Controversies in EMS

Transcription

1 Controversies in EMS Mike McEvoy, PhD, NRP, RN, CCRN EMS Coordinator Saratoga County, NY Staff RN Cardiovascular Surgical ICU and Chair Resuscitation Committee Albany Medical Center 1

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3 Disclosures No financial support, conflicts or disclosures. I do not intend to discuss any unlabeled or unapproved uses of drugs or products.

4 Changes and Evidence Change is constant, especially in science EBM (Evidence Based Medicine) 4

5 Oxygen Should we give empirically? No How should we titrate? O 2 sats > 94% How do we know? We re still learning about it O Conner, Resuscitation 2010, Cochrane Review

6 Have you ever seen oxygen harm? 6

7 So, how can I evaluate the evidence? EBM is now in EMS Educational Standards There are many ways to look at studies 7

8 Let Someone Else Do It For You AHA Evidence Review Class/Strength I = Strong (Standard of Care) IIa = Moderate (Do it) IIb = Weak (Think first) III No Benefit (Benefit = Risk) III Harm (Don t do it) Laurie J. Morrison et al. Circulation. 2015;132:S368-S

9 Let Someone Else Do It For You AHA Evidence Review Level/Quality A = High Quality B-R = Moderate Quality (RCT) B-NR = Moderate Quality C-LD = Limited Data C-EO = someone likes the idea Laurie J. Morrison et al. Circulation. 2015;132:S368-S

10 When Oxygen May Harm Tissue injury: ACS Stroke Trauma Neonates Post Resuscitation COPD Exacerbation (prehospital) 10

11 Oxygen is a drug use it carefully! Titrate by oxygen saturations Keep > 94% No one needs 100% Class I, LOE C-LD 11

12 Nasal Alar SpO 2 Sensor Xhale.com FDA approved

13 Nasal Ala Last branch external carotid First branch internal carotid Saban, et al. Nasal Arterial Vasculature: Medical and Surgical Applications Arch Facial Plast Surg. 2012;14:

14 Response to Neosynephrine Alar PPG signal IV bolus Finger PPG signal

15 Backboards and Collars 15

16 Circa

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18 18

19 The problem 19

20 NEXUS (1992) National Emergency X-Radiography Utilization Study Prospective, observational study, 21 centers across US: 34,069 stable blunt trauma patients at risk for cervical spine injury. Five risks identified: 1. Tenderness at the posterior midline of the cervical spine 2. Focal neurologic deficit 3. Decreased level of alertness 4. Evidence of intoxication 5. Clinically apparent pain that might distract from cervical spine injury pain 20

21 Canadian C-spine Rule (study) CCR (2001) A prospective, observational study of 10 centers across Canada: 8,924 alert and stable patients with blunt trauma who were at risk for cervical spine injury. 21

22 Change to Spinal Motion Restriction Some irrational treatments can be safely discarded: Use of backboards for transportation Cervical collar use except in specific injury types Immobilization of ambulatory patients on boards Prolonged attempts to stabilize the spine during extrication Mechanical immobilization of uncooperative or seizing patients Forceful in-line stabilization with airway management Hauswald M. Emerg Med J,

23 NNT and NNH Number Needed to Treat or Harm A statistical method to evaluate care 45,284 penetrating trauma patients: 4.3% were immobilized NNT to potentially benefit one patient = 1,032 NNH to contribute to one death = 66 For every 1 patient helped, 16 would die Try it out sometime: Haut ER et al. J Trauma. 2010;68:

24 ALS versus BLS Medicare claims : trauma, stroke, AMI, respiratory failure Survival & neuro fxn 30 and 90 days, 1 and 2 yrs ALS = substantially higher mortality and worse neuro outcomes for all conditions Ann Intern Med 2015;163:

25 ALS versus BLS: Cardiac Arrest Medicare claims : OOH cardiac arrest 31,292 ALS and 1,643 BLS Survival & neuro fxn 30 and 90 days, care costs ALS = substantially higher mortality and worse neuro outcomes, greater costs of care JAMA Intern Med.2015;175:

26 ALS versus BLS Systematic review 1,081 studies, 18 used ALS increases survival in non-traumatic cardiac arrest patients Resuscitation. 2011;82:

27 ALS versus BLS: Trauma Prospective study of 236 penetrating trauma patients xpt by EMS; ALS interventions did not benefit patients Injury, Int J Care Injured. 2013;44:

