EMS most important recent articles FINAL€¦ · Most Important Recent Articles Corey M. Slovis,...

10/14/2019

1

Firehouse Expo 2019

EMS

Most Important Recent Articles

Corey M. Slovis, M.D.Vanderbilt University Medical Center

Metro Nashville Fire DepartmentNashville International Airport

Nashville, TN

Epinephrine

New Engl J Med 2018;379:711-21

• Large double blind placebo controlled trial

• 8,014 pts, UK EMS, adults ≥ 16 yo

• 4,015 pts, 1 mg epi Q 3-5 min

• 3,999 placebo receiving patients

What is the role of epinephrine in cardiac arrest?The study evaluated 30 day outcomes and

functional neurologic outcomes at discharge and at 3 months

New Engl J Med 2018;379:711-21

0%

10%

20%

30%

40%

50%

60%

Hundreds

30.7

ROSC and EMS Transport

ROSC EMS Transport

11.7

Placebo Epi Placebo Epi

New Engl J Med 2018;379:711-21

36.3

50.8

0%

1%

2%

3%

4%

5%

2.4%

30 Day Survival

Placebo

3.2%

Epinephrine

New Engl J Med 2018;379:711-21

OR = 1.39p = 0.02

NNT = 112

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New Engl J Med 2018;379:711-21

30 Day Neurologic Outcomes

0.0

0.5

1.0

1.5

2.0

2.51.9%

Rankin 0 - 3

Placebo

2.2%

Epinephrine

New Engl J Med 2018;379:711-21

OR = 1.18CI = 0.86-1.61

0.00.10.20.30.40.50.60.70.80.91.01.11.21.31.41.51.6

1.35%

Favorable Neurologic OutcomeRankin 0 - 2

Placebo

1.29%

Epinephrine

New Engl J Med 2018;379:711-21

0%

10%

20%

30%

40%

50%

60%

17.8%

Severe Neurologic Disability (30 d)Rankin 4, 5

Placebo

31.0%

Epinephrine

New Engl J Med 2018;379:711-21

Adjusted AnalysisParamedic Witnessed

Favors Placebo Favors Epinephrine

New Engl J Med 2018;379:711-21

Adjusted AnalysisVF/pVT vs Non Shockable

Favors Placebo Favors Epinephrine

New Engl J Med 2018;379:711-21

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Adjusted AnalysisMedical vs Traumatic

Favors EpinephrineFavors Placebo

New Engl J Med 2018;379:711-21

Positive Result Conclusion

Epinephrine in OOHCA arrest improves ROSC and likelihood

for hospital discharge

Neutral Result Conclusion

Epinephrine does not improve neurologically intact survival

in OOHCA

Negative Result Conclusion

Epinephrine in OOHCA just increases the likelihood of being neurologically

devastated without significantly increasing the number of neurologically

intact survivors

May 29, 2019

Resuscitation 2019;140:55-63

Does epinephrine affect shockable vs non-shockable rhythms differently?

• England’s PARAMEDIC-2 + Australian PACA combined

• 1518 VF/VT pts and 6330 AS/PEA pts

• These are the only 2 large randomized epi trials

• Compared 3919 epi pts to 3929 placebo pts

• ROSC, long term survival, and neuro outcomes compared

10/14/2019

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0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

33.37%

24.63%

ROSC

EpiPlacebo

48.74%

Epi


Placebo

7.39%

AS/PEA VF/VT

OR = 2.32OR = 6.52

0%

2%

4%

6%

8%

10%

12%

14%

1.6%

10.50%

Survival to Discharge

EpiPlacebo

12.41%

Epi


Placebo

0.43%

AS/PEA VF/VT

OR = 1.27

OR = 2.52

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

0.53%

8.81%

Favorable NeuroModified Rankin 0-3

EpiPlacebo

9.37%

Epi


Placebo

0.3%

AS/PEA VF/VT

Poor NeuroModified Rankin 4-5


AS/PEA⁃ 16 neurologically devastated patients with epi⁃ 4 patients with placebo

VF/VT⁃ 23 neurologically devastated patients with epi⁃ 12 patients with placebo

“There was insufficient evidence to suggest that favorable neurological outcomes at

discharge differed between treatments arms (p = 0.288) and it was not found to differ

according to rhythm type (p = 0.295)”Resuscitation 2019;140:55-63

Annals Emerg Med 2019 online August

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Resuscitation 2019 online May 1

• Is there a number of doses of epinephrine that after which, survival is no longer seen?

