“Dedicated to the men and women of EMS who advocate daily for the sick and injured,” the 17th annual EMS State of the Science: Gathering of Eagles Conference began bright and early today. The conference is jam packed with topics, faculty and attendees ready to dive into the latest science in EMS, much of which was reported in the latest JEMS/Eagles State of the Science editorial supplement.
The group is credited with advancing the EMS profession with proven equipment and treatment practices such as:
- Adult (EZ-IO) IO use,
- Therapeutic hypothermia during resuscitation,
- Reduced call-to-cath lab times and STEMI/blockage removal results;
- Improved ROSC with expanded use of mechanical compression devices, particularly the Physio-Control LUCAS 2 device,
- Effective use of the impedance threshold device (ITD, ResQPod);
- Implementation of the proven “pit crew” approach to resuscitations,
- Use of the MAD (Mucosal Atomized Device),
- BLS and police administration of Narcan for narcotic overdose reversal,
- Reduced use of full spine boards; and
- ALS (and now BLS) use of CPAP to improve care and reduce intubations and associated—and often fatal—complications such as VAP (Ventilator Associated Pneumonia).
A conference overview and philosophy presented by Raymond L. Fowler, MD, officially dubbed, “The First Eagle,” and course coordinator, Paul E. Pepe, MD, MPH, kicked off the meeting. (See Eagles Conference history and philosophy, and origins and current status.) A customary review of the five most important publications of the past year, presented by Corey M. Slovis, MD, medical director of Nashville EMS, Nashville Fire Department and Nashville International Airport, as well as professor and chair of emergency medicine at Vanderbilt University School of Medicine, followed the opening presentation.
Dr. Slovis’ Top 5 (plus one) Studies of the Year:
Valsalva for PSVF can be Improved and Effective in the Field
The Valsalva maneuver hasn’t been shown to be very effective in most studies. However, Slovis noted that, in EMS, we don’t do it enough. The old way of performing the Valsalva in PSVT has variable effectiveness. It only works 17–54% of the time and is usually only 10–20% effective. However, it’s been found that Valsalva response can be improved—from 5.3% to 31.7%—if you lay the patient flat or in reverse Trendelenburg, and have them bear down maximally for at least 15 seconds, not 5 seconds.
No Morphine Use for MIs
Slovis explained why morphine is no longer the best analgesic in STEMI patients with nitrate refractory CP. Of 300 PCI patients with STEMI, where 95% received MS, it was shown there was increased platelet activity and significant vomiting. Corey’s recommendation: Use Fentynol and antiemetics.
Epi Has Limited Benefit When used During Codes
Slovis showed that four key studies show there is no strong data that Epi works in cardiac arrest.
• Epi versus placebo (1) n = 534 ROSC
No differences in survival or neuro outcome.
• Epi versus High dose Epi (6) n = 6,174
No differences in survival or neuro outcome.
• Epi versus Epi + Vasopressin (6) n = 5,202
No differences in ROSC, admit, survival or neuro.
• Epi versus Vasopressin (1) n = 336
No differences in ROSC, admit, survival or neuro.
He concluded his comments on Epi by stating that we have to continue to watch for new studies showing what happens if we use a combination of Epi with other drugs, such as vasopressors.
Epi and Calcium in CPR
Slovis noted that there’s no conclusive evidence that administration of calcium during CPR improves survival. He recommended not routinely using calcium unless it’s specifically indicated, such as in hyperkalemia.
Hands-on Defibrillation Not Really Recommended
Slovis said he didn’t feel that EMS crews should continue to do CPR during defibrillations and, instead, concentrate on staying on the chest (performing compressions) as much as possible. He said that, if a system chooses to allow hands-on CPR during defibrillation, they should definitely wear gloves and stay away from the defib pads.
“Resolved” STEMIs seen on ED arrival don’t mean the patient hasn’t had an MI
Slovis noted that a UPMS (Pittsburgh) study showed 1 in 5 prehospital STEMI ECGs appearing to have “resolved” (ST segment resolution) didn’t mean that person hadn’t had a STEMI/MI.
