(Almost) (Almost) Everything You Know Everything You Know About EMS Is WrongAbout EMS Is Wrong

Amy Gutman MDEMS Medical Director / prehospitalmd@gmail.com

Overview

• From the very new to the very experienced, all providers, administrators & medical directors must continually ask, “Does this practice, procedure, or drug improve outcomes?”

• Then ask… “Really?”

• When you get the answer… ask again!

It is better to not understand something true, than to understand something false. Neils Bohr

“All of these are things in which some people desperately wish to believe, despite the utter lack

of credible evidence of their existence”

Greaves I. Fluid resuscitation in prehospital trauma: J.R.Coll.Surg.Edinb. 2002.

Q: Does Prehospital Diuresis Help Congestive Heart Failure?

Myth: Myth: Prehospital Diuresis Fixes CHFPrehospital Diuresis Fixes CHF

• Historical prehospital CHF treatment: O2, MSO4, diuretic

• Many SOPs include furosemide for respiratory distress despite few studies on effectiveness

• Rationale: utilize rapidly acting medication to decrease work of breathing

Reality: Reality: No Data Prehospital No Data Prehospital Diuresis Effective or SafeDiuresis Effective or Safe

• Evaluation of prehospital use of furosemide in patients with respiratory distress. PEC 2006.

• 144 pts receiving prehospital furosemide• 59% CHF; furosemide “appropriate”• 42% no respiratory dx; “inappropriate”• 17% sepsis, dehydration, pneumonia;

“harmful”• Conclusion: Prehospital furosemide frequently

inappropriately administered & harmful

• MSO4 + furosemide resulted in increased ETI, ICU admissions, longer hospitalizations, higher mortality

• Many CHF pts taking furosemide; boluses have little acute effect

Morphine and outcomes in ADHF: an ADHERE analysis. EMJ.2011

Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus

high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary

edema. Lancet. 1998

Comparison of NTG, MSO4 & furosemide in treatment of presumed prehospital

pulmonary edema. Chest. 1987

Reality: Reality: Other Modalities Have Greater Other Modalities Have Greater Immediate Benefit With Less RiskImmediate Benefit With Less Risk

• Hubble. Effectiveness of prehospital CPAP in the management of acute pulmonary edema. PEC 2006• All pts presenting to ED via EMS in 1 year with impression

of “pulmonary edema” • Control: O2, nitrates, furosemide, MSO4, +/- ETI • Intervention: CPAP +/- standard therapy

• Results: • Pts on standard Rx 4 times more likely to be intubated/die

than those receiving standard therapy w/CPAP • Intubation: 9% CPAP, 25.3% control • Mortality: 5% CPAP, 23.2% control

Q: Are Tasers Deadly Weapons?

Myth: Myth: Tasers Kill PatientsTasers Kill Patients

• Electrical current disrupting voluntary muscle function causing “neuromuscular incapacitation” via involuntary muscle contractions

• High-voltage, short-pulse• 3 microsec pulse followed by 100 microsec pulses• Low-impedance current pathway across propelled barbs

• Multiple animal studies demonstrated safety, with “clinically irrelevant” arrhythmia, QT prolongation, acidosis

• Tasers attracted media attention for “contributing” to deaths of violent individuals by police

Reality: Reality: Tasers “Less Lethal”, Tasers “Less Lethal”, Not “Non-Lethal”Not “Non-Lethal”

• Increased VF / VT vulnerability:• Cardiac disease, long QT,

pre-excitation • Increased adrenergic tone • Electrolyte abnormalities• Acidosis

• Post-Taser • Metabolic acidosis• QT prolongation• VT/VF secondary to “r on T” • Additive risk of death from excited delirium

Reality: Reality: Conflicting Human StudiesConflicting Human Studies

• Taser-related death series• 37 males, 18-50 yrs• 54% cardiac disease • 84% illicit drugs• 76% deaths from

“excited delirium”• 27% TASER

“contributory” COD

• Vilke:• No “clinically relevant

ECG changes” in 32 healthy males post 5 sec taser shock

• QT shortened / widened “insignificantly” in 50%

• Low pH immediately post shock

• Levine:• QT short / wide,

tachycardia in 105 healthy police volunteers after 5 sec taser shock

Strote. PEC. 2006Vilke. AJEM. 2008Levine. JEM. 2007

Reality: Reality: Tasers Less Lethal Than Tasers Less Lethal Than GunfireGunfire

• 218 individuals subdued by police with firearms vs Tasers

• 1.4% mortality (TASER group)

• 50% mortality (firearm group)

Ordog GJ. AEM 1987; 16:73-78.

Q: Are EMT-Initiated Refusals Safe?

Myth: Myth: EMT-Initiated Refusals Are SafeEMT-Initiated Refusals Are Safe

• Public Utility Models of EMS care offer transport to everyone who calls delivering “care best for the patient, not necessarily the system”

• Risk of error when dispatchers / EMTs attempt to determine who safely can be denied transport

• Medico-legal conclusion: eliminate risk by providing every patient requested care

Reality: EMT-Initiated Refusals Often Unsafe

• Evaluation of protocols allowing EMTs to determine need for transport PEC. 2000

• 1,300 pts • 79% required transport• 15% told to go to ED via

alternative means• 6% no transport

• Outcomes:• 30/277 (11%) untransported

had critical event • 7 (3%) required resuscitation

prior to EMS recall

• Medic determinations of medical necessity. PEC. 2009• 85 pts medics felt

transport unnecessary• 15 (18%) admitted• 5 (6%) admitted ICU

• Cone “ALS call-offs:• 87% if BLS crew

cancelled ALS, pt needed ALS interventions in ED

Data overwhelmingly does not support EMS determining if patients require ambulance transport…except…

Reality: EMS Cannot Transport Everyone

• “Prospective Evaluation of an EMS-Administered Alternative Transport Protocol” PEC 2009

• Can experienced medics (10 yrs+) using guidelines identify pts who can be safely alternatively transported

• 93 pts given taxi voucher • Average time from taxi dispatch to ED 43 mins • 10% transported by taxi admitted to hospital• No emergent procedures or adverse events• Conclusion: Experiences providers using SOPs may be

able to triage patients to alternative transport

Q: Are ALS Interventions Better than BLS in Improving OOHCA Survival?

Myth: Myth: ALS Saves Lives in OOHCAALS Saves Lives in OOHCA

• Ontario Prehospital Advanced Life Support Study

• 5,638 pts over 7 years

• Results:• ALS more expensive with no

better outcomes than BLS + AED• OOHCA ~1% EMS run volumes• US & Canadian survival ~5% • Of cities with higher survival,

almost all improvement attributed to BLS

Myth: Myth: Two Medics Better Than Two Medics Better Than One in OOHCAOne in OOHCA

• Cities with more paramedics have worse pt outcomes • Boston 10:100,000; 40% survival to admission• Omaha 44:100,000; 3% survival to discharge

• Paramedics with OOHCA 4.68 cases / yr = 27% discharge• Paramedics with OOHCA 1.63 cases / yr = 4% discharge

• 2 cities wth identical demographics, response times & run volumes ~ only difference ALS vs BLS 1st response• 38% ROSC BLS 1st response• 13% ROSC ALS 1st response

Sayre. AEM 2006Dunn. EMS Today 2007

Reality: Reality: ALS Does Improve Some ALS Does Improve Some OutcomesOutcomes

• ALS clinically & statistically better outcomes for respiratory distress, CP & hypoglycemia vs BLS ONLY if the intervention is ability to initiate IV therapy

• Multiple studies show if patient does not require IV meds or BLS initiates CPAP, dextrose & naloxone, BLS patients have better outcomes

Q: Are Paramedics Good At Endotracheal Intubation?

