remains unknown whether the time to first shock delivery by emergency medical services (EMS) clinicians varies across patients’ races and ethnicities. Methods This retrospective cohort study included adults (≥ 18 years) with nontraumatic initially shockable OHCA in the Pragmatic Airway Resuscitation Trial, a cluster randomized control trial, comparing the effects of laryngeal tube and endotracheal intubation at 27 EMS agencies in the US from 2015 through 2017. We compared the differences in restricted mean survival time (RMST) of time from EMS arrival on the scene to the first shock delivery: the average time-to-event duration in survival analysis, across non-Hispanic White (hereafter, White), non-Hispanic Black (hereafter, Black), and Hispanic patients, with and without adjustment for patient demographics and cardiac arrest characteristics. Results Four hundred thirty-four individuals (White: 303, Black: 103, Hispanic: 28) were included. The median interval between EMS arrival and shock delivery was 4.3 minutes (IQR 3.0–7.2) in White, 5.2 minutes (IQR 3.4–7.8) in Black, and 5.0 minutes (IQR 3.6–9.0) in Hispanic patients. The unadjusted RMST was 6.37 minutes (95% CI 5.78–6.97) for White, 7.47 minutes (95% CI 6.36–8.57) for Black, and 9.47 minutes (95% CI 6.62–12.33) for Hispanic patients. Compared to White patients, the unadjusted RMST differences were 1.10 minutes (95% CI -0.16–2.35) for Black and 3.10 minutes (95% CI 0.18–6.02) for Hispanic patients, and the adjusted RMST differences were 0.42 minutes (95% CI -0.88–1.72) for Black patients and 3.25 minutes (95% CI 0.43–6.07) for Hispanic patients. Conclusions In this cohort study, compared to White patients, Hispanic patients had longer time from EMS arrival to first shock delivery, whereas time to shock delivery in Black patients was not significantly different.

Importance:During out-of-hospital cardiac arrest (OHCA), initial airway device choice as well as final device choice in the event of failure may both influence overall procedural success and patient outcomes. Understanding national practice patterns in airway device placement may inform resuscitation strategies and system-level quality improvement. Objective:To assess patterns in the order of advanced airway device use for adults in the United States receiving OHCA treatment during emergency medical service (EMS) activations. Design, Setting, and Participants:This retrospective cross-sectional study used data from the National EMS Information System (NEMSIS) database from January 2018 to December 2023. During this period, NEMSIS included more than 256 million EMS activations from nearly 14 000 agencies across 54 states and territories. Activations for 911 responses during adult OHCA with advanced airway device attempts after EMS arrival, with documented success (yes or no) and number of attempts, were included. Exposures:Advanced airway devices documented by EMS clinicians. Main Outcome and Measures:Order of advanced airway device use, measured by EMS clinician documentation. Results:From 2018 to 2023, EMS reported 2 365 224 activations involving adults having an OHCA, with 650 440 patients (0.3%) receiving either endotracheal intubation (ETI) and/or supraglottic airway (SGA). Most patients received a successful initial airway device attempt (503 774 [77.4%]). Although ETI was the most common initial airway device (458 546 [70.5%]), SGA had a higher first-pass success rate (93.0% vs 71.0%). Among patients whose first ETI attempt failed (133 177 of 458 546 [29.0%]), the final documented device remained ETI in 72 167 cases (72.3%) and changed to SGA in 27 651 (27.7%). Among patients whose first SGA attempt failed, 13 480 (61.9%) remained with SGA and 3388 (38.1%) were switched to ETI. Conclusions and Relevance:In this cross-sectional study, most patients with OHCA received ETI as the first advanced airway procedure, despite higher SGA first-pass success. Among patients whose initial attempt failed, most continued with the same device. However, switching from ETI to SGA had a higher final success rates. These findings highlight the importance of airway device sequence in prehospital care and may inform training and protocols for airway management.

Community Consultation and Public Disclosure (CC/PD) are essential ethical requirements for clinical trials conducted under Exception from Informed Consent (EFIC). Traditional CC/PD approaches, such as advertisements, manual surveys, and inperson meetings, are often resource-intensive and limited in scale, geographic reach, and community representativeness. Digital technologies, such as social media campaigns, digital survey panels, and virtual video conferencing, offer new modalities to disseminate information, solicit feedback, and facilitate bidirectional dialogue with community populations. Digital CC/PD strategies can expand measurable reach, shorten implementation timelines, and provide quantifiable indices of engagement while maintaining acceptability among Institutional Review Boards. When deployed alongside local engagement activities, digital technologies offer additional tools that may strengthen the practical conduct of CC/PD. This review summarizes contemporary digital approaches to CC/PD and highlights their impact on modern emergency care research.