Adding a 6th study this year, Slovis asked that all EMS personnel work to improve their health, citing a study showing that running at any speed for 51 minutes every day can significantly improve their health and longevity.
All Disasters Are Global: Yesterday, Today and Tomorrow at the National Disaster Medical System (NDMS)
Andrew L. Garrett, MD, from ASPER (the Office of the Assistant Secretary for Preparedness and Response), reviewed the three primary roles of the 6,000 member/86 response team NDMS system:
1. Medical Response
2. Patient Evacuation by air from affected areas
3. Delivery of definitive care through the Disaster Medical System teams
First Core Area Discussed at the 2015 Eagles Conference
New Utility in Determining Futility: Two-Thousand & Fifteen Ways for Dealing with Termination of Resuscitation and Using Technology to Ensure Better Decision-Making
Stay, Stay, Stay, Stay, Stay – Just a Little Bit Longer! Why we’re Raising the Limits on On-Scene Termination of Resuscitation
Presented by J. Brent Myers, MD, MPH (Raleigh/Wake County)
Myers told the attendees that the old 25 minute resuscitation termination “rule” no longer applies. His Wake County data now illustrates that you can have neurologically intact survivors even after an hour of resuscitative efforts if you do the right things, such as using the coordinated pit crew approach for resuscitative efforts.
He pointed out that the delivery of uninterrupted compressions, use of an ITD (ResQPod) and hospital cooling during resuscitative efforts makes a difference.
He noted that an experienced provider must make a decision whether to continue the resuscitation after 25 minutes and that the decision should involve a combination of rhythm and continuous ETCO2 waveform interpretation. At present, his system’s experience has been that the “number of minutes” is somewhere around the 30-minute mark.
I’ll Echo That! Prehospital Use of Ultrasound in Terminating Efforts
Presented by Andrew J. Harrell, MD (Albuquerque)
Harrell reported that, while few EMS systems are currently using ultrasound in the field, his system has found that prehospital ultrasound can assist in determining when to cease codes—his system uses two small units in the field.
Often just used in trauma cases via FAST exam, Albuquerque, Minneapolis and Odessa (Texas) Fire Department use have found, with portable ultrasound use on PEA patients to determine cardiac standstill, you can determine proper hand position during codes and make a decision on the futility of effort—as reported on in JEMS. Review the REASON 1 trial at www.clinicaltrials.gov.
TEE-ing Off the Cardiac Arrest Sand-Trap: Shadow-Boxing for CPR Vectors, Missed VF & Pseudo-PEA
Presented by Scott T. Youngquist, MD (Salt Lake City)
Using Transesophageal Echocardiography (TEE) in cardiac arrests, Salt Lake City physicians are showing we may be able to more accurately make decisions on termination in the field in the future, particulary because 31% of SVTs aren’t properly interpreted and 16% of AED interpretations don’t advise for the shock that should occur.
The promising potential for TEE is that it may help us identify PEAs that aren’t currently being treated and should be, as well as assist in the placement of the hands properly for cardiac compressions to maximize cardiac output. TEE has been valuable more than 30% of the time in determining the cause of a cardiac arrest. However, a current detractor for this compact technology is the $30,000 cost of TEE units.
It is a “No-Brainer”: Using Bispectral Index (BIS) Monitoring (to determine blood flow to the brain) in Determining Futility
Presented by R. J. Frascone, MD (St. Paul)
Frascone cited the case of Tim Franko, a LUCAS/ITD survivor who had 32 defibrillations and LUCAS 2 compressions applied for two hours and 45 minutes, survived through to the cath lab with successful clot removal, and was discharged neurologically intact, as an example why codes cannot be terminated if there are solid indicators of brain perfusion— as reported in the JEMS 2014 EMS Supplement. With the ITD and LUCAS 2 in use, this patient showed clear response to care through eye and body movements.
Frascone said that BISS (Bispectral Index Monitoring) is showing promising results by allowing us to “look” at cortical activity in the brain and determining the 35–50 sweet spot/normal range where success can still be achieved.
He was clear that ITD use, LUCAS 2 compressions and ECMO are now showing to be a big part of solving the cardiac arrest puzzle through proper brain resuscitation.
Second Core Area Discussed at the 2015 Eagles Conference
Resuscitating Resuscitation: New Technologies and Approaches to ROSC
Ghost in the Machine: Do Mechanical Compressions Actually Worsen Outcomes?
Presented by Michael K. Levy, MD (Anchorage)
Levy said the studies on mechanical CPR devices aren’t always showing the true head-to-head comparison of manual versus mechanical CPR devices. He said it’s more important to look at the metrics of how people are trained and how they deploy the device than some of the studies.
In his system, they have very positive results with the LUCAS 2 device because they can now put it on in less than seven seconds with very limited interruption in compressions or per-shock pause.
In Anchorage, through a very coordinated application effort where they put the LUCAS back plate in during two rounds of manual CPR and then apply the gantry in place, there’s very limited interruption in compressions and therefore limited loss in perfusion pressure. He noted that mechanical compression devices offer a better solution for consistent compressions and in the resuscitation of re-arrests.
Tennessee Two Step: Memphis’ Advice on the Physio-Control LUCAS 2 Device
Presented by Joe E. Holley, MD (Memphis)
With 125,000 runs and full use of LUCAS 2, Memphis has found that the device has allowed them to improve ROSC by at least 10% over manual CPR, thanks to their consistency of compressions.
Not Much Pause Should Be Your Cause: 2015 Ways to Analyze Cardiac Arrest Performance
Presented by Jeffrey M. Goodloe, MD (Tulsa & OKC)
With 1,271 cardiac resuscitations annually, Goodloe showed that sound fundamentals are the keys to successful resuscitations. He stressed that elimination of peri-shock pauses (keeping them to 10 or less seconds) and use of metronomes to keep you from giving compression >120 per minute. He said that, with the impedance compression device, the max may actually be 110 per minute.
Goodloe’s take-away messages were:
1. Fundamentals always matter,
2. Going faster (higher) than 110–120 will definitely result in fewer resuscitations, and
3. The use of metronomes, and a regimented plan and coordinated approach to resuscitations, can truly impact and improve ROSC and survival of patients with no neurological deficit.
Don’t Mind the Pressure – Go with the Flow: “Heads-Up” CPR may soon be a method to improve resuscitations
Presented by Paul E. Pepe, MD, MPH (course director)
Pepe presented an amazing new finding by noted researcher Keith Lurie, MD, founder of Advanced Circulatory Systems (now owned by ZOLL) and ResQPod ITD developer, that shows dramatic results in resuscitation with just a 30% elevation of the patient during resuscitation.
All indications are that this simple change in patient position will significantly reduce intracranial pressure and help us resuscitate patients.
Proven now in animal labs, this slight elevation (Head-up CPR):
• Improves blood flow to the brain (brain perfusion).
• Reduces intracranial pressure (ICP) and therefore improves cardiac arrest resuscitations and successful outcomes of codes with no neurological deficit.
Eagles “Bullet” Rounds
1. AED Firing in the Awake Patient –Dave Keseg, MD (Columbus), reported on a 9-year-old boy who was shocked by an AED that in turn shocked (200 J) an awake SVT (WPW) patient at a school. It resulted in the school changing their protocol to not push the AED.
2. STEMI Right into The Lab – Glen Asaeda, MD (FDNY), reported on great success of moving patients directly to the cath lab.
3. Mobile Stroke Care – David Persse, MD (Houston), reported on a new regional mobile stroke unit that’s being used in his region by sending a small, mobile CT scanner to the scene. It’s showing that 42% of the patients can receive very effective stroke care in less than 55 minutes. Check back with JEMS for a detailed update on this model.