Reality: Most Paramedics Are “Inexperienced” Rather than ”Bad” at ETI

• Minimum required training ETIs:• Anesthesiologist: 400• CRNA: 200• Emergency Medicine: 100-200• Paramedic USDOT: 5

• Research shows medic students require at least 15-20 intubations to attain basic proficiency

Bledsoe B. “The Future of Intubation” 2011.

Wang H. Defining the learning curve for paramedic student ETI. PEC 2005

Reality: Some Paramedics Are Good at ETI (Bledsoe 2010)

Author(s) No of Intubations(Misplaced/Total)

Misplaced Intubations (%)

Jenkins et al 2/39 5.1

Bozeman et al 1/100 1

Stewart et al 3/779 0.4

Sayre et al 3/103 2.9

Pointer 5/383 1.3

Jenkins WA. The syringe aspiration technique to verify endotracheal tube position. AJEM. 1994Bozeman WP. EDD versus detection of ETCO2 level in emergency intubation. AEM. 1996

Stewart RD. Field ETI by paramedical personnel. Chest. 1984Sayre MR. Field trial of ETI by basic EMTs. AEM. 1998

Pointer JE. Clinical characteristics of paramedics’ performance of ETI. JEM. 1988

Reality: More Attempt Leads to Improved Success, But At What Cost?

• Prehospital ETI often requires multiple attempts

• 1,941 cases of prehospital ETI:• >30% required >1 attempt

• Cumulative success (arrest)• 69.9%, 84.9%, 89.9%

• Cumulative success (non-arrest)• 57.6%, 69.2%, 72.7%

Wang HE. How many attempts required to accomplish out-of-hospital ETI. AEM.

2006

Reality: Paramedic Are Even Worse at Pediatric ETI

• 1989 study of pediatric cardiac arrests:• ETI success rate: 64%

• 63 pediatric patients in Milwaukee WI:• ETI success rate: 78%

Aijian P. ETI of pediatric patients by paramedics. AEM. 1989

Losek JD. Prehospital pediatric ETI performance review. PEC. 1989.

Reality: The More You Do, The Better You Do

• Rural Maine ETI success:• 74% in medics with <5

annual ETI• 86% in medics with >5

annual ETI

• Rural Pennsylvania 1 yr study of 11,484 ETIs by 5,245 medics:• 67% performed <2 ETIs• 39% had no ETIs

Burton JH. ETI in a rural state: procedure utilization and impact of skills maintenance guidelines. PEC. 2003

Wang HE. Procedural experience with out-of-hospital ETI.

CCM 2005.

Reality: Some Paramedics Are Really Good at ETI

• San Diego: • 1 UEI/264 PEDIATRIC

intubations (99%)

• Seattle/King County:• 98.4% success

• Bellingham, WA:• 20-year review• 95.5% ETI success • 0.3% UEI Vilke GM. Out-of-hospital pediatric ETI by

paramedics: San Diego experience. JEM. 2002 Bulger EM. Analysis of advanced prehospital airway

management. JEM. 2002

Wayne MA. Prehospital use of succinylcholine: a 20-year review. PEC. 1999

Myth Corollary: ETI Saves Lives in OOHCA, Therefore We Must Make the Attempt

• 2000 LA study demonstrated outcomes for intubated pediatric cardiac arrest patients were no better or often worse than those managed with BVM

• 2010 ACLS guidelines: “If advanced airway placement will interrupt chest compressions, providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts, or demonstrates ROSC”

• 2010 NEMSIS data showed worse outcomes for ETI OOHCA pts • MI: VF/VT survival to discharge decreased with field ETI• CA: survival to discharge 4 X greater if BVM vs ETI • NC: 5 x greater ROSC in non-ETI

Reality: Prehospital ETI Often Worsens Outcomes

Mortality by Distance Category OR (95% CI)

Nonintubated patient at any distance Reference

OOH-ETI with distance < 10 miles 2.70

OOH-ETI with distance 10 miles - <20 miles 1.87

OOH-ETI with distance 20 miles - <30 miles 1.80

OOH-ETI with distance 30 miles - <40 miles 0.90

OOH-ETI with distance 40 miles - <50 miles 0.20

OOH-ETI and 50 miles 1.83

Helicopter 0.36

Reality: Alternative Airways Will Replace ETI Within 10 Years (But ETI Will Never Go Away)

• Large body of research demonstrates improved safety profile, advanced airway management success & better patient outcomes using alternative airways management (i.e. VGI)

• www.theairwaysite.com is an outstanding resource

Q: Is Spinal Immobilization Beneficial & Necessary For Trauma Patients?