Background:Emergency care trials may require compliance with federal Exception from Informed Consent (EFIC) regulations, including community consultation (CC) and public disclosure (PD). The reach of traditional CC and PD modalities is limited. We describe the application of novel digital engagement tools to enrich CC and PD in a pediatric emergency care trial. Methods:In support of EFIC CC and PD efforts for the Pediatric Prehospital Airway Resuscitation Trial (Pedi-PART), a multicenter trial of paramedic airway management in critically ill children, we deployed two digital engagement tools: 1) social media advertisements, and 2) marketing research panels. We disseminated social media advertisements (Facebook and Instagram) describing the study to targeted users in 10 communities. We determined social media advertisement impressions and engagements (shares, reactions, saves, comments, likes and clicks). We also disseminated community surveys using a marketing research panel (Qualtrics Marketing Research Services), determining the number of completed surveys, time to achieve 200 surveys, demographics of survey respondents and percentage with supportive responses. Results:There were 23.3 million social media advertisement impressions (range 1.8-2.7 million per community) reaching 3.4 million unique users (range 239,494-439,360 per community) and resulting in 13,873 engagements (range 828-1,656 per community). Distribution of the community survey through the marketing research panel resulted in 6,771 completed surveys (range 531-914 per community). Across communities, time to 200 completed surveys ranged from 5-28 days. Survey respondents were 61.9% female, 27.0% minority race and 40.8% household income <$50,000. Most survey respondents (90.7%) supported the trial. Conclusions:Digital engagement tools efficiently reached a large and diverse population and yielded key community feedback to inform research trial deployment. Digital engagement tools offer valuable techniques to enrich EFIC CC and PD efforts.

INTRODUCTION:Airway management is one of the most important interventions performed by paramedics in the prehospital setting. While the standard of care for over 40 years, multiple studies highlight pitfalls associated with prehospital airway management in adults. Considerably less research describes prehospital airway management in children. AREAS COVERED:We searched PubMed for articles from 2000 to present using the keywords 'children,' 'airway management,' 'intubation intratracheal,' 'Emergency Medical Services,' and 'paramedic.' Studies highlight the pitfalls of adult prehospital endotracheal intubation such as tube misplacement and dislodgement, multiple and failed insertion attempts, interruptions in chest compressions, and inadvertent hyperventilation. Multicenter clinical trials including the PART and Airways-2 trials support the use of newer supraglottic airways as potential alternatives to intubation in adults. Only limited data describe prehospital airway management in children, including only one clinical trial performed 25 years ago. EXPERT OPINION:New studies are needed to guide paramedic pediatric airway management practices. The Pediatric Prehospital Airway Resuscitation Trial (Pedi-PART) is an ongoing multicenter clinical trial that will provide critical new knowledge to guide prehospital pediatric airway management practices.

OBJECTIVES:ImageTrend Collaborate (ITC) is a new dataset of emergency medical services (EMS) patient care events. While offering a new option for prehospital research, it is unclear if ITC data accurately reflects EMS event characteristics across the United States. Our objective was to assess the national representativeness of the ITC dataset. METHODS:We performed a cross-sectional study comparing the 2022 ITC with the 2022 National EMS Information System (NEMSIS) research dataset, a federally funded national EMS data repository. We compared 9-1-1 EMS activations across call (e.g., agency level of service, urbanicity, census region), patient (e.g., age category, sex, dispatch complaint, response time, primary symptom, primary impression), and intervention (e.g., procedures) characteristics. We quantified absolute proportional differences (PD, ITC% - NEMSIS%) with 95% confidence intervals (CI) and standardized mean differences (SMD) to evaluate the effect size of observed differences. RESULTS:We included 9,592,122 EMS events in ITC and 41,997,730 in NEMSIS. ImageTrend Collaborate included a higher proportion of fire-based agencies (PD 8.2, SMD 0.16) and Advanced Emergency Medical Technicians (PD 2.1, SMD 0.12) and lower proportion of volunteer agencies (PD -1.4, SMD -0.12). Census Region differences included West (PD 13.9, SMD 0.31), Northeast (PD -11.0, SMD -0.33), and Midwest (PD -5.2, SMD -0.14). Age, sex, dispatch complaint, and primary impression had absolute proportional differences less than 1.0% with SMD less than 0.10 (i.e., negligible) except for "sick person" dispatch (PD -3.0, SMD -0.08) and "other general" primary symptom (PD -1.5, SMD -0.11). Median response times were identical in both databases. The most common procedures were similar between the datasets, but differed in proportion, including: catheterization of vein (PD -4.8, SMD -0.12), 12 lead electrocardiogram (PD -7.9, SMD -0.22), and evaluation procedure (PD -3.8, SMD -0.15). CONCLUSIONS:ImageTrend Collaborate reflects most national EMS call, patient, and intervention characteristics. Notable and expected differences between ITC and NEMSIS include fire-based agency and census region representation, likely due to self-selection; however, differences in procedures may reflect tradeoffs between granularity of a single vendor dataset versus an aggregated national dataset. Prehospital researchers should understand the characteristics of the ITC dataset to ensure proper use and analysis.