28 The Golden Hour Conceived by Maryland Shock Trauma Newgard: 3,656 trauma patients, 146 agencies SBP < 90 RR < 10 or > 29 GCS < 13 Advanced airway intervention No association between time & mortality for any intervention or times OR 1.00, 95% CI Newgard CD, et al. Emergency Medical Services Intervals and Survival in Trauma: Assessment of the Golden Hour in a North American Prospective Cohort. Ann Emer Med. 2010; 55:

29 Odds Ratios The Golden Hour 29

30 But Wait Or Don t Analysis of Orange County Trauma Registry , n = 19,167 Time matters in penetrating trauma! McCoy, Ann Emerg Med

31 TOR: Termination Of Resuscitation Morrison, Resuscitation

32 TOR: Termination Of Resuscitation Morrison, Resuscitation

33 From China: simplified TOR for trauma Blunt injury + asystole on AED/EKG Identified 100% of non-survivors TOR in Trauma Chiang W-C et al. Emerg Med J

34 Morphine for Chest Pain Nitro refractory CP, given to 30% of MI s Side effects: Vomiting, hypotension, resp. depression New: attenuates antiplatelet Rx and reperfusion Class: I STEMI, IIb NSTEMI No LOE Very difficult to conduct clinical trials IMPRESSION trial stopped for ethical concerns McCarthy CP et al. Am Heart J. 2016;176:

35 Morphine for Chest Pain We don t know if it s helpful or harmful What to do? Lowest possible doses Use beta blockers Consider other analgesics (NSAIDS) Consider benzos for anxiety Administer antiplatelet agents IV or chewed Large clinical trials needed McCarthy CP et al. Am Heart J. 2016;176:

36 Automatic CPR Devices 36

37 Automatic CPR Devices Cochrane Collaboration, 2011 updated

38 Automatic CPR Devices Evidence from RCTs in humans is insufficient to conclude that mechanical chest compressions during cardiopulmonary resuscitation for cardiac arrest are associated with benefit or harm. Widespread use of mechanical devices for chest compressions during cardiac events is not supported by this review. Cochrane Collaboration,

39 ACLS Medications Oslo, Norway , n=851 No significant difference in survival to d/c IV Drugs No IV P = Admit with ROSC 32% 21% < Favorable neuro outcome 9.8% 8.1% 0.45 Survival to d/c 10.5% 9.2% year survival 10% 8% 0.53 Olasveengen TM et al. 2009;302:

40 ACLS Medications Epi vs. placebo Australian double blind RCT, n = 534 ROSC: better with epi Survival to d/c: no difference 2011;82:

41 ACLS Medications Hagihara A et al. 2012;307(11): Japan, prospective observational study (epi 2006), n = 417,188 ROSC: better with epi Alive at 1 month: worse with epi Neuro outcomes: worse with epi 41

42 PARAMEDIC 2: the adrenaline trial RCT in UK Welsh, West Midlands, North East, South Central and London Ambulance Services Started December 2014 Results in late

43 And this just in Randomized, double-blind trial, 10 sites n = 3026, initial shock refractory vf, VT ~ 23% survival to d/c, no difference 43

44 ACLS Meds: where we stand today No survival benefit from vasopressors No evidence atropine, amiodarone, lidocaine, procainamide, bretylium, magnesium, buffers, calcium, hormones, or fibrinolytics during human CPR increases survival to discharge? Harm Morrison, Circulation, 2010 Lin, Resuscitation,

45 Oh, and one more thing Survival to discharge OR (odds ratios): Bystander CPR: 3.7 Rapid defibrillation: 3.4 ACLS (paramedics): 1.1 BLS Matters! Stiell, NEJM

46 Response Times < 8 minutes 90% of the time Eisenberg, JAMA 1979 Cardiac Arrests 43% Generalized to EVERYTHING! 46

47 Response Times Denver EMS, 1998 (all calls = 49,851) Most calls: no effect from response time Medium risk: suicide, exposure, uncons, diff breather, hypotension High risk: cardiac arrest Survival benefit for < 4 minutes but not 8 Pons, Acad Emerg Med

48 I ve Fallen and I Can t Get Up date Nishijima DK et al. Ann Emerg Med 2012;59:460-8 CT scans of 1,064 blunt head traumas in patients taking warfarin or clopidogrel Most were ground level falls w/ GCS 15 ICH found in 5.1% of warfarin patients and 12% of clopidogrel patients 48

49 78 yo male patient fell in bathroom Requests lifting assistance No visible trauma, GCS 15 On Coumadin Lift Assist 49

50 Do we need evidence for everything? Uhm, Published cases of survivors falling from airplanes No published evidence parachutes actually work BMJ, Dec

51 Thanks for your attention!