Myth: “Spinal Motion Restriction” Beneficial & Necessary

• Primary injury: time of trauma; Keeping pt still does not reverse damage

• Secondary injury: post-injury cord inflammation, injury from bony fragments, worsening primary lesion. Restricting movement limits potential for more damage

• Zero evidence restricting movement if neurologically intact spinal fractures does any good (vast majority are stable fxs)

Myth: Spinal Immobilization Beneficial & Necessary

• Gutman. Neck and Back Pain. EMS: Clinical Practices & Systems Oversight. 2009. • No randomized prospective studies demonstrate ANY

aspects of immobilization prevent or lessen morbidity of spinal injuries

• Baez asked 1,500 EMTs the following “beliefs” about immobilization followed by a Cochrane Review (2006):• Spinal immobilization prevents cord injury• Manual neck stabilization required until C collar applied• C collars inadequate to prevent cervical movement• KEDs reduce paraplegia • Cloth tape acceptable to secure pt • Prehospital skin breakdown does not occur

Reality: Spinal ImmobilizationHurts Patients

• Malayan C-Spine Study 5 yr retrospective chart review

• 454 pts with SCI• 0/120 Malayan pts

immobilized• 334/334 New Mexico pts

immobilized

• Neuro disability less for Malayan pts (11% vs 21%)

• Conclusion: immobilization has no significant effect on neurologic outcome

• 2002 Maine EMS spinal clearance protocol• 16,019 trauma transports• 7,014 immobilized• 86 (0.01%) spinal fxs• 12/86 not immobilized • 11 stable fxs, 1 unstable

T-spine fx• Unstable fx pt w/o

neurological deficits

• Conclusion: immobilization has no significant effect on neurologic outcome

Reality: Providers Can Safely Clear C-Spines

• NEXUS (National Emergency X-Radiography Study) criteria minimizes unnecessary x-rays

• 34,069 pts• 818 cervical fxs, all but 8

identified with clinical criteria

• NEXUS Exam Criteria:• No midline c-spine tenderness• No intoxication• Normal alertness• No focal neurological deficit• No distracting injuries

• Canadian C-Spine Study

• 8,924 pts w/same NEXUS results except:• >65 yo greater risk• Clearer MOI • Injury above clavicles

greatest determining factor for neck injury

Reality: Spinal Immobilization Has Serious Consequences

• Pain / Anxiety

• Increased ICP & IOP

• Vomiting / aspiration

• Respiratory decompensation

• Decubitus ulcers can begin within 20 mins

• 15% reduction respiratory capacity

Q: Does the ‘Golden Hour’ of Trauma Improve Patient Outcomes?

Myth: Myth: The “Golden Hour” is a The “Golden Hour” is a Standard of CareStandard of Care

• R. Adams Cowley father of trauma care & developer of Golden Hour

• PR tool promoting importance of rapid surgical intervention in trauma pts at newly opened U Maryland “Shock Trauma”

• “Pts must arrive at a trauma center within 1 hour of their injury in order to have their best chance of survival.”