Background Advanced airway devices facilitate ventilation and oxygenation during out-of-hospital cardiac arrest (OHCA). Differences in gas exchange between advanced airway devices are unknown. Objective Characterize arterial blood gases (ABG) in laryngeal tube (LT) or endotracheal intubation (ETI) cases in the Pragmatic Airway Resuscitation Trial (PART). Methods We included adult OHCAs with ABG collected ≤ 1.5 h after emergency department (ED) arrival. We collected 1) last prehospital airway technique used 2) ABG measurements (pH, PaO2, PaCO2), and 3) average prehospital end-tidal capnography (EtCO2) values for the last five minutes. We compared airway types, ABG values, and PaCO2-EtCO2 absolute difference (PaCO2-EtCO2) using the Mann-Whitney test, stratifying by circulation status. We also determined prehospital EtCO2 and ED PaCO2 correlation. Results Of 3004 cases, 401 met inclusion with 272 LT and 129 ETI. Among cases achieving return of spontaneous circulation (ROSC), pH (7.1 vs. 7.2, p = 0.10) and PaO2 (142 vs 170 mmHg, p = 0.08) did not differ. PaCO2 was higher in LT than ETI (58 vs 50 mmHg, p = 0.003). Among cases without ROSC, pH (7.0 vs. 7.0, p = 0.55) and PaCO2 (64 vs. 61 mmHg, p = 0.58) did not differ, but PaO2 was lower in LT than ETI (85 vs. 123 mmHg, p = 0.03). EtCO2 did not correlate with PaCO2 in any airway device/ROSC combination. PaCO2-EtCO2 difference was wider in both LT and ETI non-ROSC cases compared to ROSC cases (27 vs 18 mmHg, p = 0.03). Conclusions ABG values may vary by prehospital advanced airway management methods. The correlation between EtCO2 and PaCO2 in OHCA patients remains unclear.

OBJECTIVES:Ventilation is important in out-of-hospital cardiac arrest resuscitation; however, few studies describe ventilation rates during pediatric out-of-hospital cardiac arrest (pOHCA). Our objective was to characterize ventilations and end-tidal capnography (EtCO2) after advanced airway placement by emergency medical services (EMS) during pOHCA resuscitation. METHODS:This was a retrospective cohort study that included pediatric (age < 18 years) non-traumatic OHCA treated by an urban fire-based EMS system (Columbus Division of Fire, Columbus, Ohio) from April 2019 to December 2020. We identified ventilations delivered during resuscitation by manual review of continuous EtCO2 recorded by cardiac monitors. We also identified ventilations using automated detection algorithms previously validated in adult resuscitation. Mean ventilation rate and EtCO2 were summarized in one-minute (min) epochs from advanced airway insertion through end of resuscitation efforts. We compared return of spontaneous circulation (ROSC) vs non-ROSC ventilation rates using Student's t-tests. Cochran-Armitage test of trend was used to evaluate EtCO2 temporal trends. Associations between ROSC and EtCO2 were tested using a regression model. RESULTS:We identified 38 pOHCA cases and 30 cases were included for ventilation analysis. Cases were primarily infants (0.7 years, IQR 0.17-2), male (52.6%), and African-American race (63.1%). Most pOHCAs were unwitnessed (65.8%) with non-shockable rhythms (94.8%) and infrequent bystander cardiopulmonary resuscitation (31.2%). Eight patients achieved ROSC (21.2%) and two patients survived (5.3%). Advanced airway attempts included supraglottic airway devices (71.1%), endotracheal intubation (7.8%), or both (7.8%). Ventilation rates ranged from 0-23 per minute. Automated ventilation detection algorithms performed well in pediatric ventilation detection where the mean standard error was 3.7 mmHg in EtCO2 values and 1.3 per minute in ventilation rates. Ventilation rates differed between ROSC and non-ROSC groups (9.2 vs 6.9 per min, p < 0.001). Ranges of EtCO2 values included 0-100 mmHg during resuscitation. The EtCO2 trends over time differed between ROSC and non-ROSC groups (59.82 mmHg to 75.9 mmHg vs 20.7 mmHg to 19.0 mmHg, p < 0.01). EtCO2 was significantly associated with ROSC (OR 1.0 95% CI 1.00-1.01, p < 0.001). CONCLUSIONS:These results offer one of the first perspectives of ventilation in pOHCA. Differences were observed in ventilation rates and EtCO2 trends between ROSC and non-ROSC cases.

BACKGROUND:Community consultation (CC) is crucial for exception from informed consent (EFIC) trials. Digital marketing platforms offer a novel and efficient way to gather community input through surveys. This study aimed to determine if the demographics of digital CC survey respondents align with those of their targeted communities. METHODS:We deployed an EFIC CC digital survey for Pedi-PART, a multicenter study on paramedic airway management in critically ill children. A seven-item survey, developed to gauge community perspectives on emergency care research and the trial, was disseminated through a digital marketing platform (Qualtrics Inc.). The survey targeted adults aged 18-65 residing within the geographic service areas of 10 participating EMS agencies. We determined community demographic data from the 2022 American Community Survey (ACS) for the dominant county in each service area. We compared survey respondent demographics (age, sex, race, ethnicity, household income, education) with those of the corresponding communities. RESULTS:We received 6630 completed surveys (528 to 913 per community). The proportion of individuals over 35 years old was similar between survey and community populations (67.1% vs. 66.5%). Survey respondents were more likely to be female (60.0% vs. 50.9%) and report household incomes < $100,000 (77.5% vs. 60.2%). Survey respondents were less likely to be Black, American Indian, Pacific Islander, or other race (33.9% vs. 52.1%), Hispanic ethnicity (15.3% vs. 34.9%), or have at least a high school education (23.2% vs. 34.9%). Demographic differences between survey respondents and communities varied across the 10 communities. CONCLUSIONS:Demographic differences may exist between digital survey respondents and their targeted communities. Study teams should account for these factors when utilizing such platforms for EFIC CC.

Background Over 70% of patients with out-of-hospital cardiac arrest (OHCA) present with a non-shockable initial rhythm, asystole or pulseless electrical activity (PEA), which is associated with lower survival than a shockable initial rhythm. Advanced airway management and oxygen delivery are important OHCA interventions, but their impact based on different presenting rhythm groups are incompletely defined. Our objective was to determine if advanced airway strategy is associated with outcomes in shockable, PEA and asystolic OHCA. Methods We performed a secondary analysis of data collected from the Pragmatic Airway Resuscitation Trial (PART), which assigned adults with OHCA to a strategy of either endotracheal intubation (ETI) or laryngeal tube (LT) for initial advanced airway management. We stratified patients by initial cardiac rhythm: shockable (ventricular fibrillation/pulseless ventricular tachycardia (pVT), AED shock), PEA or asystole. We excluded AED non-shockable and unknown rhythms. The primary outcome was 72-h survival. Secondary outcomes included return of spontaneous circulation (ROSC) at emergency department arrival, survival to hospital discharge, and survival with good neurological function (modified Rankin score ≤3). We used general estimating equations to determine the associations between airway strategy initial arrest rhythm and outcomes, adjusted for age, sex, witnessed status, and bystander CPR. Results There were 3004 patients in the parent trial of which 2847 were included in this analysis. Of these 575 (20.2 %) were shockable, 671 (23.6 %) were PEA, and 1601 (56.2 %) were asystole. Compared with ETI, LT airway use was not associated with improved 72-h survival in shockable rhythms (adjusted [AOR] 1.30 (0.91, 1.67)), PEA (AOR 0.97 (0.65, 1.45)), or asystole (AOR 1.13 (0.79, 1.64)). Similarly, we noted no significant interaction between airway strategy and initial rhythm for the secondary outcomes of ROSC, survival to discharge, and survival to discharge with good neurological function. Conclusion Prehospital advanced airway management strategy (ETI vs. LT) was not significantly associated with outcomes regardless of initial cardiac rhythm.