• 1 year retrospective review from London Ambulance Service

• 3151 cardiac arrest cases

• Epinephrine administered every 3-5 minutes

• VF/VT pts received epi beginning after 3rd shock

How does number of repeat doses of epinephrine affect survival?

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

1.7

Epinephrine Doses and SurvivalAsystole

32

1

10


5

2.9

1 4

2.4

0

P < 0.001

0

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

1.7

Epinephrine Doses and SurvivalPEA

32

1

10


5

4.5

1 4

6.1

0

P < 0.001

0

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

25

Epinephrine Doses and SurvivalVF/VT

32

1.7

10


5

38

1 4

40.6

20.4

P < 0.001

1.52.1 03.9 2.4

9876

Epinephrine and SurvivalTake Homes

• Survival falls as time of the arrest and epinephrine doses increase

• No one survives after 10 doses

• Almost no one survives after 5 doses

• We need to establish limits on epinephrine doses and use patient history and ETCO2 also

• No ROSC after 5 doses = TOR?

Epinephrine in Cardiac ArrestTake Homes

• Epinephrine improves ROSC and Survival to Discharge

• Epinephrine effects are much more pronounced in non-shockable rhythms

• Epinephrine does not improve Neurologic Outcomes

• The increase in survival to discharge results in More Neurologically Devastated Survivors

• Decide: how long, how many epi doses

10/14/2019

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Antiarrhythmics in VF

Resus 2018;132:63-72

• 14 randomized trials; 8 observational studies

• 1 additional pediatric observational study

• 1,213 pts studied with Amiodarone vs placebo

• 987 pts Amiodarone vs Lidocaine

• 19,517 pts Lidocaine vs placebo

How effective are antiarrhythmics in VF/pVT arrests?

Antiarrhythmics vs PlaceboAmiodarone, Lidocaine, Magnesium

Resus 2018;132:63-72

No proven benefits of antiarrhythmic therapy in cardiac arrest due to shockable rhythms

in OHCA when measuring survival to hospital discharge and especially when

evaluating favorable neurologic outcomes and long term survival.

Resus 2018; 132: 63-72

Do Antiarrhythmics Make A Difference?

What do you do after 3 unsuccessful shocks?

We need to have a strategy for refractory VF

Refractory VFib

• Move pads Ant-Lat Ant-Post

• Consider Beta Blockade

• Consider Double Sequential Defibrillation (DSD)

• PCI

• ECMO

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DSD

Acad Emerg Med 2018;00:1-8

• 40 yo, 40 min of VF, 7 shocks

• 8th was dual defibrillation < 1 second apart

• Patient D/C’d 24 d later, neuro intact at 1 yr

Prehosp Emerg Care 2015;19:554-7

First case report of neurologically intact survival after double sequential defibrillation for refractory VF


• Matched case control comparison

• 205 patients with refractory VF (3 shocks)

• 64 DSD vs 64 Standard defibrillations

• 2 blinded observers; matched same year pts

• Same epi doses, downtimes, witnessed, bystander CPR

Is DSD more effective in refractory VF?

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%40.8%

16%

DSD vs Standard DefibrillationROSC and Survival to Discharge

STDDSD

23.3%

STDDRD

20%

ROSC Survival to D/C


“Our current protocol of considering DSD after the third conventional defibrillation in out-of-hospital

cardiac arrest is ineffective”

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• No increase in ROSC

• No improvement on survival to discharge

PreHospital Emerg Care 2019 online August

Largest study to date evaluating DSD

• 310 patients, 71 (23%) received DSD

• Houston Fire Department and UT Health

• Evaluated ROSC, hospital admission, discharge

Effectiveness of DSD

ROSC

39.4%


PreHospital Emerg Care 2019 online August

60.3%

OR = 0.6320.9%OR = 0.46

14.3%

DSD DSDSTD STD

DSD 2019 – 2020 Take Homes

No study has shown benefit of DSD and there is a consistent trend of inferiority

PCI S/P Cardiac Arrest


• 599 OHCA registry pts

• UPMC and Mercy Hospitals

• Early vs Later vs no Cath/PCI

• STEMI and no AMI pts

How valuable is PCI s/p cardiac arrest?

