Prevalence and Outcomes of Endotracheal Intubation-Related Cardiac Arrest in the Emergency Department Byuk Sung Ko MD, Ryeok Ahn MD, Seung Mok Ryoo MD, Shin Ahn MD, Chang Hwan Sohn MD, Dong Woo Seo MD, PhD, Kyoung Soo Lim MD, PhD, Won Young Kim MD, PhD PII: DOI: Reference:
S0735-6757(15)00639-7 doi: 10.1016/j.ajem.2015.07.083 YAJEM 55208
To appear in:
American Journal of Emergency Medicine
Received date: Revised date: Accepted date:
29 June 2015 30 July 2015 31 July 2015
Please cite this article as: Ko Byuk Sung, Ahn Ryeok, Ryoo Seung Mok, Ahn Shin, Sohn Chang Hwan, Seo Dong Woo, Lim Kyoung Soo, Kim Won Young, Prevalence and Outcomes of Endotracheal Intubation-Related Cardiac Arrest in the Emergency Department, American Journal of Emergency Medicine (2015), doi: 10.1016/j.ajem.2015.07.083
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ACCEPTED MANUSCRIPT Original article
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Emergency Department
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Prevalence and Outcomes of Endotracheal Intubation-Related Cardiac Arrest in the
Byuk Sung Ko, M.D.*1, Ryeok Ahn, M.D*.2, Seung Mok Ryoo, M.D.1, Shin Ahn, M.D.1, Chang
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Hwan Sohn, M.D.1; Dong Woo Seo, M.D., Ph.D.1, Kyoung Soo Lim, M.D., Ph.D.1; Won
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Young Kim, M.D., Ph.D.1,*
Department of Emergency Medicine, Ulsan University College of Medicine, Asan Medical
Center, Seoul, Korea
Department of Emergency Medicine, Ulsan University College of Medicine, Ulsan, Korea
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* These authros contributed equally to this work
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Running title: Endotracheal intubation-related cardiac arrest
Correspondence: Won Young Kim, MD, PhD
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The Authors declare that there is no conflict and financial funding.
Department of Emergency Medicine, Ulsan University College of Medicine, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea. Tel.: +82-2-3010-3350; Fax: +82-2-3010-3360; Email:
[email protected] Key Words: Intubation; Airway management; Complication; Cardiac arrest; Outcomes Abbreviations: CA, cardiac arrest; CPC, cerebral performance category; CPR, cardiopulmonary resuscitation; ROSC, return of spontaneous circulation.
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ACCEPTED MANUSCRIPT Abstract: Background: Emergency endotracheal intubation-related cardiac arrest (CA) is not well documented. This study compares the clinical features and outcomes of intubation-
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related CA and other causes of in-hospital CA. Methods: All study patients were consecutive
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adults (≥18 years) who developed CA in the emergency department between January 2007 and December 2011. Emergent endotracheal intubation-related CA was defined as occurring
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within 20 minutes after successful intubation. Clinical variables were compared between
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patients with intubation-related CA and intubation-unrelated CA. The primary outcome was a good neurological outcome defined as a cerebral performance category score of 1–2. The secondary outcome was survival to hospital discharge. Results: Of the 251 patients who developed CA, 41 were excluded due to trauma-related CA or ‘do not resuscitate’ protocols,
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thereby leaving 210 patients. The prevalence of intubation-related CA was 23.3%, and the median duration between successful intubation and CA was 5.0 minutes (interquartile range =
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2.0–9.5). Pulseless electrical activity was more commonly noted as the first arrest rhythm in
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the intubation-related CA group (75.5% vs 59.0%; p=0.03) compared with patients with other causes of CA. However, the rates of good neurological outcomes (14.3% vs 21.1%) and
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survival to discharge (34.7% vs 35.4%) were not significantly higher in intubation-related CA group (both p > 0.05). Conclusion: Endotracheal intubation related-CA occurred higher than commonly recognized and patient outcomes were not better than other causes of CA. These data highlight the importance of efforts to prevent intubation related CA. However, further prospective larger study will be required to generalize this result. Key Indexing Terms: Intubation; Airway management; Complication; Cardiac arrest; Outcomes
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ACCEPTED MANUSCRIPT INTRODUCTION Determining the prognosis according to the cause of cardiac arrest can be challenging in
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could help guide patient management and the goals of care.[2]
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many cases.[1] However, more accurate information regarding the prognosis of cardiac arrest
Emergency endotracheal intubation to critically ill patients can be fraught with severe
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life-threatening complications, including hypoxemia, hypotension, arrhythmia, and even
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cardiac arrest (CA).[3-10] Nonetheless, physicians seem to have underestimated prognosis of intubation related CA and literatures have not been interested in such a serious complication.[11] One study has reported that the incidence of intubation-related CA may be higher than commonly appreciated and is associated with hospital deaths.[12] However, the
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clinical features and prognosis of intubation-related CA in comparison with other causes of in-hospital CA remain unclear. This study describes and compares the clinical features and
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outcomes of patients with emergency endotracheal intubation-related CA and other causes of
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in-hospital CA that developed in the emergency department.
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ACCEPTED MANUSCRIPT METHODS Study design and population
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This retrospective, single-center cohort study was conducted at Asan Medical Center, a
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2800-bed, university-affiliated, tertiary referral center in Seoul, Korea. We included consecutive adult patients (≥18 years) who developed CA in the emergency department
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between January 2007 and December 2011. Exclusion criteria included age