Slovis - Most Important EMS Articles 2013.pptx - Gathering of Eagles
Transcript of Slovis - Most Important EMS Articles 2013.pptx - Gathering of Eagles
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EAGLES 2013 Most Important EMS Articles
2013 Corey M. Slovis, M.D.
Vanderbilt University Medical Center Metro Nashville Fire Department Nashville International Airport
Nashville, TN
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CPR 2013
EMS Airways
TXA
Anaphylaxis
ACC/AHA STEMI 2013
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CPR 2013
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Compression Rate
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• Mean compression rate 112 ( + 19) min • ROSC peaked at 125 • < 80/min or > 140/min significantly
•
Circulation 2012 ;125: 3004- 3012
decreased survival
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BCLS/ACLS 2013 New, Changed, Modified
• Atropine gone in AS and PEA
• Epi’s role continues to decline
• Compression Fraction > 80%
• Rate at 100 -120
• Not faster or slower
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BCLS/ACLS 2013 New, Changed, Modified
• Switch compressors Q 1-2 min
• Depress 2 inches in adults
• Survival by 10%/0.2 inch
• No if above 2 inches
• Metronome or light works
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BCLS/ACLS 2013 New, Changed, Modified
• Interruptions cost 5 -10 compressions
• Perishock pauses must be < 20 seconds
• Mechanical CPR benefits stay
• ITD still controversial too
• Compression – decompression + ITD
controversial
works
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BCLS/ACLS 2013 New, Changed, Modified
• SGAs may be better than ETT
• SGAs may impair carotid blood flow
• Take all VF/VT arrests to lab
• TH for all VF/VT comatose pts
• No ST VF/VT = PCI too!!
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• 2013 Non-VF patients from ROC
• 64% Asystole, 28% PEA
• Median Compression Rate: 110/min
• ROSC 24.2%
• 2% Survival to D/C
Resuscitation 2011;82:1501-1507
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Resuscitation 2011;82:1501-1507
• Increasing CCP = Increased ROSC
• Target a CCP of 80%
Take Home
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Compression should be 100-120 / minute
Not faster, Not slower
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Compression Depth
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• Does Depth of Compression affect
Crit Care Med 2012;40:1192-1198
outcomes from cardiac arrest?
• 1,029 patients from 7 ROC sites
• 2006 – 2009 Data
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ACLS Depth of Compression Recommendations
• 2005: 1.5-2 inches (38-50 mm)
• 2010: 2 inches (at least 50mm)
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As Rate of CPR Increased,
Depth of Compression Decreased
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For each 0.2 inches of increased depth,
survival was increased by almost 10% (up to 2 inches total depth).
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No increased survival for > 2.0 inches of compressions
vs. prior recommendations of 1.5-2.0 inches.
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• ROSC Improved by 24%
• 1 Day Survival Improved by 52%
• Survival to Discharge Improved by 91%
Crit Care Med 2012;40:1192-1198
If Compression 1.5-2.0 Inches
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CPR Compressions Take Homes
• 1.5-2.0 inches is essential for effective CPR
• Depth may fall as rate goes up
(especially above 120)
• We must be vigilant on CPR compression depth
• Need objective measure of depth
• Current Recommendations of > 2 inches may not be based on objective data
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Emerg Med J ;2012 :in press
Can a two tone metronome
Result in deeper compression?
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40
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Mm
Dep
th
Compression Depth
Emerg Med J ;2012 :in press
Normal Fast Very Fast
120 BPM
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Metronomes in CPR Take Homes
• Use of a light or tone is • Two tone may even be better
essential for correct rate
to determine cycle time to maximize depth
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J Emerg Med 2012; 1-5 in press
• Participants knew CPR quickly
• Do we quickly tire doing CPR?
• Manikin Study 62 students
• 5 minutes CPR recorded
was being monitored
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• 7% decline in depth at 1-2 minutes
Rescuer Fatigue Results
• No significant change in rate over 5 minutes
• Fatigue subsequently reported at 167 seconds
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0
10
20
30
40
50
60
1 2 3 4 5
Rescuer Fatigue
Minutes
%
Correct
53%
46% 42% 40%
38%
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Rotating CPR Members Take Homes
Rotate every 1-2 minutes
Every 1 minute may be best
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Airway
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• Great Review
• Authors are two EM Airway Experts
• A must read kind of article
Ann Emerg Med 2012;59:165-175
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• CPAP
• Head Elevation 20o- 30o
• Reverse Trendelenburg
• Jaw Thrust / Nasal Trumpet
• Nasal Cannula at 15 L/min
EMS Preoxygenation Aids
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Prehosp Emerg Care 2011;15:44-49
• 1,414 pts, William Beaumont, Michigan • 1,220 intubated • 613 VF/VT; 742 non VF/VT • Retrospective study
• Does ETI benefit patients?
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Prehosp Emerg Care 2011;15:44-49
• Endotracheal intubation significantly decreased survival to discharge in VF/VT patients by about 50% (OR = 0.52)
• Intubation increased survival to hospital but not discharge alive in AS and PEA
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• Is ETT better or worse than a SGA?
• 10,455 adult OHCA from ROC PRIMED
• 81.2% ETI vs. 18.8% King, Combitube or LMA
• ROSC, 24 hr survival, survival to discharge
Resuscitation 2012: In press
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• Age, sex, bystander CPR, witnessed, initial
Results
rhythm all controlled for in multivariate analysis.
• ETT increased probability of ROSC by 1.78 (95% CI: 1.54 – 2.04)
• ETT increased of 24 hr survival by 1.74 (95% CI: 1.49 – 1.89)
Resuscitation 2012: In press
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• Do SGA’s impair carotid blood flow?
• Is large balloon in retropharyngeal space
Resuscitation 2012;83:1025-1030
• ETT vs. King LTD vs. LMA vs. Combitube
• Animal study: pigs in VF with CPR
deleterious ?
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0
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Open Airway
Mean Carotid Blood Flow ml/min Resuscitation 2012;83:1025-1030
King Combi LMA ETT
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• SGA’s significantly decreased carotid
• SGA’s appear to have potential
• An animal model study
• Imperative that human studies occur
SGA’s vs. ETT Results and Conclusions
Resuscitation 2012;83:1025-1030
blood flow (p < 0.05)
deleterious effects
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We need a prospective multicenter trial before
deciding whether ETI or SGA is better
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• 649,359 prehospital cardiac arrests • Prospective nationwide Japanese Study • 57% bag valve mask ventilation • 43% advanced airway (6% ETT, 37% SGA) • Evaluated which airway “best”
JAMA 2013;309:257-266
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• 6.5% ROSC
• 4.7% 1 month survival
• 2.2% Neurologically good
JAMA 2013;309:257-266
Overall Results
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0.0
0.5
1.0
1.5
2.0
2.5
3.0
Neurologically Favorable at 1 Month
1.0
2.09
JAMA 2013;309:257-266
1.1
ETT SGA BVM
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• Multivarient analysis with all possible arrest variables shows advanced airway techniques decrease likelihood for a neurologically intact pt by 55% for ETT and 63% for SGA.
• Bag valve mask ventilation appeared more than twice as likely to give favorable neurologic outcomes
JAMA 2013;309:257-266
Summary
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• Authors state we need a well done randomized US trial on out of hospital arrest patients
JAMA 2013;309:285-286
“Patients with cardiac arrest and the out-of-hospital rescuers who care for them deserve to know what is best”
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STEMI 2013
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Update to 2004, 2007, 2009 Guidelines Circulation 2013;127:529-555
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2013 ACC/AHA Guidelines D2B
• D2B of ≤ 90 minutes now reads “an ideal of FMC* -to-device time. System goal of ≤ 90 minutes” (1B)
• FMC of 120 minutes or less is new target for patients who arrive at a non-PCI center (1B)
* (FMC = First Medical Contact)
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2013 ACC/AHA Guidelines EMS
• FMC = Paramedic at patient
• 12 Lead performed by EMS (1B) • EMS should transport to PCI hospital (1B)
EMS is now officially the
Beginning of “D2B”… E2B
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2013 ACC/AHA Guidelines PCI and Hypothermia
• Therapeutic hypothermia should be started ASAP for all comatose STEMI patients and out of hospital arrests due to VF or VT (1B)
• Immediate PCI is indicated in all STEMI arrest patients including those who are receiving therapeutic hypothermia (1B)
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E2B < 90 min!!
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TXA
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Lancet 2010;376-23-32
• Does TXA work in severe hemorrhage?
• 20,211 patients with major trauma
• 10,046 patients got TXA within 8 hours
• Hospitals in Africa, Asia, Eastern Europe
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0
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Dea
th (%
)
30d All Cause Mortality Crash-2
16% 14.5%
Lancet 2010;376:23-32
p=0.0035
Placebo TXA
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• Reanalyzes prior CRASH-2 data
• 20,211 trauma patients
• Randomized to TXA or placebo
• Administered up to 8 hours post trauma
Does time to TXA matter?
Lancet 2011;377:1096-1101
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RR
0.68 0.79
1.44
Bleeding Death with TXA vs Placebo Lancet 2011;377:1096-1101
<1 hr 1-3 hr 3 hr
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• Crash-2 showed early TXA reduced mortality from traumatic bleeding
• Could it really affect worldwide mortality?
• Should TXA only be used in third world countries?
BMC Emerg Med 2012;12: 1-7
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TXA Potential Benefits (if given within 3 hours)
BMC Emerg Med 2012;12: 1-7
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Crash- 2
TXA reduces trauma mortality
if given within 3 hours
from bleeding by about 1/3
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• At the present time both the US and British
Current TXA Use
• UK National Health Service recommends
Armies include TXA in trauma protocol
TXA for all major trauma victims
• TXA is now a WHO “ Essential Medication”
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Authors Conclude
TXA has the potential to save between 112,000-128,000 lives per year worldwide
BMC Emerg Med 2012;12: 1-7
if given within 1-3 hours of trauma
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Arch Surg 2012;147:113-114
• TXA vs. no-TXA
• US Troops in Afghanistan • All pts required >1 unit blood • Subgroup got > 10 units PRBC • Retrospective study, 896 pts
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Mortality %
TXA in US Military
23.9% 17.4%
ISS 25.2
ISS 22.5
p =0.03
Arch Surg 2012;147:113-1141
No TXA
N=603
TXA
N=293
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Mortality %
TXA in Massive Transfusion
28.1%
14.4%
p =0.004
Arch Surg 2012;147:113-114
No TXA
N=196
TXA
N=125
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• TXA dramatically decreased mortality
• Benefits greatest in those requiring
Conclusions
• TXA decreased coagulopathy
TXA in the Military
massive transfusion
• TXA increased survival by factor of 7.228 for those requiring massive transfusion
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• Seems to decrease bleeding deaths acutely
• Need to give within 3 hours of event
TXA 2013 Take Homes
• Role in Level 1 Trauma unclear
• Has potential to save 100,000 + lives
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Anaphylaxis
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• Online survey, 3357 NREMTs
• 98.9 recognized classic case
• Evaluated Epi use
• Evaluated routes of admin
Prehosp Emerg Care 2012; 16(4):527-34
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Epinephrine in Anaphylaxis
Only 46.2% said Epi was initial drug in a classic case of a hypotensive, wheezing, tachycardia patient with tingling in his throat & hands, and hives on his chest.
Prehosp Emerg Care 2012; 16(4):527-34
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Epinephrine in Anaphylaxis
• An almost equal number (40%) started
• More gave Epi SQ (58.4%) than
• 1.7% gave Epi IV!
with Benadryl as started with Epi (46.2%)
IM (38.9%)
Prehosp Emerg Care 2012; 16(4):527-34
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← 0.3cc
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• One of the most important EMS
• Half of our paramedics may not give
Anaphylaxis Care
• Too many in EMS (and Medicine) think
Take Home Points
Epi when they should • More than half of our paramedics give
Epi SQ rather than IM
Benadryl is the first line drug for
emergencies
anaphylaxis
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J Emerg Med 2012 in press
without increasing morbidity
• Excellent literature review
• 407 articles screened; 15 evaluated
• TPA is safe and effective
• Use 3-4.5 hrs post stroke improves outcome
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In Summary
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Pump hard, deep, fast, perfect
SGA’s may decrease cerebral flow and survival
Pre-hospital ECG begins D2B
Anaphylaxis needs more teaching
Bag valve mask must be best
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VanderbiltEM.com