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 www.mikemcevoy.com 1
Disclosures No financial support, conflicts or disclosures. I do not intend to discuss any unlabeled or unapproved uses of drugs or products. www.mikemcevoy.com
Changes and Evidence Change is constant, especially in science EBM (Evidence Based Medicine) www.mikemcevoy.com 4
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 2013 www.mikemcevoy.com 5
Have you ever seen oxygen harm? www.mikemcevoy.com 6
So, how can I evaluate the evidence? EBM is now in EMS Educational Standards There are many ways to look at studies www.mikemcevoy.com 7
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-S382 www.mikemcevoy.com 8
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-S382 www.mikemcevoy.com 9
When Oxygen May Harm Tissue injury: ACS Stroke Trauma Neonates Post Resuscitation COPD Exacerbation (prehospital) www.mikemcevoy.com 10
Oxygen is a drug use it carefully! Titrate by oxygen saturations Keep > 94% No one needs 100% Class I, LOE C-LD www.mikemcevoy.com 11
Nasal Alar SpO 2 Sensor Xhale.com FDA approved 3-17-15 www.mikemcevoy.com 12
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;14:429-436. www.mikemcevoy.com 13
Response to Neosynephrine Alar PPG signal IV bolus Finger PPG signal
Backboards and Collars www.mikemcevoy.com 15
Circa 1970 www.mikemcevoy.com 16
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The problem www.mikemcevoy.com 19
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 www.mikemcevoy.com 20
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. www.mikemcevoy.com 21
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, 2012 www.mikemcevoy.com 22
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: www.thennt.com Haut ER et al. J Trauma. 2010;68:115-120 www.mikemcevoy.com 23
ALS versus BLS Medicare claims 2006-2011: 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;163:681-690 www.mikemcevoy.com 24
ALS versus BLS: Cardiac Arrest Medicare claims 2009-2011: 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;175:196-204 www.mikemcevoy.com 25
ALS versus BLS Systematic review 1,081 studies, 18 used ALS increases survival in non-traumatic cardiac arrest patients Resuscitation. 2011;82:1130-1137 www.mikemcevoy.com 26
ALS versus BLS: Trauma Prospective study of 236 penetrating trauma patients xpt by EMS; 2008-2009 ALS interventions did not benefit patients Injury, Int J Care Injured. 2013;44:634 638 www.mikemcevoy.com 27
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 0.95-1.05 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: 235-260 www.mikemcevoy.com 28
Odds Ratios The Golden Hour www.mikemcevoy.com 29
But Wait Or Don t Analysis of Orange County Trauma Registry 1996 2009, n = 19,167 Time matters in penetrating trauma! McCoy, Ann Emerg Med 2013 www.mikemcevoy.com 30
TOR: Termination Of Resuscitation Morrison, Resuscitation 2007 www.mikemcevoy.com 31
TOR: Termination Of Resuscitation Morrison, Resuscitation 2009 www.mikemcevoy.com 32
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 2016 www.mikemcevoy.com 33
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;176:114-121 www.mikemcevoy.com 34
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;176:114-121 www.mikemcevoy.com 35
Automatic CPR Devices www.mikemcevoy.com 36
Automatic CPR Devices Cochrane Collaboration, 2011 updated 2014 www.mikemcevoy.com 37
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, 2014 www.mikemcevoy.com 38
ACLS Medications Oslo, Norway 2003-2008, n=851 No significant difference in survival to d/c IV Drugs No IV P = Admit with ROSC 32% 21% < 0.001 Favorable neuro outcome 9.8% 8.1% 0.45 Survival to d/c 10.5% 9.2% 0.61 1 year survival 10% 8% 0.53 Olasveengen TM et al. 2009;302:2223-9 www.mikemcevoy.com 39
ACLS Medications Epi vs. placebo Australian double blind RCT, n = 534 ROSC: better with epi Survival to d/c: no difference 2011;82:1138-1149 www.mikemcevoy.com 40
ACLS Medications Hagihara A et al. 2012;307(11):1161-1168 Japan, prospective observational study 2005 2008 (epi 2006), n = 417,188 ROSC: better with epi Alive at 1 month: worse with epi Neuro outcomes: worse with epi www.mikemcevoy.com 41
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 2018 www.mikemcevoy.com 42
And this just in Randomized, double-blind trial, 10 sites n = 3026, initial shock refractory vf, VT ~ 23% survival to d/c, no difference www.mikemcevoy.com 43
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, 2014 www.mikemcevoy.com 44
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 2004 www.mikemcevoy.com 45
Response Times < 8 minutes 90% of the time Eisenberg, JAMA 1979 Cardiac Arrests 43% Generalized to EVERYTHING! www.mikemcevoy.com 46
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 2005 www.mikemcevoy.com 47
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 www.mikemcevoy.com 48
78 yo male patient fell in bathroom Requests lifting assistance No visible trauma, GCS 15 On Coumadin Lift Assist www.mikemcevoy.com 49
Do we need evidence for everything? Uhm, Published cases of survivors falling from airplanes No published evidence parachutes actually work BMJ, Dec 2003 www.mikemcevoy.com 50
Thanks for your attention! www.mikemcevoy.com