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10/31/2018

1

EMS World Expo

The Most Important Recent Practice-Changing

EMS Articles for 2018Corey M. Slovis, M.D.

Vanderbilt University Medical CenterMetro Nashville Fire DepartmentNashville International Airport

Nashville, TN

Epinephrine

Anesth Analg 1963;42:599-606

• The two fathers of modern CPR

• Both anesthesiologists

• Baltimore City Hospital, Johns Hopkins, University of Maryland

• Used small dogs to evaluate drugs in CPR Anesth Analg 1965;44:746-52

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0.48

0.30

Epi Dosing and SurvivalCPC 1 - 2

1 Mg 2 - 5 Mgs

0.23

> 5 Mgs

OR

JACC 2014;64:2360-7

Resuscitation 2018;124:43-48

Could less than 1.0 mg be better dose of epinephrine?

• 2,255 pts from Seattle, 2008-2016• 554 (24.6%) VF/VT; 1,701 (75.4%) AS/PEA

• Before and after type study• VF/VT: 0.5 mg min 4, 8; AS/PEA: 0.5 mg Q 2 min• Evaluated ROSC, Discharge, CPC 1-2

10/31/2018

2

Low Dose Epinephrine

• Not a randomized trial

• Cross overs from either group

• 3.4 mg vs 2.6 mg in VF/VT; 3.5 mg vs 2.8 mg in AS/PEA

Reducing the dose of epinephrine in OOH cardiac arrests does not affect ROSC, hospital discharge frequency or neurologic outcomes in

either shockable or non-shockable rhythms

Epi improves ROSC

Summary as of 8/20/18

Survival benefits unproven

Give early, not late

Give after second shock in VF

Await London study

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

Times and Dose

6.6 min Call to EMS arrival (median)

21.4 min Call to epinephrine or placebo

4.9 ± 2.5 mg Epinephrine dose (mean)

New Engl J Med 2018;379:711-21

0%

10%

20%

30%

40%

50%

60%

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

10/31/2018

3

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

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

10/31/2018

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Adjusted AnalysisVF/pVT vs Non Shockable

Favors Placebo Favors Epinephrine

New Engl J Med 2018;379:711-21

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

Antiarrhythmics in Cardiac Arrest

10/31/2018

5

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?

Bicarbonate in CPR


How does bicarbonate administration during CPR affect outcome?

• 15,601 OOH cardiac arrests Vancouver

• 5,165 (37%) received IV bicarbonate

• Evaluated survival and good neuro outcome

• Also performed propensity scoring comparisons 0123456789

1011121314

12.3%

10.8%

Bicarb vs No BicarbUnadjusted, Unmatched


Survival Good Neuro

1.6%

Bicarb No Bicarb Bicarb No Bicarb

%

1.3%

10/31/2018

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Adjustment via propensity analysis required, as patients getting

bicarbonate usually are in arrest longer with refractory arrests and higher total doses of epinephrine

Bicarbonate in Cardiac ArrestResuscitation 2017;119:63-9

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.03.5%

2.8%

Bicarb vs No BicarbPropensity Analysis


Survival Good Neuro

2.2%

Bicarb No Bicarb Bicarb No Bicarb

%

OR=0.64 OR=0.59

1.8%

Bicarbonate in Cardiac ArrestsTake Homes

• Don’t routinely use

• Decreases survival and favorable neuro

• Generates CO2 and is hyperosmolar

• Use for pre-existing acidosis or OD(DKA, sepsis, methanol, EG, TCA)

• Great in Hyperkalemia

• 100,029 CPR patients, 349 hospitals

• 4,173 (4%) got D50W

• Compared D50 to no D50

• Looked at ROSC, discharge, neuro outcome

Critical Care 2015;19:160

Is glucose helpful or dangerous in cardiac arrest?

Do not use!

• Decreases survival to discharge ( 51%)

• Decreases neurological outcomes ( 67%)

• Has no benefits and is dangerous

Glucose is Bad in CPRUnless Patient Hypoglycemic

What do you do after 3 unsuccessful shocks?

We need to have a strategy for refractory VF

10/31/2018

7

Refractory VFib

• Move pads Ant-Lat Ant-Post

• Consider Beta Blockade

• Consider Double Sequential Defibrillation (DSD)

• PCI

• ECMO


Is double sequential defibrillation (DSD) beneficial in refractory VF/pVT?

• 45 patients treated with DSD

• Retrospective observational study

• London Ambulance Service

• Compared to 175 who got standard defibrillation

• Only patients with ≥ 6 shocks compared

• 3 standard Ant-Lat defibrillations

• Anti-arrhythmic administration

• 3 standard Ant-Post defibrillations

• Double sequential defibrillation

• Done 3 – 4 seconds apart

Double Sequential ProtocolResuscitation 2017;117:97-101

0

5

10

15

20

25

30

35

40

45

50

55

60

35%38%

Standard vs DSD in VF/pVT

EMS ROSC

56%59%


%

STD STDDSD DSD

6.6% 7%

Discharged

STD DSD

Hosp ROSC

Double Sequential DefibrillationTake Homes

• Not a randomized trial

• Many pts got up to 10 shocks pre DSD

• The role of Double Sequential Defibrillation is not yet clarified and needs a randomized larger trial

10/31/2018

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Annals Emergency Medicine 2018;71:109-12

Is Dual Sequential Defibrillation (DSD) dangerous to the defibrillators?

• Zoll M and/or Physio-Control LP 15s

• Two DSDs: 1 Zoll & 1 LP @ 560 J synched

• Two DSDs with 2 LPs at combined 720 J

• All 4 DSDs done A-P

• One LP found to become nonfunctional

Dual Sequential DefibrillationTake Homes

• May not be more effective

• May damage defibrillator

• Is a crowd pleaser

ECMO

Resus 2018;132:47-55

• 100 transported VF/pVT pts

• University of Minnesota in Minneapolis

• All pts 3 shocks without ROSC

• Amiodarone 300 mg IV

• EMS transport with LUCAS device

Does ECPR really improve survival s/p refractory VF/pVT arrest?

EMS Cardiac Cath Labin less than 30 minutes

ECMO begun ASAP in CCL

Resus 2018;132:47-55

Declared Dead on CCL Arrival

• ETCO2 < 10 mm Hg

• PaO2 < 50 mm Hg

• Lactate > 18 mmol/L

• EMS CCL time > 90 min

10/31/2018

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hun

dre

ds

Fate of 100 Refractory VF/pVT pts

CCLResus

Good NeuroCPC 1

92%

CVICUAdmit

Poor Neuro

83%

7.2%

Resus 2018;132:47-55

48%

ECPR Complications

• Mean time on ECMO 3.5 days

• All patients developed MOSF

• Anoxic CNS insult #1 cause of death

• ¼ of pts will have CPR trauma

• Requires team of intensivists, surgeons, cardiologists

Resus 2018;132:47-55

Resus 2018;132:47-55

Does ECPR really improve survival s/p refractory VF/pVT arrest?

48% good neuro forShock resistant VF/pVT

Airways

JAMA 2018;320:769-778

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

• Pragmatic crossover randomization, 13 clusters

• King LT SGA vs ETI

• 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

10/31/2018

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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%

Hun

dre

ds

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;320:769-778

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

• I believe mandates ETI focused service to aggressively train to use an SGA as rescue after 1-2 fails and/or hypoxic patients

JAMA 2018;320:779-791

• 9,296 patients, pragmatic study

• 4 ambulance services, England

• Computer generated randomization

• SGA: I-Gel, ETI: Direct and Bougie

• Utilized modified Rankin Score

Is Endotracheal Intubation (ETI) really superior to a Supraglottic Airway (SGA)

for ultimate neurologic outcome?

0%

1%

2%

3%

4%

5%

6%

7%

8% 6.4%

All Randomized PatientsRankin 0-3

SGA

6.8%

ETI

p = nsCI = 0.6%-0.3%

JAMA 2018;320:779-791

10/31/2018

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0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

3.9%

Received Advanced Airways (81%)Rankin 0-3

SGA

2.6%

ETI

OR = 1.57CI = 1.18%-2.07%

JAMA 2018;320:779-791

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

4.2%

First Airway UsedModified Rankin 0-3

SGA

2.0%

ETI

OR = 2.06CI = 1.51%-2.81%

JAMA 2018;320:779-791

Additional Findings

• SGA significantly better for ventilation within 2 attempts (87.4% vs 79%)

• No overall differences in vomiting or aspiration

• More pre-intubation vomiting/aspirations vs more seen post SGA insertion

• 2 x loss of SGAs than ETI

JAMA 2018;320:779-791

Take Home

The choice of using an I-Gel as a supraglottic airway vs endotracheal intubation should be

service chosen –

Neither proved clearly superior

But SGAs easier to use successfully

Resus 2018 Aug 30;epub ahead of print

How many endotracheal intubations during cardiac arrest does it take

to be competent at ETI?


• How long to become “Qualified”- ETI < 60 sec during CPR- No complications

• How long to become “Highly Qualified”- ETI < 30 sec during CPR- No complications

• CPR interruptions must < 10 sec

• Required a 90% success rate

10/31/2018

12


• First study to prospectively evaluate

• Began with 1st year Korean ED residents

• Utilized video review of ETIs

• Direct laryngoscopy only, no video DL

90% successful ETI < 60 secrequires at least 137 patient

attempted intubations


Expertise in ETI during CPR

90% successful ETI < 30 secrequires at least 243

attempted intubations


Expertise in ETI during CPR90% ETI Success < 30 sec

Number RequiredResus 2018 Aug 30;epub ahead of print

90% ETI Success < 30 secDays Required


Becoming an expert in invasive airway management requires years,

not months, and hundreds of invasive airway attempts

ETI Expertise during CPRTake Home

10/31/2018

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JAMA May 2018;319:2179-89

Does routine Bougie use improve likelihood of first pass endotracheal intubation success?

• 757 patients randomized, Hennepin Med Center

• Bougie first vs ETT with Stylet

• Done with Mac blades and Storz C-MAC

• 58% DL; 21% all video; 20% video passage

• ½ (380) of pts had difficult airway characteristics

JAMA May 2018;319:2179-89

• Difficult vs All vs WNL airways

• Difficult = 1 or more:- Body fluids obscuring view- Airway obstruction or edema- Obesity, short neck- Small mandible, large tongue- Cervical spine immobilization

Bougie vs ETI with StyletComparison Groups

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

96%

82%

Bougie vs ETI with Stylet

Difficult

98%

87%

JAMA May 2018;319:2179-89

Bougie BougieETT ETT

99%

87%

WNL Airway

Bougie ETT

All

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

100%

78%

Most Difficult Airways

C Spine Immobilized

96%

75%

JAMA May 2018;319:2179-89

Bougie BougieETT ETT

97%

60%

Incomplete glottic views

Bougie ETT

Obese

Bougie Use for ETITake Homes

• Use bougie’s more

• They are central to airway management

• Start with a bougie on difficult airwaysor go to one quickly after first look

Circulation 2018;137:2114-24

Does post-resuscitation hyperoxiaadversely affect neurologic outcome?

• 280 pts, multicenter prospective trial

• 38% (105 pts) were hyperoxic: PaO2 > 300

• All pts comatose, ventilated, received TH

• 55% overall survival, 70% overall poor neuro

10/31/2018

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0%

10%

20%

30%

40%

50%

60%

70%

80%

Hun

dre

ds

77%

Poor Neurologic OutcomeCirculation 2018;137:2114-24

65%

P=0.035

Hyperoxia No Hyperoxia

Hyperoxia and Poor Neurologic OutcomeAdjusted Relative Risk

Circulation 2018;137:2114-24

Each hour of hyperoxiais independently associated

with a 3% increase in poor neurological outcome

Oxygenation S/P Arrest Once ROSC Obtained

• Maintain O2 saturation below 100%

• Aim for 95-96%

• Await further refinements

100% by non-rebreather s/p arrest in normotensive patients is no longer good care

STEMI

Prehosp Emerg Care 2018 Mar 29:1-7

How important is minimizing EMS response and on-scene time with STEMI patients?

• 550 pts from Charlotte NC, Mecklenburg EMS

• Mean 911 to PCI time 81.8 min (SD = 20)

• Evaluated mortality at one year

• Survival was evaluated vs 911 to PCI time

• Multivariate analysis: age, sex, BP, prior AMI etc.

10/31/2018

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For every one minute increase in time to PCI, the odds of survival

decrease by 3%

Mortality for STEMI increases by 30% for every 10 minute delay

J Emerg Med 2018;55:71-7

How good is our software in diagnosing *** STEMI ***

• San Diego EMS 2012 data

• False notifications were evaluated

• Significant with new monitors

• 6 mos pre and post new algorithm

• Decreased false positives: 64% to 28%

True STEMI

Before• False STEMI = 150/234

After• False STEMI = 40/138

J Emerg Med 2018;55:71-7

Non STEMI “STEMIs”What To Beware Of

• RBBB

• LBBB

• Atrial Fibrillation

• Benign Early Repolarization

• Pacer

• Poor Quality ECG

STEMI IdentificationTake Homes

• Beware most common false positives

• BBB and Poor Quality are our enemies in prehospital alerts

10/31/2018

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STEMI Evolution

EMS ECG

ED ECG 12 minutes later

• 83 prehospital ECGs with STEMI

• 217 EMS agencies; UPMC Medical Control

•All patients went to cath lab

Prehosp Emerg Care 2014;18:174-179

How often does a prehospital STEMI arrive with a resolved ECG?

0

10

20

30

40

50

60

70

80

90

100 n = 83 78.3% (65)

STEMI Resolution

Total AMI

ED STEMI

21.6% (18)

ST Resolution


• 1 in 5 prehospital STEMIs have ECG changes

• There was no difference in % occlusion in those

• Patients without STEMI resolution are more


that resolve prior to ED arrival

with and without ST resolution of STEMIECG changes

likely to have multivessel disease

10/31/2018

17

ST segment resolution of a STEMI still

equals a STEMI and mandates rapid

transport to coronary catheterization

ST Segment Resolution = NO STEMI

Prehosp Emerg Care 2018;Jan 16:1-8

Do serial 12 leads during EMS transport add any useful information in diagnosing a STEMI?

• 728 STEMI transports, Quebec EMS

• Used BLS-EMTs transmitting Q 2 minutes

• 24 minute average transport time (15-38)

• “Persistent” STEMI vs “Evolution” vs “Loss”

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

Dynamic STEMI ECGs15.7% (114 / 728)

No STEMI STEMI STEMI No STEMI


4.5%

STEMI No (multiple changes)

7.7%8.0%

Results

• 84.3% of STEMIs were persistent

• 15.7% of STEMIs were dynamic

• 8% of STEMIs not evident on first ECG


STEMI Evolution

• 12.3 min was median time from No STEMI

• Females had more dynamic changes then men

• Longer transports = more dynamic changes


Some STEMIs stay persistent

Some STEMIs “come and/or go”


10/31/2018

18

No STEMI STEMITake Homes

One ECG begets another

EMS and STEMI Take Homes

• Time = muscle

• Time = survival

• Minimize all intervals

STEMI No STEMITake Homes

A STEMI is a STEMI if seen even just once!!

Anaphylaxis

True Definition of Anaphylaxis

• Reduced BP after exposure to known

• Acute onset of skin or mouth symptoms

• Involvement of 2 or more systems:– Skin– Mucous membranes– Respiratory– Cardiovascular– Gastrointestinal

allergen

plus wheezing or hypotension/tachycardia

Pediatrics 2017;139:e20164006

Epinephrine is the drug of choice

10/31/2018

19

The #1 cause of death in anaphylaxis is the failure to give epi in a timely manner


• 471 anaphylaxis pts, NC database, 2010-13

• All patients had “allergic reactions”

• Anaphylaxis: either hypotension and/or respiratory distress

How often is epinephrine administered to patients < 18 yo with anaphylaxis?

Only 32.4% of patients received epinephrine

Age < 10 Epi use by almost 3x


Atrial Fibrillation

Acad Emerg Med 2018;in press August

• 450 pts, double-blind, placebo controlled

• 3 groups of pts from 3 Tunisian hospitals

• High dose vs Low dose vs Placebo

• MgSO4 9 grams vs 4.5 grams vs Placebo

• Given over 30 minutes

Is Magnesium effective for rate control in “Rapid” Atrial Fibrillation?

10/31/2018

20

Measured effectiveness as HR < 90or rate lowering by > 20%


0%

10%

20%

30%

40%

50%

60%

70% 59.5%64.2%

EffectivenessHR < 90 or HR > 20%

9 Grams 4.5 Grams

43.6%

--


High Dose Mg Low Dose Mg Placebo

This paper is not what it seems


• Essentially all patients got other rate control agents

• 45-50% received Digoxin

• 30% received Diltiazem

• 20% received Beta Blockade

Magnesium for Rate Control in AFTake Homes

• Adjunct? – maybe; Primary – NO

• 2.5 grams or 4.5 grams?

• 9 grams = lots of flushing (10-15%)

• Was very safe, < 1% hypotension

• Read this paper carefully

Annal Emerg Med May 2018;72:184-93

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

10/31/2018

21

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

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

PlasmaLyte / Normosol

Na 140 meq/L

Cl 98 meq/L

Osm 294 mOsm

pH 7.4

Acetate 27 meq/L

Gluconate 23 meq/L

K 5 meq/L

Mg 3 meq/L

N Engl J Med 2018;378:829-39 N Engl J Med 2018;378:829-39

10/31/2018

22

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

12%

Hun

dre

ds

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

Epinephrine’s role still unclear

Summary

No routine bicarbonate in CPR

No routine D50 in CPR

Double Sequential??

ECPR if done early

SGAs are excellent

Summary

Bougies are great

Expertise in ETI takes time

Beware 100% O2

Time = Muscle

ECGs change

Summary

Anaphylaxis = Epi!

Magnesium is an adjunct in AF

Sniffed isopropyl for nausea

Love Lactated Ringers

10/31/2018

23

VanderbiltEM.com

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