VanderbiltEM.com. Prehospital STEMIs. EMS Today 2018 Research That Should Be On Your Radar Screen 3/1/2018

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1 EMS Today 2018 Research That Should Be On Your Radar Screen Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville International Airport Nashville, TN VanderbiltEM.com Prehospital STEMIs 1

2 STEMI Resolution Prehosp Emerg Care 2014;18: Prehosp Emerg Care 2014;18: How often does a prehospital STEMI arrive with a resolved ECG? 83 prehospital ECGs with STEMI 217 EMS agencies; UPMC Medical Center n = % (65) 21.6% (18) All patients went to cath lab Total AMI ED STEMI ST Resolution Prehosp Emerg Care 2014;18: in 5 prehospital STEMIs have ECG changes that resolve prior to ED arrival There was no difference in % occlusion in those with and without ST resolution of STEMI ECG changes ST segment resolution of a STEMI still equals a STEMI and mandates rapid transport to coronary catheterization ST Segment Resolution = NO STEMI Patients without STEMI resolution are more likely to have multivessel disease Dynamic STEMI ECGs 15.7% (114 / 728) Prehosp Emerg Care 2018;ePub Jan Prehosp Emerg Care 2018;ePub Jan Do serial 12 leads during EMS transport add any useful information in diagnosing a STEMI? 728 STEMI transports, Quebec EMS Used BLS-EMTs transmitting ECGs Q 2 minutes 24 minute average transport time (15-38) Persistent STEMI vs Evolution vs Loss % 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% 8.0% 7.7% No STEMI STEMI STEMI No STEMI 4.5% STEMI No (multiple changes) 2

3 Results 84.3% of STEMIs were persistent 15.7% of STEMIs were dynamic Prehosp Emerg Care 2018;ePub Jan STEMI Evolution Prehosp Emerg Care 2018;ePub Jan 12.3 min was median time from No STEMI Females had more dynamic changes then men Longer transports = more dynamic changes 8% of STEMIs not evident on first ECG STEMI No STEMI Take Homes Some STEMIs stay persistent Some STEMIs come and/or go Prehosp Emerg Care 2018;ePub Jan One ECG begets another Repeat ECGs every few minutes if no initial STEMI Every 5 minutes? Always do if any VS or symptoms change A STEMI is a STEMI if seen even just once!! High Quality BLS Compress at 0-120/minute The right amount of epinephrine in CPR Compress 2 inches Allow full chest rise Minimize interruptions Do not hyperventilate (8-/minute) 3

4 High Quality ACLS Intubate Oxygenate and Hyperventilate ACLS like BCLS continues to evolve Epinephrine 1 mg Q 3 minutes Atropine 1 mg Q 3 minutes Calcium Chloride 1 mg Q 3 minutes Bicarbonate 2 amps IVP / 1 Q 5 min Epinephrine is the ACLS drug that has stood the test of time Resuscitation 2014;85:350-8 Does dosing interval of epinephrine affect survival in CPR? 20,909 adult pts, 505 GWTG hospitals Looked at survival vs dosing interval Adjusted via multi-variate analysis Most common intervals were 4-5 and 5-6 min Epinephrine Dosing Intervals (min) Adjusted Odds Ratio for Survival Resuscitation 2014;85:350-8 OR Resuscitation 2017;117:18-23 Does spacing out epinephrine more than PALS/ACLS recommends affect pediatric CPR outcomes? 1,630 pediatric in-hospital arrests Intervals of 1-5, 5-8 min and 8- min evaluated Multi-variate analysis used to control co-morbidities Separately analyzed vasopressor use pre-arrest 4

5 Epinephrine Dosing Intervals (min) Adjusted Odds Ratio for Survival Resuscitation 2017;117: Epinephrine Dosing Interval Take Homes Although ACLS guideline say Q 3-5, it appears that spacing epinephrine doses out to up to 8- minutes may be optimal This is a violation of current guidelines No randomized study exists Give less not more Maybe then, reduced dose epinephrine in cardiac arrest is the answer? Resuscitation 2018;124:43-48 Could less than 1.0 mg be better dose of epinephrine? 2,255 pts from Seattle, (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 % 60 VF/VT Outcomes 0.5 mg vs 1.0 mg Epinephrine Resuscitation 2018;124: % 54.2% % 40 AS / PEA Outcomes 0.5 mg vs 1.0 mg Epinephrine Resuscitation 2018;124: % 35.8% % 34.2% 32.9% 30.5% % 5.1% 3.1% 3.5% 0 Std ROSC Low Std Low Discharged Std Low Good Neuro 0 Std ROSC Low Std Low Discharged Std Low Good Neuro 5

6 Low Dose Epinephrine Take Homes 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 Epinephrine in Cardiac Arrest Take Homes Use appears to decrease functional neurological status in survivors More epi = worse outcomes May increase ischemic-reperfusion and postanoxic injury PCI and hypothermia do NOT attenuate Epi s negative effects As usual, more study needed, but epi alone is not the answer to improved neurologic intact survival Epinephrine Use 2018 Summary and Recommendations Epinephrine s role in cardiac arrest remains unclear as of today more than 50 years post the beginning of modern ACLS The dose of epinephrine is 1 mg, but giving it Q 5+ minutes (6-) appears superior to Q 3 Wait for the second shock before giving epinephrine in VF Late dose epi (> min post arrest) is deleterious Tranexamic Acid An anti-fibrinolytic Blocks fibrin clot dissolution binds to plasminogen Blocks plasminogen fibrin interaction TPA Plasminogen Plasmin Fibrin Clot Dissolution Fibrin Split Products FDA approved in 1989 for hemophilia 6