• This “Golden Hour” concept repeated so often that it has been “willed” into truth

Reality: Reality: No Data Behind the No Data Behind the Golden HourGolden Hour

• 2001 AAEM found no data supporting ‘Golden Hour’ • “Nobody wants to talk about this false

notion…because it shakes the roots of EMS & trauma care.” B Bledsoe MD

• Little evidence in “Platinum 10 Minutes” • Applies only in setting of hemodynamically unstable trauma

pts in which EMS should “be on scene <10 mins” before transporting patient to ED for surgical intervention

• Often results in shoddy assessment, care & packaging

• Benefit of rapid surgical intervention for trauma pts “obvious”, but no data identifies optimum time frame

Myth Corollary: Myth Corollary: Lights & Sirens Save LivesLights & Sirens Save Lives

• North Carolina• 43.5 sec savings with

lights & siren vs without

• Syracuse• “L&S reduce response by

average of 106 secs”• Unlikely clinically relevant

• Philadelphia• Pt outcomes when EMS

strictly limited use of lights & sirens

• “No adverse outcomes identified related to non-lights & siren transport”

Is ambulance transport time with lights and siren faster than that without? 1995

Do warning lights and sirens reduce ambulance response times? PEC 2000

Patient outcome using medical protocol to limit “lights and siren transport. PDM 1994

Reality: Reality: Faster is Better For Some Faster is Better For Some Medical EmergenciesMedical Emergencies

• 4 min response associated with increased survival in OOHCA If:• Unwitnessed arrest• No bystander CPR• No AED

• However, rapid response less important than appropriate scene care & destination facility

• 9,273 OOHCA pts (OPALS)

• 4% survival if <6 min to defibrillation • “Steep decrease in 1st 5

mins of survival curve, beyond which levels off”

• ALS 8 min response not assoc w/ improved survival

• 4 mins response improves survival in pts with high mortality risk

Reality: Reality: Response Recommendations Response Recommendations Based on Conjecture not ScienceBased on Conjecture not Science

• 8 mins goal for 90% responses to “save most persons in need”

• Time to travel between 2 points determined by speed. Speed affected by traffic, road / vehicle conditions, operator experience

• Shorter response intervals not without safety & monetary costs

Blackwell. Lack of association between prehospital response times and patient outcomes. PEC 2007Bailey. Considerations in establishing EMS response time goals. PEC 2003

Q: People Survive Cardiac Arrest on TV All The Time Just Like Real Life…Right?

Myth: Myth: The Dead Will The Dead Will RiseRise

• Researchers watched 2 yrs of ER, Chicago Hope & Rescue 911• 65% OOHCA in children or teens• 75% survived arrest• 67% survived to discharge

• Los Angeles: • 2,021 consecutive OOHCA pts• 1.4% survived neuro intact• 6.1% survival bystander-

witnessed VF• 2.1% survival bystander CPR• 3.2% survival witnessed arrest &

bystander CPR• 1% survival w/o bystander CPR

CPR on television. Miracles and misinformation. 1996

Cardiac Arrest Resuscitation in Los Angeles: CARE- LA. 2005

Reality: Despite 30+ Years & Expenditure of Billions of Dollars, Majority of Dead Remain Dead

• No change in traumatic arrest survival since Crimean war

• Some improvements in medical OOHCA• Bystander CPR / Early AED • Effective compressions

• Is there a benefit in saving the very very few vs the safety risk to EMS, public & financial expenditure?

Q: Fluid Resuscitation Raises Blood Pressure & Saves Trauma Patients

Myth: Myth: Aggressive Fluid Resuscitation Aggressive Fluid Resuscitation Saves Trauma PatientsSaves Trauma Patients

• Known for decades, but recent military studies changed trauma resuscitation• Hypotensive resuscitation during active

hemorrhage: impact on in-hospital mortality, J Trauma 2002.

• Hypotensive resuscitation strategy reduces transfusion requirements & severe postoperative coagulopathy in trauma pts with hemorrhagic shock. J Trauma 2011.

• Effect of plasma & RBC transfusions on survival in pts with combat related traumatic injuries, J Trauma 2008.

• Early aggressive use of FFP does not improve outcome in critically injured trauma patients, Ann Surg 2008.