10/14/2019

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0%

10%

20%

30%

40%

50%

60%

70%

65.6%

Survival to DischargeEarly PCI vs CCU

Early Cath Lab

31%

CCU Only

p = 0.0001


Early Coronary AngiographyTake Homes

• Early CCL essential to find intervenable lesions

• If PCI indicated: survival doubles with good neuro

• Non ST elevation AMI: intervenable lesions about 30% of time

• They, too, greatly benefit

• Be aggressive for high ROI

Doing Optimal “BCLS” •3643 pts; 2007-2009 ROC data

•150 EMS agencies from US and Canada

JAMA Cardiol 2019 online August14

What is the optimal depth and rate for closed chest CPR?

• 107 compressions per minute

• 1.85 inches depth of compressions

Optimal CPR is within 86 - 128 compressions/minute

and 1.5 - 2.2 inches

More than ½ of patients did not receive optimal CPR

(± 20% of target)

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1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

Survival with Optimal BLS

1.5 – 2.2 inches86 – 128 compressions

6.0%

Out of range

4.3%

JAMA Cardiol 2019 online August14

p = 0.0228% difference

High quality CPR is done less than 50% of the time in some of the best EMS services in the country, with

personnel who know they are having their CPR quality monitored

Supervising CPR

• 100 – 120 compressions/min

• 2 inches depth

• Allow full recoil

• Minimize interruptions

• Only 8 – 10 breaths/min

Our Job is to Ensure High Quality

Rotate your compressors every 2 minutes

Mechanical CPR


How much additional benefit does mechanical CPR provide vs manual CPR?

• 2,999 pts, San Antonio EMS

• 2,236 manual vs 763 mechanical

• Measured ROSC, survival, neuro outcomes

• Prior Cochran reviews 2011, 2014: no benefit

• CIRC, LINC, PARAMEDIC: No benefits

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0

5

10

15

20

25

30

35

40

45

50

9%

44%

7%

BLS

Mechanical CPR vs Manual CPRPrehosp Emerg Care 2018;22:338-44

ROSC Survival

46%

Man Mech Man Mech

P=0.32

P=0.13

0

1

2

3

4

5

6

7

8

9

10

6%

Mechanical CPR vs Manual CPRPrehosp Emerg Care 2018;22:338-44

4%

CPC 1-2 Outcomes

P=0.036

Man Mech


Results • Manual only CPR pts:

- Higher frequency of witnessed arrests

- More King Airways

• Mechanical CPR pts:

- Higher rates of bystander CPR

- More public AED use

- Higher doses of epi- More likely to have ETI

Mechanical vs Manual CPRTake Homes

• No differences in prehospital ROSC or survival to hospital

• Once adjusted logistic regression used: No difference in neuro outcomes

• ROSC, shockable rhythm and witnessed arrests are strongest predictors of survival with good neuro outcome

Mechanical CPR was not a significant predictor of

improved outcomesEMS Airways

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JAMA 2018;320:769-778

• 3,004 pts, 27 EMS agencies, ROC study

• Pragmatic crossover randomization, 13 clusters

• SGA vs ETI (only used LT)

• Secondary outcome: Favorable neurologic outcome

Is Endotracheal Intubation (ETI) superior to a Supraglottic Airway (SGA) in OOH Cardiac Arrest?

0%

5%

10%

15%

20%

18.3%

72 Hour SurvivalSGA vs ETI

SGA

15.4%

ETI

p = 0.04RR = 1.19

JAMA 2018;320:769-778

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

7.1%

Hospital Discharge-Favorable NeuroSGA vs ETI

SGA

5.0%

ETI

p = 0.02CI = 0.3%-3.8%

JAMA 2018;320:769-778

0%

10%

20%

30%

40%

50%

Hundreds

4.5%

Unsuccessful or ≥ 3 Attempts

Unsuccesful ≥ 3 Attempts

11.8%

SGA ETI SGA ETI

44.1%

18.9%

JAMA 2018;320:769-778

Additional Findings

• 2 x pneumothoraces with ETI (7.0% vs 3.5%)

• 2 x rib fractures with ETI (7.0% vs 3.0%)

• Airway misplacement or dislodgment (1.8% vs 0.7%)

• Only 51% ETI success rate

JAMA 2018;320:769-778JAMA 2018;320:779-791

Are SGAs superior to ETIs during out of hospital cardiac arrest?

• The AIRWAYS-2 Trial of 9296 pts

• Evaluated 30d neuro outcomes

• Also insertion success, regurgitation, and aspiration

• From 4 Brittish ambulance services

10/14/2019

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0%

1%

2%

3%

4%

5%

6%

7%

8%6.8%

Good Neuro OutcomesRankin 0-3

JAMA 2018;320:779-791

6.4%

SGA ETI

p = ns

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% 79%

Initial Ventilatory Success1-2 Attempts

JAMA 2018;320:779-791

87.4%

SGA ETI

or = 1.92

0%

1%

2%

3%

4%

5%

2.6%

Good Neuro OutcomesHad Airway Inserted

JAMA 2018;320:779-791

3.9%

SGA ETI

or = 1.57

SGA vs ETI Additional Finding

• No difference in regurgitation (26.1% vs 24.5%)

• No difference in aspiration (15.1% vs 14.9%)

SGA = ETI for airwaysSGAs more likely to be successful

JAMA 2018;320:779-791

SGA vs ETITake Homes

• SGAs are easier to insert successfully

• SGA or ETI easily justifiable first airway

• Oxygenation must be focus (not ETI vs SGA)

• Hypoxia is our enemy

• ETI focused services need to move to SGA for rescue after 1-2 failed ETI attempts and or for refractory hypoxia

10/14/2019

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Does a Supraglottic Airway improve time to epinephrine vs Endotracheal Intubation in cardiac arrest?

• 2652 pts, 1299 ETI vs 1353 SGA

• Pragmatic Airway Resuscitation Trial secondary analysis

• SGA previously shown to time to airway

• SGA also shown to first attempt success

• Hypothesis: earlier airway = earlier epi = survival 0

1

2

3

4

5

6

7

8

9

109.0

Median Time to EpinephrineResuscitation 2019 online May 2019

8.6

SGA ETI

p = ns

min

SGA patients were 8% more likely to receive epinephrine vs ETI


0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10% 7.4%

6.1%


> 10< 10

5.3%

> 10< 10

8.8%

SGA ETI


There was no significant association between airway strategy and time to

epinephrine administrationResuscitation 2019 online May 2019

SGA vs ETI and EpinephrineTake Homes

• Time to Epi is not affected by choice of ETI vs SGA

• The role of Epi remains unclear

• Earlier is better than later

• I believe ETI takes a lot of practice to be expert; SGA takes less practice and less experience

• ETI skills should not be the gold standard for EMS –oxygenation and ventilation are the gold standard

10/14/2019

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Hypotension

Annal Emerg Med 2017;70:522-30

How deleterious is hypotension in patients with traumatic brain injury (TBI)?

• 7,251 TBI pts ages 10 and older

• Statewide EMS database for Arizona

• Median age 40 yo; IQR 24-58 yo• 7.2% (539) of patients had BP < 90 mm Hg

• Evaluated time and depth spent hypotensive

“Dose of Hypotension

90 – SBP = Depth of Hypotension x Minutes

Hypotension “Dose”

10 minutes at 80 SBP = dose of 10 x 10 = 100

10 minutes at 70 SBP = dose of 10 x 20 = 200

Thus 10 minutes at 70 mm Hg increases mortality 20% over 10 minutes at 80 mm Hg


Each 2 fold increase in hypotension dose, increased mortality by 20%

Depth and Duration of Hypotensionvs Mortality


Hypotension in TBITake Homes

• Dramatically increases mortality

• 20% for each doubling of dose (time x 90-SBP)

• Avoid hypotension, treat hypotension

• Not clear if 90, 100, or 120 SBP is optimal s/p TBI

10/14/2019

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Depth and Length of Hypotension in TBI are both critical! Nausea

Annal Emerg Med May 2018;ePub ahead of print

How effective is inhaled isopropyl alcohol vs oral ondansetron for nausea?

• 120 subjects

• 41 isopropyl vs 41 oral ondansetron vs 40 both

• Placebo controlled with inhaled or oral placebo

• Used visual analog nausea scale

• Also evaluated rescue antiemetic therapy

0%

5%

10%

15%

20%

25%

30%

35%32%

9%

Mean Nausea Decrease

Inhaled Isopropyl

Oral Ondansetron


30%

Both

0%

10%

20%

30%

40%

50%

25%

45%

Rescue Antiemetic Need

Inhaled Isopropyl

Oral Ondansetron


27.5%

Both

Inhaled Isopropyl for Nausea Take Homes

• Inhaled alcohol pad isopropyl alcohol works better than oral ondansetron

• Use it first line, before IV even started

10/14/2019

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Ketamine

Am J Emerg Med 2017;ePub ahead of print

Is ketamine an effective therapy for delirious patients?

• Prehospital study of 49 patients

• All combative, very violent or out of control

• Only highest level agitation pts included

• Ketamine dosed at 5mg/kg IM

Ketamine For Agitation/Delirium5 mg/kg IM

• 4.2 min median time to sedation

• Sedation times varied 2.5-5.9 minutes (CI)

• 14% required 2nd dose

• 90% adequately sedated

• 57% (28/49) intubated during ED stay

• Hypersalivation 18%

• Vomiting 6%

• Emergence 2.4%

Am J Emerg Med 2017;ePub ahead of print

Complications of Ketamine

In 82% of patients, intubation time was less than 24 hours and the number one reason for ETI was

“Airway unprotected NOS”

Ketamine for Excited DeliriumTake Homes

• Great, great sedating agent

• Fast onset and 90% effective

• Patients may hypersalivate or vomit

• Many may need ETI - maybe

• Is it a primary drug or adjunct to benzos?

10/14/2019

18

Narcotic ODs andNaloxone

Annal Emerg Med 2019 online July

What is the one year prognosis after a non-fatal narcotic OD?

• 17,241 non-fatal Massachusetts opioid ODs

• July 11, 2011 – Sept 30, 2015

• Followed for 1 year s/p OD

• Used 3 overlapping statewide databases

• Evaluated mortality 1 year post opioid OD

5.5% of patients died within 1 year of a non-fatal narcotic OD requiring an

ED visit

Deaths s/p Non-Fatal ODAnnal Emerg Med 2019 online July

Non-Fatal Narcotic ODTake Homes

• One in 20 will be dead in 1 year

• 20.5% of the deaths occurred within 1 month of OD

• Role of buprenorphine or naloxone prescriptions not studied

• We need to intervene or deaths will continue

Prehosp Emerg Care 2019 online March

How long after expiration is Naloxone still usable and bioavailable?

• Recommended shelf life is 1 - 2 years per manufacturer and FDA

• Auto Injector has 1 year “shelf life”

• IV and IN have 2 year “shelf lives”

• Samples came from fire trucks, ambulances, and PD

• Assays by mass spec and chromatography

10/14/2019

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Prehosp Emerg Care 2019 online March

Assays up to 27 years oldPrehosp Emerg Care 2019 online March

Naloxone is 90 - 99% effective over a quarter of a century!

NaloxoneUse it but respect it

ACS

Acute Hypotension with NTG5 Causes

• Right Ventricular AMI

• Relative or Absolute Volume depletion

• Viagra, Levitra, Cialis

• Bezold-Jarisch Reflex

• Drug Sensitivity (valvular dsx, idiopathic)

• 1,466 STEMIs, 56% received NTG

• Montreal Quebec EMS 2010-2012

• Evaluated BP changes in Inf vs Non-Inf AMIs

• BP < 90 or BP > 30mm Hg s/p NTG


How dangerous is NTG in Inferior AMI?

10/14/2019

20

0%

5%

10%

15%

20%

25%

STEMI BP Changes Post NTGPrehosp Emerg Care 2016;20:76-81

BP < 90 BP > 30mm Hg

8.2%

InfNot-Inf InfNot-Inf

23.4%

P=NS

P=NS8.9%

23.9%PreHospital Emerg Care 2019 online

How safe is NTG in r/o AMI and does it effectively relieve pain?

• Prospective study, 780 pts, suspected STEMI

• LA County EMS and UCLA

• “Suspected STEMI” by ECG plus paramedic

• 0.4 mg SL NTG, up to 2 more doses

• BP < 100 mm SBP pts excluded

-14

-12

-10

-8

-6

-4

-2

0

NTG in suspected STEMIMedian BP Fall

NTG

-10 mm Hg

No NTG

-3 mm Hg

PreHospital Emerg Care 2019 online

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

NTG in suspected STEMISystolic BP fall > 30 mm Hg

NTG

5.3%

No NTG

6.7%


0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

NTG in suspected STEMIPain Relief

NTG

2.6%

No NTG

1.4%


P < 0.0001

Hypotension from NTG

•Borderline BPs

• Increasing Tachycardia

10/14/2019

21

NTG for r/o AMI

•NTG is safe in AMI

•NTG is safe in Inferior AMI

•NTG relieves Anginal pain in ACS

• Respect NTG but use it

Fluids in EMS

N Engl J Med 2018;378:819-28

Is LR or NSS more advantageous in non-critical ED patients admitted to the hospital?

• 13,347 adult ED patients, 1 hospital

• Pragmatic, multiple cross overs

• ED pts admitted to non ICU beds• 1,089 ml LR (Plasma-Lyte) vs 1,071 ml NSS medians

• Hospital free days and major adverse kidney events

Major Adverse Kidney Events

• Death

• New Renal Replacement Therapy

• Final serum Cr > 200% baseline

0

5

10

15

20

25

30

Major Kidney Events

N Engl J Med 2018;378:819-28

Hosp Free Day Major Kidney Event

25d

5.6%

P=0.01

25d

4.7%

Getting a median of about 1100 cc of NSS or LR (mean 1600 cc) results in a significant increase of renal dysfunction at 30 days

when saline is used vs a balanced electrolyte solution of LR or Plasma-Lyte

10/14/2019

22

N Engl J Med 2018;378:829-39

Is LR or NSS more advantageous in ED patients admitted to the ICU?

• 15,802 adult pts from 1 hospital• Pragmatic, multiple cross overs

• ED pts who were then ICU admitted

• 1,000 ml LR/Plasma-Lyte vs 1,020 ml NSS median

• Compared mortality, new RRT, persistent Cr 2 x N Engl J Med 2018;378:829-39

N Engl J Med 2018;378:829-39

0%

2%

4%

6%

8%

10%

12%

14%

16%

18% 15.4%

Major Adverse Kidney Events

NSS

N Engl J Med 2018;378:829-39

14.3%

LR

P=0.04

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

12%

Hundreds

11.1%

10.3%

Death, Renal Replacement Therapy and Cr 2 x

Mortality

2.9% 2.5%

N Engl J Med 2018;378:829-39

NSS NSSLR LR

6.6% 6.4%

Cr

NSS LR

RRT

p < 0.6

p < 0.08

p < 0.06

Balanced Crystalloids vs NSSTake Homes

• Same cost, same color, same manufacturers

• NSS is hyperchloremic and acidotic

• LR (or Plasma-Lyte) appears safer in 29,000 pts

• I see no benefit to routine NSS

Love it s/p vomiting with dehydration

10/14/2019

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Role of Epinephrine remains unclear

Summary

Five doses seems like enough

Antiarrhythmics are not of great value

DSD: NO

SGA = ETI, SGAs easier

Ensure optimal BCLS

Summary

NTG is safe in Inferior AMI

Isopropyl for Nausea

Plasma is great – longer runs

LR appears superior to NSS

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