Administration and Leadership, News

EMS State of the Science: A Gathering of Eagles XVIII

This is a brief, encapsulated report by JEMS editor-in-chief A.J. Heightman from the Eagles conference. He recommends that you go to www.gatheringofeagles.us  after the conference to download and read the full presentation slides, background, research and recommendations, and that you receive your medical director’s approval before implementing any changes to your protocols and care practices.

Friday, Feb. 19, 2016              

Paul E. Pepe, MD, MPH, Eagles Conference course coordinator, opened the 18th annual conference by introducing Dr. Corey Slovis, who was recently awarded the prestigious Excellence in Medical Leadership Award by the American Academy of Emergency Medicine (AAEM). Slovis presented multiple key research findings, which he will further detail next week at EMS Today 2016 in Baltimore, Feb. 25–27. Among these are:

Improved Valsalva maneuver — Slovis told the audience about a new Valsalva maneuver technique that works vastly better than the way we have been doing it in the past. The improved technique involves having the patient lie down with their legs elevated and having them bear down or blow into the discharge end of an empty 10 cc syringe as though they are trying blow the plunger out for 15 seconds.

Amiodarone over Lidocaine —Slovis reported on research that shows we should use amiodarone first over lidocaine for patients in in v fib. He presents detailed information on this topic in the March 2016 issue of JEMS.

Citizen alert apps are showing great promise — Slovis noted that bystander CPR can double survival rates and cited the importance of software products that now alert the public on their phones that a cardiac arrest is near their location.

Decompressing tension pneumothorax via the second intercostal space has been found to have a failure rate of 38%, but a study has shown that by using the anterior axillary line in between the fourth and fifth intercostal space, failure to decompress was just 13%.

 

Standard of Care or Contentious Consensus: 2016 Perspectives on Current Resuscitation Guidelines

Below are key takeaways from presentations delivered thus far at the Eagles conference.

What I am (and what I’m not) using from the New PALS Guidelines — Presented by Peter M. Antevy, MD

  • Should you withhold fluids in pediatric shock? An initial fluid bolus of 20 cc/kg is reasonable.
  • Should you use atropine prior to intubating children? The simple answer: Yes.
  • Should you perform targeted temperature management (therapeutic hypothermia) in kids? Dr. Antevy’s recommendation is that we continue to do TTM on peds (with a goal of 33 degrees).

Managing Cardiac Arrest in Those with Child — Presented by Kathleen S. Schrank, MD

  • You must avoid aortocaval compression by laying a pregnant patient on her left side during non-arrest care.
  • During CPR, it is recommended to use continuous manual left uterine displacement (push the uterus to the left).
  • IV access should be above the diaphragm.
  • You should strive to have at least four people at OB codes with one assigned to pushing the uterus to the left.
  • EMS personnel should NOT be expected to perform perimortem C-sections in the field.
  • Rapid transport to a specialty center is advised.
  • Start fluids early when the patient is in PEA.
  • Defibrillation of the mother is fully acceptable – same procedure as for non-pregnant patients.

Taking the Guessing Out of Decompressing the Pressing: Post-FDA Experience with ACD-ITD CPR — Presented by Jeffrey M. Goodloe, MD, and Joe E. Holley, MD

  • ACD-CPR and the ITD enhance the vacuum effect in the chest.
  • There is real potential for success in cardiac arrest comes during the decompression phase of CPR.
  • Systems are finding improved resuscitation success (early results upward of 60% ROSC in some systems) with the new, FDA-approved ResQCPR combination of active compression/decompression (ACD) and impedance threshold device (ITD).
  • There is a distinct technique involved in using the ACD device.
  • It is more work (about twice the effort over standard CPR) and is therefore further evidence that frequent rotation of compressors is important.
  • Retraining of personnel is critically important.
  • Do not use the ResQPUMP if standing or straddling the patient, because there is a potential to use too much force.
  • A pneumothorax has been found to develop in some patients, so be aware and vigilant in looking for it.
Patient airway pressure with standard CPR vs. notable improvement when an ITD was utilized.
Patient airway pressure with standard CPR vs. notable improvement when an ITD was utilized.
 

The Emerging Role of Intrathoracic Pressure (ITP) Regulation in Resuscitation — Presented by R. J. Frascone, MD

  • The key to the ITD is that it reduces intracranial pressure and allows for better perfusion of the patient’s perfusion.
  • The ITD has a marked effect on increasing intrathoracic pressure by checking/retaining pressure in the chest during the exhalation phase.
  • Frascone recommends the use of the ACD device and the LUCAS mechanical compression device from Physio-Control for optimal resuscitation success.    

Upper Body (“Head Up”) CPR: Elevating the Science on Gravity-Assisted Resuscitation — Presented by Paul E. Pepe, MD, MPH

  • Lowering intracranial pressure is definitely a new key to resuscitation success.
  • Flat CPR increases both arterial and venous pressure, plus pressure in the brain as well.
  • Increased intracranial pressure inhibits blood flow to the brain.
  • A change in the head position (elevated up 30 degrees with the upper body tilted up) during CPR definitively improves perfusion of the brain and neural survival.
  • Early results show head-up resuscitation in Palm Beach County improved ROSC from 16% to 33%.

Paul Pepe, MD, updates the Eagles audience on the amazing results being seen during early trials of CPR with patients elevated 30 degrees up in a waist/head high configuration. The patient elevation shows that intracranial pressure drops and allows for better brain profusion.

Paul Pepe, MD, updates the Eagles audience on the amazing results being seen during early trials of CPR with patients elevated 30 degrees up in a waist/head high configuration. The patient elevation shows that intracranial pressure drops and allows for better brain profusion.

 

A Cerebral Vascular Accident Waiting to Happen: 2016 Approaches for CVA Management

Below are key takeaways from presentations delivered thus far at the Eagles conference.

Managing Strokes with Great Dispatch! — Presented by David A. Miramontes, MD, NREMT

  • San Antonio has had great success with its use of 9-1-1 centers (with paramedic call-takers) to identify stroke patients via the FAST process.
  • Rapid care and transport to stroke centers are emphasized.

Brain Docs Making House Calls: On-Scene Dual-Processing of Neuro Emergencies — Presented by W. Scott Gilmore, MD

  • St. Louis is using an effective crew to physician (call-in) process to expedite assessment, CVA determination and transport of stroke patients.
  • Streamline your processes.
  • Get patients to the CT scanner fast so TPA can be given with best results.
Scott Gilmore, MD, Medical Director of the St. Louis Fire Dept. EMS System displays his Street Medicine Society lapel pin
Scott Gilmore, MD, Medical Director of the St. Louis Fire Dept. EMS System displays his Street Medicine Society lapel pin.
 

Improving Triage for Comprehensive vs. 1o Stroke Centers — Presented by Jason T. McMullan, MD

  • Time is of the essence in assessing and caring for stroke patients.
  • Comprehensive stroke centers make a big difference.

Facilitating Cerebral Embolectomy for Large Vessel Occlusion (ELVO) — Presented by Peter M. Antevy, MD

  • Patients with ELVOS need CAT and CATH lab intervention.
  • You must institute early stroke alerts because it takes time (often 40 minutes) to mobilize the CATH lab and success really depends on mobilizing resources and shaving time off the door-to-TPA time. 

Experience with a Mobile Care Stroke Unit and Its Impact — Presented by David E. Persse, MD

The results from the cooperative mobile stroke unit now in operation in Houston have been very promising and that project is being continued.