Reality: Reality: Consensus Statement from the Consensus Statement from the European & American Trauma SurgeonsEuropean & American Trauma Surgeons

• IV en route unless entrapped or delay in transport• Only 2 IV attempts or 1st attempt IO• Transfer should not be delayed to obtain IV access

• Saline or blood products as 1st line fluids

• 250cc NS boluses titrated against presence or absence of radial pulse (caveats: penetrating torso injury, head injury, infants)

Greaves I. Fluid resuscitation in prehospital trauma care: A consensus view. Coll.Surg.Edinb. 2002.

Prehospital EKGs ~What Are Your “Myths”?

Myths: Myths: Prehospital EKGPrehospital EKG

• If you're close to the ED, a 12-lead is a waste of time• Closest hospital not necessarily

most appropriate!

• ED must repeat ECG to confirm STEMI• Nothing magic about the ED's EKG• Serial ECGs extremely important

• If ST elevation resolves by ED arrival, it's not a STEMI• If elevation resolves, pt still has

an occlusion. Why else would the segment elevate in the 1st place?

More Prehospital EKG Myths

• It's easy to identify STEMI• Identifying true ST segment

elevation easy but deciding between STEMI and STE-mimics difficult

• Impossible to identify STEMI with a LBBB• It’s hard, but doable. Perform

serial ECGs as you can see evolutions in the ST segments

Q: Does Trendelenburg Position Improve Blood Pressure?

Myth: Myth: Trendelenburg Position Trendelenburg Position Improves Blood PressureImproves Blood Pressure

• During WWI, Trendelenburg popular to increase cardiac output & perfusion

• In 1967, Los Angeles researchers evaluated the Trendelenburg & found it did not provide any benefit in improving circulation

• In 1980 British researchers: “Our study failed to document any consistent beneficial or detrimental effect of Trendelenburg positioning in acutely ill normo- or hypotensive patients.”

• 30+ studies show Trandelenburg increases venous pressure, but does not raise SBP significantly

Trendelenburg ComplicationsTrendelenburg Complications

• Cardiogenic shock

• Pulmonary edema

• Aspiration

• Visual loss increased IOP (2-10 x nml)

• 25% decreased SV

• 35% decreased CO

• No change in MAP or HR

Malloy BL. Implications for postoperative visual loss: steep trendelenburg position & effects on IOP. AANA

J.2011. Popescu WM. A pilot study of pts with clinically severe

obesity undergoing laparoscopic surgery. J Cardiothroacic Vasc. Anes. 2011.

Zorko N. Influence of the Trendelenburg position on haemodynamics: comparison of anaesthetized patients with ischaemic heart disease and healthy volunteers. J

Int Med Res. 2011.

Q: Do “Code” Medications Save Lives?

Myth: Resuscitation Medications Improve Outcomes in Cardiac Arrest

• 2002: bretylium, isoproterenol & high-dose epinephrine removed from guidelines

• 2005: lidocaine largely replaced by amiodarone

• 2010: atropine essentially removed

• 2012: epinephrine, vasopressin & many antiarrhythmics being questioned in research trials

• 2009 JAMA editorial: “The best available observational evidence indicates that epinephrine may be harmful to patients during cardiac arrest”

Reality: Epinephrine Ineffective

• 2003 Norway researchers evaluated ACLS medications vs none in a 6 year trial

• ROSC rates improved (32% control vs. 21% placebo), but no change in survival to discharge or favorable neurological outcome

• 2006 Australian researchers evaluated epinephrine against placebo• Higher ROSC in the epinephrine vs placebo group (24% vs 8%), but

no significant improvement in survival to discharge

• 2012 Japanese researchers evaluated epinephrine vs nothing or nothing in 400,000 patients• ROSC improved (18% vs. 5%) but 1 month survival unchanged &

neurological outcomes worse

Current ACLS Research

• “Amiodarone, Lidocaine or Placebo for OOHCA Due to VF or VT (ALPS)” • University of Washington• Enrollment of 500+ patients

• 2012 meta-analysis of 6 trials comparing epinephrine vs vasopressin found no improvement in sustained ROSC, long-term survival or good neurological outcome• Insignificantly higher long-term

survival in asystole patients

Q: Are Thrombolytics Like tPA Are Standard of Care For Ischemic Strokes?