7 Decreasing Blood Loss Tooth extractions in hemophilia Refractory nose bleeds Decrease surgical blood loss (orthopedics: spine and hip; ob/gyn: hysterectomy) During cardiopulmonary bypass Post major trauma? Hyperfibrinolysis Acute Coagulopathy of Trauma Seen in 25-40% of severe trauma patients Hypoperfusion Acidosis Hypothermia Activation of protein C LY30 > 3% fibrinolysis Hyperfibrinolysis (HF) in patients with severe trauma = 70-0% mortality LY30 > 3% Lancet 20; Does work in severe hemorrhage? 20,211 patients with major trauma,046 patients got within 8 hours Hospitals in Africa, Asia, Eastern Europe 30d All Cause Mortality Crash-2 Lancet 20;376:23-32 Lancet 20; hospitals in 40 countries 1 gram of in minutes 1 gram over next 8 hours Death (%) % 14.5% p= Death in hospital including: 0 AMI, CVA, PE, MOSF, CHI Placebo 7

8 Death from Bleeding Lancet 20;376:23-32 Bleeding Death with vs Placebo Lancet 2011;377: % 4.9% 6 p= RR= RR Placebo <1 hr 1-3 hr 3 hr Crash- 2 Crash- 2 Lancet 2011;377:96-11 reduces trauma mortality from bleeding by about 1/3 if given within 3 hours given after three hours increases the risk of death by bleeding by about 40% What about a study that directly applies to trauma in the US Arch Surg 2012;147: vs. no- US Troops in Afghanistan All pts required >1 unit blood Subgroup got > units PRBC Retrospective study, 896 pts 8

9 in US Military Arch Surg 2012;147: in Massive Transfusion Arch Surg 2012;147: % Mortality % ISS % 17.4% ISS 25.2 p = % Mortality % % p = % 5 5 No No N=603 N=293 N=196 N=125 Conclusions in the Military dramatically decreased mortality Benefits greatest in those requiring massive transfusion increased survival by factor of for those requiring massive transfusion decreased coagulopathy Does have a role in a US Level 1 Trauma Center J Trauma and Acute Care 2014;76: Level 1 trauma patients - Miami FL All required immediate OR or blood 1 gram IV then 1 G over 8 hours 54% penetrating trauma, 25% TBI 150 pts and 150 matched controls J Trauma and Acute Care 2014;76:1373 August 2009 January % SBP < 120 mm Hg 30% SBP < 70mm Hg ¾ required surgery and transfusion Evaluated mortality in 150 matched pts 9

10 Mortality vs Standard Care J Trauma and Acute Care 2014;76: % 17% P = % Use new drugs as soon as possible Before they develop side effects or loose efficacy No vs No Deaths in 2 hrs excluded J Trauma and Acute Care 2014;76: % J Trauma and Acute Care 2014;76:1373 Authors state groups perfectly matched group received more fluids, RBCs and FFP in OR If the death within 2 hours patients excluded then: 17% P = % Changes 81 deaths to 61 total deaths No Lancet 2017;389:25-16 Does decrease mortality in post-partum hemorrhage? 20,021 women, vs placebo Randomized, double blind controlled 193 hospitals, 21 countries Also looked at hysterectomy incidence 1 gram IV over minutes 2 nd gram for continued bleed and/or restart Lancet 2017;389:25-16 Death from bleeding was significantly reduced by, especially in those who received it within 3 hours? (1.2% vs 1.7%; p=0.008; RR 31%)

11 Results No effect on hysterectomy incidence No decrease from 42 day all cause mortality No increase in PE, DVT, or AMI Lancet 2017;389:25-16 significantly need for laparotomy (0.8% vs 1.3% p=0.002; RR 36%) Lancet 2018;391: Does time to treatment affect the efficacy and/or safety of? 40,138 pts from 2 trials 1 trauma study: CRASH-2 20,127 pts 1 OB post-partum trial: WOMAN 20,011 pts No other large trial results available Stratified pts by age, systolic BP and time to Benefits of decrease by % for every 15 minute delay in administration No benefits are seen after 3 hours Reduction in Effectiveness of with Increased Treatment Delay Lancet 2018;391: Lancet 2018;391: Use and Time Delays Take Homes If you are going to use, sooner is better Prehospital > ED > OR The efficacy of in a US level 1 trauma system is not yet proven nor widespread What about in a Level 1 Trauma Center and evaluating based on level of fibrinolysis? 11

12 Effect on Mortality J Surg Res 2017;220: J Surg Res 2017;220: consecutive pts, Denver Health, 43 MTF Compared 3 fibrinolytic studies Shutdown vs Physiologic vs Systemic fibrinolysis Compared each group of fibrinolysis types Analysis done with matching for injury severity Use and Mortality Injury Severity Adjusted Physiologic Fibrinolysis (LY30: 0.9%-2.9%) Significant increase in mortality (p=0.018) Hyperfibrinolysis (LY30: > 2.9%) Increased mortality (p-ns; 0.116) J Surg Res 2017;220: Fibrinolysis Shutdown (LY30 < 0.9%) No affect on mortality (p=0.5971) Use in Level 1 Trauma Center Denver Take Homes There was no clear benefit in this study remains a significant predictor of mortality for patients with physiologic fibrinolysis J Surg Res 2017;220: in Level 1 Urban Trauma My Take Home The role of in mature trauma systems remains unclear and emerging data supports it may have adverse effects? The role of in mature trauma systems remains unclear and emerging data supports it may have adverse effects? J Surg Res 2017;220: