2014 Emergency Medical Services Lifelong Learning and … · and Self Assessment . Andrew McCoy MD...

2014 Emergency Medical

Services Lifelong Learning

and Self Assessment

Andrew McCoy MD MS EMS Fellow - University of Washington Brian Clemency DO MBA EMS Fellowship Director - University at Buffalo Adam Frisch MD Assistant Professor - Albany Medical College

Dr. McCoy’s Fellowship was sponsored by a grant from Phyiso Control.

Drs. Clemency and Frisch have

no relevant conflicts of interest.

Objectives

• Cover each article in less than 6 minutes • Review articles Methods, Results and Conclusions • Discuss important study limitations • Prepare participants to pass the LLSA exam

4

2014 EMS LLSA Articles • Silbergleit R et al. IM vs IV therapy for status epilepticus. • Verbeek PR et al. Serial prehospital 12-lead electrocardiograms • Galvagno SM et al. HEMS vs GEMS for adults with major trauma • Blanchard IE et al. EMS response time and mortality • Bakalos G et al. ALS vs BLS: a meta-analysis. • Lammers R et al. Root causes of errors in a pediatric emergency. • Kragh JF et al. Battle casualty survival with emergency tourniquet • Haut ER et al. Spine immobilization in penetrating trauma • Aufderheide TP et al. Active compression-decompression CPR & ITD • Aufderheide TP et al. ITD in out-of-hospital cardiac arrest. • Bobrow BJ et al. Compression-only CPR by lay rescuers • Stiell IG et al. Early vs later rhythm analysis in OOHCA arrest • Hagihara A et al. Prehospital epinephrine use in OOHCA • Wang HE et al. ETI vs supraglottic airway in OOHCA • Austin MA et al. High flow oxygen in COPD

Background

• Optimal prehospital therapy for status is unknown.

• Does route of administration effect efficacy?

Study Design

• Non-inferiority trial • Double blind, randomized treatment of Status

Epilepticus (>5min) • All patients received 2 administrations:

– IM autoinjector (drug or placebo) AND – IV injection (drug or placebo)

• Rescue meds by local protocol • Primary outcome: seizure on ED arrival

Primary Outcome

0

10

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50

60

70

80

Seizures Terminated without Rescue

Rescue Therapy Given

IM Midazolam IV Lorazepam Pe

rcen

t

Secondary Outcomes

0

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40

50

60

70

IM Midazolam IV Lorazepam

0

Perc

ent

Time Data

Take Home Points

• IM group less likely to be seizing on arrival in ED than IV group

• IM administered faster, Overall time to action similar

• Fewer IM pts were hospitalized • 26% of pts had seizure refractory to

benzodiazepine • IM may be a simpler, faster route of treatment

Background

• ACC/AHA recommends serial ECGs in ED at 5-10 min intervals if there is a high suspicion following a nondiagnostic initial ECG – No prehospital guidelines currently for serial ECG

Evolving STEMI

“CODE STEMI” Protocol

• For patients with symptoms concerning for ACS – Perform a 12 lead at initial contact

• if not a STEMI – Perform a 12 lead in ambulance prior to leaving the

scene • If still not a STEMI

– In the ambulance bay of the receiving hospital

Methods

• Retrospective Chart Review • Toronto EMS (Two Tiered 3rd Service) • One year period

• How many “lost opportunities” would there be

if providers only performed a single ECG

Results

• 289,000 calls ,180,000 transports

• 325 “CODE STEMI”s in one year – 275 found on the 1st EKG (84.6%) – 30 found on the 2nd EKG (93.8%) – 20 found on the 3rd EKG (100%)

So if they only did

a single ECG:

There would have been 15% or 50 less “CODE STEMI”s

• 12 Leads were not routinely reviewed to

determine if activation was appropriate

• Also, the absence of PCI reports means we can’t know how many additional true STEMI’s were found.

Conclusion “This suggests that EMS systems relying on acquisition of a single prehospital ECG are subject to a potential missed opportunity to identify cases of prehospital STEMI.”

Take Home Points

• Multiple ECG may improve sensitivity for evolving STEMIs

• Multiple ECGs Increase the number of STEMI alerts, but this study was not designed to determine if this correlates with true STEMIs identified

Background

• HEMS is often used to transport the most critically ill patients to the most appropriate facility

• Trauma patients often require HEMS transport to stay within the critical hour

• Previous studies have had less rigorous statistical analysis

Methods

• Retrospective cohort study from the 2007-2009 American College of Surgeons National Trauma Data Bank

• Transports to level I or level II trauma center • Age > 15 • ISS > 15 • Regression Variables: SBP, RR, HR, Motor GCS, ISS,

MOI, age, sex, type of trauma, transport mode • Endpoint: Survival to hospital discharge

Results

• 223,475 patients – 61,909 air/161,566 ground

• Overall, 12.6% of air and 11% of ground transports died

• Propensity score-matched multivariable regression model shows improved odds of survival with HEMS transport to Level I – OR 1.16, 1.14-1.17, p<0.001

Patient Disposition by Transport Type

Limitations/Discussion

• Data base issues • Issues with imputation for missing variables • Potential “convenience sample” • All forms of analysis show similar results for

better outcomes via HEMS transport • No analysis of lower acuity patients

Take Home Points

• Sick trauma patients require definitive surgical care

• In many cases, HEMS transport may be the fastest way to reach definitive treatment

• For the sickest of patients (ISS>15) HEMS transport appears to lead to decreased mortality

Background / Hypothesis

• Eisenberg et al in 1979 found that intervals of

4 min to CPR and 8 min to defibrillation maximized survival

• Basis for most response time goals • Do these intervals have any effect on survival?

Study Design

• 7943 pts with ALS responses linked to ED and inpatient records

• Retrospective study, 1 year of data in single system

• MPDS Echo- or Delta-level events • Response time – interval between receipt of 911

call and arrival of first ALS EMS unit on scene • <8 minutes vs >8 minutes (also analyzed 4 and 9

minutes) • Primary outcome: all-cause mortality

Mortality by response time

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9

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Overall mortality

<8 minutes >8 minutes

Perc

ent

Mortality by Response Time

Take Home Points

• No difference in mortality at 8 min response time

• No adjusted difference in mortality at 4 min or 9 min

• Response time is not associated with all-cause mortality

Background

Does Any Of This Crap Really Matter?

Methods

• Meta-Analysis of Studies Comparing ALS vs. BLS • Eligibility:

– Randomized Controlled Trials – Controlled Before and After Trials – Other Controlled Trials

• Risk of Bias of individual studies evaluated • Outcomes:

– Primary: Survival to hospital Discharge – Secondary: Survival at hospital admission

Fig. 1. Study selection & disposition.

Inclusion/Exclusions Flow Chart 1081 potentially relevant articles

Trauma Results • 9 trials • 16,857 patients • BLS only mortality: 18% • ALS mortality: 29% • OR 0.658, 95% CI:0.594-0.732 • In almost all studies decreased

survival was though to be due to: • Trauma severity (ISS) • Time spent on scene

• Leave-one-Out Sensitivity analysis produced non-significant results

Non-Traumatic Cardiac Arrest Results

• 9 studies • 7,659 patients • ALS was associated

with a 47% increase in survival

• OR 1.468, 95% CI: 1.593-2.631

• 20% of all patients had ROSC

Results

• Trauma: – ALS was associated with 34% lower survival to

hospital d/c – Linked to trauma severity & time spent on site

• Non-trauma: – ALS was associated with a 47% higher survival to

hospital d/c – ALS by physician was associated with a 2 fold increase

in survival – ALS was associated with an increased survival at

hospital admission (only 4 studies available for review)

Limitations

• Limited number of controlled trials • Most controlled trials were before and after • Differences in patients confounders may have

effected outcomes – Partially addressed by regression analysis

Take Home Points

• ALS wasn’t any better for trauma patients • ALS was better for non-trauma patients • MD’s were much better for non-trauma patients

Background

• Little research exists in pediatric prehospital emergency medicine

• Pediatric skills are infrequently used and may be at risk for deterioration

• Due to low frequency and location issues, difficulties exist in identifying issues when treating peds in the field

Types of Errors

Active • “Active errors occur at the

level of the frontline operator, and their effects are felt almost immediately”.

Latent • “Latent errors tend to be

removed from the direct control of the operator and include things such as poor design, incorrect installation, faulty maintenance, bad management decisions, and poorly structured organizations.”

Kohn et al. To Err Is Human: Building a Safer Health System. 2000. p 55

Methods

• Quantitative and Qualitative • On-duty EMS crews • Mobile simulation center, single scenario • Providers asked to respond to 911 call and

manage patient • Outcome: “Performance Scoring Protocol” and

facilitated debriefing

Results

• 45 simulations, 90 subjects • Crews completed an average of 47/76 scorable

items (IQR 57%-66%) • Error Rates: diazepam 47%, midazolam 60% • Major issues (qualitative):

– oxygen delivery – equipment organization – glucose measurement – drug administration – inappropriate CPR


• Single state • Simulation study • Qualitative study design • May have allowed agencies to see their

individual deficiencies • Allowed for determination of overarching

issues in pediatric prehospital care

Take Home Points

• Critical pediatric cases may be few and far between

• Like all skills, pediatric skills may deteriorate without use

• Simulation based training may show deficiencies in perceived abilities

• Review of pediatric skills, procedures and equipment may be needed on a more frequent basis

Study Design

• 1 year of patients injured in Iraq and presenting to a combat support hospital with emergent tourniquet use (prehospital or ED, not OR)

• 499 patients from 13 countries • Shock was defined as weak or absent pulse in an

uninjured limb without a tourniquet • 862 tourniquets were applied to 651 limbs • Sick population – avg initial HR was 105, INR 1.6,

and 16 blood product transfusions

Indications / Exclusions

• Indication: Apply as soon as possible to stop potentially lethal external limb bleeding – All soldiers receive PTLS curriculum

• Exclusions: Detainees and military prisoners; pts with no use of tourniquet

Early Tourniquet Use

• 90% (429/476) survival rate with application before shock – 18% (4/22) survival rate after onset of shock (p <

0.001)

• 89% (374/422) survival rate with pre-hospital application – 78% (59/76) survival rate with hospital application

(p = 0.015)

Tourniquet Application

• 10 patients presented during study with isolated limb exsanguination and tourniquet not available

• All 10 died (0% survival) • 65 deaths in group with application (87%

survival) – 16 deaths from isolated limb exsanguination (late

application) – Most had severe head, abdomen or chest wounds

Adverse Events

• 16 of 651 tourniquet applied limbs had no indication – Replaced with pressure dressings – No morbidity

• One wrong site application (laterality) • One inappropriate application as a venous

tourniquet • 13 misuse cases, addresses with device

changes and training improvements

Take Home Points

• Tourniquet use is safe in battlefield environment • Early tourniquet use (prehospital, pre-shock,

before other intervention) has survival benefit • Few adverse events, small associated morbidity • Tourniquets should be readily accessible – lethal

when in bottom of bag or in vehicle • Further Proof:

Tourniquets Save Lives

Journal of Trauma 2010; 68; 115-121

• Current prehospital plans include immobilization with penetrating injuries

• PHTLS guidelines state spine immobilization is not indicated in patients with penetrating trauma to the head, neck, or torso without neurologic deficit or complaint

• Treatment goals including scene time <10min with rapid transport to appropriate facility

Background

Hypothesis

• For victims of penetrating trauma, spinal immobilization: – Offers minimal benefit – Takes time – Delays arrival at trauma center – So therefore: increases mortality.

Methods

• Retrospective study of ACS NTDB • 2001 – 2004 • All trauma suffering penetrating injury • Must have documentation of “none” or at

least one prehospital procedure – Immobilization= application or c-collar and/or

backboard • Reviewed in-hospital mortality & associated

variables

Methods

• Multiple Logistic Regression – Gender – Race – Age – Injury Severity Score (ISS) – Insurance Status – Year of Admission – Prehospital Procedures

Results

• 45,284 patients • 4.3% immobilized • 8.1% overall mortality • GSW pts more likely to be immobilized

Results

• Number Needed to Treat – Patients with an incomplete spinal injury and required

and operative procedure – 30 of 30,956 patient had a “potential benefit” – NNT = 1,032

• Number Needed to Harm – Number of patients who would need to be immobilized

to be associated with 1 additional death – 14.7% vs 7.2% (p < 0.001) – NNH = 66

Results

Spine immobilized patients were: • 2x as likely to die • More likely to have ISS > 15 • More likely to have a complete injury & undergo

spine surgery • More likely to receive IVF, be intubated, & splinted

• No Sub group had a survival benefit

Limitations

• No hospital transport times available • No differentiation of rural/urban scenes • NTDB is only subset of hospitals • Missing Data • Not randomized

Take Home Points

• Spinal immobilization “wastes precious time” • If you were immobilized you were more than

twice as likely to die • Unstable spinal injures were rare • No subgroup showed a survival benefit.

- Dr. Rabb’s Editorial Comment

Background

• Standard CPR provides less than 25% of healthy blood flow to heart and brain

• Augmentation of negative intrathoracic pressure during the decompression phase may increase venous return and thus increase cardiac and cerebral perfusion

Methods

• Block randomized, multicenter trial in 7 sites in the U.S.

• Standard CPR vs. Active Compression-Decompression with ITD

• Non traumatic cardiac arrest, age 18+ • Endpoint: survival to hospital discharge with

favorable neurologic function (MRS ≦ 3)

Results

• 1269 total patient • Study intervention led to a 53% relative

increase in survival to hospital discharge with MRS of 3 or less – OR 1.58, 95% CI 1.07-2.36 (p=0.019)

• No difference based on initial rhythm


• Study ended early due to financial limitations – Did not reach enrollment goals

• Compression rate in intervention group 80/min

• Providers are not blinded • Which worked? Compression-Decompression

or ITD • Combination does appear to have increased

benefit for good neurologic outcome

Take Home Points

• Active compression-decompression CPR with the use of ITD appears to have benefit over CPR alone

• Manipulation of intrathoracic pressures may lead to better blood flow during CPR

Study Design

• Randomized, double blind trial of impedance threshold device (ITD) in out of hospital cardiac arrest

• Sham ITD vs real ITD • 8718 patients • Primary outcome: survival to hospital

discharge with modified Rankin score <3

Inclusion / Exclusion

• All adult patients with non-traumatic out of hospital cardiac arrest included

• Excluded incarcerated, pregnant, DNR, exsanguination, severe burns, tracheostomy, or mechanical CPR

• Analysis excluded OHCA due to hanging, drowning, electrocution, strangulation, or response time >15 minutes

Survival to Discharge with MRS <3

6.00% 5.80%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

Survival

Sham ITD Active ITD P = 0.71

ROSC at ED arrival

27.80% 27.10%

0%

5%

10%

15%

20%

25%

30%

ROSC at ED Arrival

Sham ITD Active ITD

P = 0.51

Survival to Hospital Admission

26.30% 26.10%

0%

5%

10%

15%

20%

25%

30%

Survival to Hospital Admission

Sham ITD Active ITD

P = 0.84

Survival to Discharge

8.20% 8.20%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

Survival

Sham ITD Active ITD

P = 0.99

No difference in a priori subgroups

Take home points

• No survival with satisfactory function benefit with ITD

• No increase in ROSC, survival to admission, or survival to discharge with ITD

• Overall survival in both groups better than expected secondary to increased focus, teaching and measurement of CPR and its effectiveness

Background

• 10% Cardiac Arrest Survival when resuscitation is attempted

• Bystander CPR improves survival, but is performed less than 30% of the time

• Arizona instituted a state wide compression Only CPR (COCPR) educational initiative

Background

• Goals of the Program: – Increase the rate of any bystander intervention – Increase the proportion of bystander COCPR – Increase Cardiac Arrest Survival

Methods • Prospective, observational cohort analysis • Arizona, January 2005 – December 2009 • Adults (>18) with OOHCA unwitnessed by EMS • 5272 OOHCAs4415 cases for analysis • Providers were trained to identify types of

bystander CPR • Data Points:

Sex, age, location of arrest, bystander witnessed or not, presumed etiology, EMS dispatch-to-scene-arrival time, initial prehospital EKG, CPR type, EMS protocol, therapeutic hypothermia, survival to hospital discharge, and neurologic status

Results

• 45% witnessed arrests • Lay bystander performed CPR in 34%

– 15% conventional, 19% COCPR

• 913 cases with medical professional providing CPR only 71 used COCPR – 2019 cases with lay people 1086 received COCPR

2005 to 2009 Progression

• Annual rate of any bystander providing CPR increased from 28.239.9%

• COCPR increased from 19.675.9% • Overall survival increased from 3.79.8% • Survival in witnessed arrests with shockable

rhythm increased from 10.830.4%

• 4310 were able to have neurologic status f/u – 4.2% were good outcome

• Differed among type of CPR: no CPR 3%, conventional CPR 5.2%, COCPR 7.6%

Limitations

• Observational Study • Risk of ascertainment bias

Take Home Points

• Bystander CPR increased over time • Increased in likely hood of COCPR being done • Significant association between survival and

COCPR compared to either conventional CPR or no CPR

Background

• Conflicting reports on analyze early vs analyze late success

• 2005 AHA/ILCOR Guidelines can provide 2 minutes of CPR prior to analyzing rhythm

• 2010 guidelines report that there is no data to support or refute need for analysis time

Methods

• ROC study • Cluster randomization by EMS

agency/locations – CPR prior to analysis: 30-60 sec vs 180 sec

• Endpoint: Survival to hospital discharge with MRS score of 3 or less

Results

• 9933 patient were included in analysis • No obvious difference between groups • 5.9% in both early and late group were

discharged with good neurologic function • No difference in any sub group analysis


• 36% of patients did not have appropriate length of pre-analysis CPR performed

• Randomized differently in each EMS agency • Part of ROC-PRIMED

– Also evaluated ITD

Take Home Points

• No obvious difference between analyze early and analyze late

• Brief CPR and early analysis may be of greater benefit in patients who received bystander CPR

• CPR while applying defibrillator pads and setting up to analyze is important to maintain blood flow

Study Design

• Retrospective, observational study of all out of hospital cardiac arrest (OHCA) in Japan over 4 years

• Registry of all OHCA, 431,968 entries • Primary outcomes

– Pre-hospital ROSC – Survival at 1 month – Survival at 1 month, CPC 1 or 2 – Survival at 1 month, OPC 1 or 2

• Secondary analysis with propensity matching

Inclusion / Exclusion

• Inclusion – all OHCA, epinephrine measured if field administered

• Exclusion – Age <18, missing data

Results

• 417,188 OHCA met criteria

• 15,030 received Epinephrine

• Pre-hospital Epinephrine became a “pre-hospital skill” during the study – Administration increased from 190 in 2005 to

8,123 in 2008

• Pre-hospital ROSC favors Epinephrine, p < 0.001 • 1 month survival mixed • 1 month neuro intact survival favors no Epi, p <

0.001

• Propensity matched • Pre-hospital ROSC favors epi, p < 0.001 • 1 month survival favors no epi, p < 0.001 • 1 month survival with intact neuro outcome

favors no epi, p < 0.001

Weaknesses

• Low baseline survival rate • Low number of epinephrine cases • No CPR quality data • Limited in-hospital data availability

Take home points

• In this registry, epinephrine improved pre-hospital ROSC

• No clear improvement in survival, harm shown in most groups

• Low rates of intact survival • Low rate of epinephrine administration • Further work, including RCT of epinephrine is

needed

Methods

• A secondary analysis of ROC PRIMED Data • Adults >18, treated, non-traumatic OHCA

receiving OH advanced airway • Comparing:

– Successful SGA or Successful SGA and ETI – Successful ETI

• Choice of airway was at provider discretion • Procedural failures were excluded

Outcomes

• Survival to hospital discharge (with MRS ≤ 3) • 24 hour survival • Return of Spontaneous Circulation (ROSC) • Major Airway or Pulmonary Complications

Results

• 10,455 patients 8487 ETI, 1968 SGA • Type of SGA reported in 1444 (909 King LT, 296

Combitube, 239 LMA) • 85% successful attempts with one device • Survival to hospital D/C: 4.7% for ETI & 3.9% for SGA • ETI had increased functional status on D/C &

increased odds of 24hr survival

• Excluding sites with infrequent SGA use= 5182 patients still had associated increased survival with ETI

• No change in survival among different types of SGAs

Limitations of this observational study

We know how they ended up… we have no idea how they got there • Success ETI on 1st attempt ETI • 2 ETI Failures, SGA sucess SGA • 8 ETI failures Exclude from data • Successful ETI and Successful SGA SGA

Take Home Point

• Patients who ended up with a successful ETI did better then patients who ended up with a successful SGA

• “In a secondary analysis we observed higher survival among patients not receiving any successful airway placement efforts”

• So neither was best!

Background

• 210 million people with COPD and 3 million people die each year

• Oxygen is often given to prevent hypoxemia • Oxygen has become the mainstay of care in

the prehospital setting

Methods

• Randomized, controlled parallel group trial with two arms – Titrated O2 vs High flow O2

• Cluster randomized by Paramedic • Titration arm maintain saturations 88%-92% • Endpoint: prehospital and in-hospital

mortality

Results

• 214 patients with COPD enrolled • Only 135 treated by protocol appropriately • ITT analysis showed difference in mortality

– RR 0.42, 0.05-0.91, p=0.02

• NNH=14 • No statistical difference in per protocol

analysis – Trend towards worse outcomes with high flow 02


• Poor adherence to protocol (63%) – Smaller numbers

• Issues with titrated oxygen were most related to high flow O2 given – Authors argue this would cause less chance of

seeing a difference

• Potentially significant mortality benefit from titrating oxygen in acute COPD exacerbation

Take Home Points

• High flow oxygen is mainstay in prehospital treatment

• Titrated O2 in acute COPD exacerbation may decrease mortality

• May be difficulty in getting prehospital providers to buy into the idea of titrated oxygen delivery

2014 Emergency Medical Services Lifelong Learning and … · and Self Assessment . Andrew McCoy MD...

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Transcript of 2014 Emergency Medical Services Lifelong Learning and … · and Self Assessment . Andrew McCoy MD...