Myth: tPA Does Not Produce Clinical Improvements in The Majority of Stroke Pts

• 750,000 ischemic stroke annually • 2-3% of these receive tissue plasminogen activator (tPA)

• Data shows relative improvement in 37% of pts, with 5% risk for an adverse outcome

• EM physicians sharply divided on the issue of whether or not tPA is an appropriate treatment modality

• ACEP’s & AAEM’s official policies reflects that split, do not take a position on whether or not tPA should be used, and thus do not set a standard for care

• But what about the AHA?

Myth: AHA Provides Unbiased Data

• AHA: “Research continues to accumulate in support of the effect of thrombolytic therapy when given to carefully selected patients within 3 hrs of the onset of acute ischemic stroke.”

• Conflict of interest?• Genentech, the manufacturer of

tPA, donated $11 million to the AHA in the decade prior to AHA recommending tPA for stroke

• Most of the association’s stroke experts have ties to the manufacturer of tPA

• 6 multi-center thrombolytic trials since 1980s in US, Europe, Australia & China• NINDS trial 1st & only to demonstrate a positive benefit

• Only “sound” study not sponsored by a drug company could not duplicate NINDS• All strokes treated at 29 Cleveland-area hospitals

over a 1 year • 1.8% (70:3948) received tPA• Results strikingly different & negative from NINDS• Rate of symptomatic ICH 16% (compared to 7% in

control group); with 6 fatal bleeds

Myth: Many Studies Have Shown the

Absolute Benefits of tPA for CVA

Katzen. Use of tPA for acute ischemic stroke: The Cleveland area experience. JAMA. 2000

N.I.N.D.S rt-PA Stroke Study Group. TPA for acute ischemic stroke. NEJM. 1995.

Myth: tPA for Stroke is Highly Recommended

• Extremely limited role of tPA in acute ischemic stroke

• Thrombolytics limited to EDs with a neuroradiologist reading CT & a neurologist administering / monitoring therapy

• “Since the NINDS trial there has not been a second randomized, double-blinded, placebo-controlled study to validate its findings. There is insufficient evidence at this time to endorse the use of intravenous tPA in clinical practice…” (ACEP, 2010)

• Following public scrutiny, the AHA recently withdrew statements that tPA for stroke “saves lives.”

Reality: NINDS Trial Results

• In 624 pts, tPA (white) or placebo (black) given to pts w/i 3 hrs of CVA SSX with (-) head CT

• tPA pts more likely to have minimal /no disability at 3 mo (50% vs 38%)

• ICH w/i 36 hrs in 6% of tPA pts vs 0.6% of placebo pts (significant)

• Mortality 3 mo 17% in tPA group vs 21% in placebo group (insignificant)

Myth: Leading EM Physician Groups Endorse tPA for Stroke

• CAEP guidelines: “thrombolytics… restricted to use in the context of formal research protocols, or in a closely monitored program”

• “It is the position of the AAEMEM that objective evidence regarding the efficacy, safety & applicability of tPA for acute ischemic stroke is insufficient to warrant its classification as a standard of care.”

• ACEP Poll: 40% would not use tPA, even in ideal pt under ideal conditions

Additional ReferencesAdditional References• Stankus JL. Does Standard of Care for Acute Ischemic Stroke in the ED Include tPA? A Legal Perspective. 2010. • Lerner. “The Golden Hour: Scientific Fact or Medical ‘Urban Legend’?” AEM 2001• Turner J. The Costs & Benefits of Changing Ambulance Response Time Performance Standards. University of Sheffield. 2006• Hunt. Is ambulance transport time with lights and siren faster than that without? Annals of EM 1995• Brown. Do warning lights and sirens reduce ambulance response times? PEC 2000• Kupas. Patient outcome using medical protocol to limit “lights and siren transport. PDM 1994• Bledsoe B. EMS Myth Busting: A Logical Approach to A Safer Reality . 2010• Boullthiet T, Dean B. FireEMS Blogs Network. The Trandelenburg Myth. 2010• Brian Bledsoe. The Current Slant on the Trandelenburg Position. 2011.• Taylor J, Failure of Trendelenburg position to improve circulation during clinical shock. Surgery, Gyn & Obstetrics. 1967• Malloy B. Implications for postoperative visual loss: steep trendelenburg position and effects on IOP. J Cardiothorac Vasc Anesth.2011 Dec;25(6):943-9. • Popescu WM. Pilot study of pts with obesity undergoing laparoscopic surgery: evidence for impaired cardiac performance.• Blackwell. Lack of association between prehospital response times and patient outcomes. PEC 2007• Bailey. Considerations in establishing EMS response time goals. PEC 2003• De Maio. Optimal defibrillation response intervals for maximum OOHCA survival rates.” AEM 2003 • Pons. 8 minutes or less: Does ambulance response time guideline impact trauma patient outcome?” JEMS 2002• Fitch and Associates Survey Group• Emerg Med J. 2002 Mar;19(2):152-4; J Int Med Res.2011;39(3):1084-9.• Kelly. Do ambulance crews with one ALS officer have longer scene times than crews with two?“. Scientific American. 1993.• Zorko N. The influence of the Trendelenburg position on haemodynamics. Acta Anaesthesiol Scand.1995 Oct;39(7):949-55.• Hirvonen EA. Hemodynamic changes due to Trendelenburg positioning & pneumoperitoneum during lap hysterectomy.• Jaronik. Evaluation of prehospital use of furosemide in patients with respiratory distress. PEC 2006.• Peacock WF. Morphine and outcomes in ADHF: an ADHERE analysis. EMJ.2011• Knappab. Prospective Evaluation of an EMS-Administered Alternative Transport Protocol . PEC 2009• Cotter G. Trial of high-dose isosorbide dinitrate + low-dose furosemide vs high-dose furosemide + low-dose isosorbide dinitrate in severe pulmonary edema. Lancet.

1998• Hoffman JR. Comparison of NTG, MSO4 & furosemide in treatment of presumed prehospital pulmonary edema. Chest. 1987• Brown LH. Paramedic determinations of medical necessity: A meta-analysis. PEC. 2009• Hubble. Effectiveness of prehospital CPAP in the management of acute pulmonary edema. PEC 2006• Overton. High Performance and EMS: Market Study. NAEMSP 2002• Cone. Can BLS personnel safely determine that ALS is not needed? PEC 2001 • Schmidt T. Evaluation of protocols allowing EMTs to determine need for treatment and transport. AEM. 2000 • Diem SJ, Lantos JD, Tulsky JA: “CPR on television. Miracles and misinformation.” NEJM 1996• Gutman. Neck and Back Pain. EMS: Clinical Practices & Systems Oversight. 2009. • Baez. "Is Routine Spinal Immobilization an Effective Intervention for Trauma Patients?" AEM 2006.• Eckstein M, Stratton SJ, Chan LS: “Cardiac Arrest Resuscitation in Los Angeles: CARE- LA.” Annals of EM 2005• N.I.N.D.S rt-PA Stroke Study Group. TPA for acute ischemic stroke. NEJM. 1995.

SummarySummary

• What we know & do in EMS is often based upon anecdotal evidence, politics, medical director mindset & available resources rather than evidence-based practice and evaluation of risk:benefit ratios

• Despite this, every day the job is performed well by overworked, underpaid & underappreciated providers

• It’s time to treat our patients based more on science than on myth & ritual procedures connecting the street with the science

Thank You For The Great Job You Do Every Day!

prehospitalmd@gmail.com

• “We are there for the good of the patient, not for the good of the protocol, not for the good of the medical director, and not for the good of the company”- Rogue Medic