Patient Positioning Improves Direct Laryngoscopy First-Attempt Success in Patients with Cardiac Arrest

Introduction: Multiple endotracheal intubation (ETI) attempts can facilitate complications and adversely affect patient outcomes. According to the AHA, in out-of-hospital urban and rural settings, patients intubated during resuscitation had a better survival rate than patients who were not intubated. Published literature on cardiac arrest (CA) patient positioning during ETI and its significance on first attempt success rate (FASR) are scarce. Objective: To compare direct laryngoscopy (DL) intubation FASR and glottic exposure with patient position during CA. Methods: An institutional review board approved, multi-agency prospective analysis was conducted comparing video laryngoscopy to DL from March 18, 2013 through March 17, 2014 performed by consented paramedics. Subsequently, a subgroup analysis was performed on CA patients, examining the effect of provider positioning on FASR during DL. Throughout this study, patient airways were managed in the following optional positions: (1) supine - floor (Floor), (2) supine stretcher - ambulance (Ambulance), and (3) supine stretcher - elevated (Elevated). We recorded the FASR, Cormack- Lehane and Percentage of Glottic Opening views within each intubation position. Results: A total of 190 first attempt DL intubations were recorded, of these 120 (63%) were successful. The DL intubation FASR by positions was: (1) Floor 37 (55%) compared to Ambulance 19 (58%) (95% CI: -0.179 - 0.216), (2) Ambulance 19 (58%) compared to Elevated 64 (71%) (95% CI: -0.047 - 0.323), (3) Floor 37 (55%) compared to Elevated 64 (71%)(95%: CI: 0.008 - 0.304). The Cormack- Lehane view grade mean was: Floor 2.6, Ambulance 2.4, and Elevated 2.0. The Percentage of Glottic Opening mean was: Floor 52%, Ambulance 53%, and Elevated 66%. Conclusions: This analysis demonstrated a 16% increase and superiority in DL intubation FASR from the Floor to the Elevated position on CA patients. The Elevated position offers an enhanced view of the airway anatomy and improved Cormack- Lehane and Percentage of Glottic Opening scores. The position of intubation should be considered when evaluating the appropriate stage in cardiac arrest to provide advanced airway management, particularly with anticipated difficult airways.