10/5/2012 1 Most Important Non-EMS Articles Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville International Airport Nashville, TN 2011-2012 EAGLES Trauma Arrests J Trauma 2011;71:1997-1002 • 294 trauma Arrests over 8 years • Mount Sinai, Chicago • Evaluated Survival • Evaluated Costs • Should we adhere to TOR protocols? • Withhold Care in Blunt Trauma if: Traumatic Cardiac Arrests NAEMSP/ACS-COT Guidelines – Apneic, Pulseless, Asystolic or PEA • Withhold Care in Penetrating: if apneic, pulseless, asystolic, and no signs of life • Do not transport if > 15 min of unsuccessful CPR • Transport penetrating trauma if: organized ECG activity (PEA > 40) +/or signs of life, including pupils J Trauma 2011;71:1997-1002 • 294 patients met TOR criteria, but were transported • 35% arrived with signs of life • 12.6% got ROSC in ED Results ED and ROSC 35% 12.6% 37 103 J Trauma 2011;71:1997-1002
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10/5/2012
1
Most Important Non-EMS Articles
Corey M. Slovis, M.D.Vanderbilt University Medical Center
Metro Nashville Fire DepartmentNashville International Airport
ConclusionsThe animal and clinical data support the conclusion that ECD shocks from a TASER model X26 delivered via probes to the chest can cause cardiac electrical capture. Furthermore, if the capture rate increases sufficiently or if R on T occurs, the development of VF, either directly or via a transition through VT, occurs in animals and, in my opinion, in humans as well.
Douglas P. Zipes, MD
10/5/2012
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There is no reliable data that shows
TASERs to be dangerous in normal patients,
even if performed after high levels
of physical activity.
TASER Take Homes Taser Take Homes
• Safe in normals
• Associated with deaths
• May induce VF
• Repeat taser is drugs bad
• We are still unsure
Repeat ECG’s• Do repeat ECGs make a difference?
Prehosp Emerg Care 2012; Early Online: 1-6
difference in STEMI diagnosis?• Do repeat prehospital ECGs make any
• Repeat sooner if patient has a significantchange in BP, pulse or chest pain.
• Encourage more than 1 ECG
Repeat Prehospital ECGsTake Home
in high risk patients
• Repeat ECG in ED per
• Repeat prehospital ECGs seemreasonable at 10-20 minutes
• Repeat sooner if patient has a significant change in BP,
AHA recommendations
pulse or chest pain
One ECG Begets Another
GIK • Can it decrease ACS → AMI
• Can we affect AMI survival ?
EMS Glucose-Insulin-Potassium
• Does EMS GIK work ?
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12
• Meta-analysis of 9 trials
• 1,932 patients randomized
• GIK reduced hospital mortality
Circulation 1997;76;1152-1156
• Authors recommend large randomized trial
• 28% reduction (p=0.004)
(16.1% vs. 21% ; p=0.004)
• Large multicenter GIK in STEMI Trial
• 470 centers, 20,201 pts
• Patients treated within 12 hrs
JAMA 2005;293:437-446
• GIK should work, does in lab
• IMMEDIATE is randomized blinded trial
• 13 cities, 36 EMS Agencies
• 871 patients, D5W vs. GIK
• Primary Outcome: ACS → AMI
JAMA 2012; 307;1925-1933 • D30% W ( 300 g/ Liter)
GIK Solutions
• 50 units/Liter Insulin
• 80 mcg KCL/ Liter
• Run at 1.5 ml/kg/hr
• Run at 100 ml/hr in 70 kg pi
1015
2025
3035
4045
50
5560
Progression of MIJAMA 2012;307: 1925-1933
52.6%
48.7%
D5W GIK
p=ns
30d Mortality and Cardiac Arrest
0
1
2
3
4
5
6
7
8
9
D5W GIK
6.1%
8.7%
p = ns
4.4%4.4%
JAMA 2012;307: 1925-1933
p = 0.01
Mortality Mortality or Cardiac Arrest
D5W GIK
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• Large multicenter GIK in STEMI Trial
• 470 centers, 20,201 pts
• Patients treated within 12 hrs
JAMA 2005;293:437-446
No differences at 30d in mortality, arrests, cardiogenic shockHF or re-infarction
• EMS GIK may be coming
• May be a cheap and effective ACS Rx
• Safe, cheap, easy to give
• Move to come in next 1-2 years
Glucose, Insulin, and PotassiumGIK Take Homes
Seizure Management• IM Midazolam vs. IV Lorazepam
• 893 prehospital seizing children and adults
• Is either more effective?
• Also evaluated complications
• Double Blind, Randomized, Non-inferiority
NEJM 2012;366:591-600
20
30
40
50
60
70
IV Ativan IV Versed
Seizures Stopped by ED Arrival
63.4%
73.4%
329448
282485
NEJM 2012;366:591-600
p < 0.001for non inferiority
0
1
2
3
4
5
6
7
AT Ver AT Ver
Min
utes
4.8
1.2
Time to Treat and Stop SeizureNEJM 2012;366:591-600
Time to Treat Time to Stop
1.2(6.0)
3.3(4.5)
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• Similar times to stop seizures
NEJM 2012;366:591-600
Results
(Ativan: 6 min vs. Versed: 5 min; p = NS)
• Need for intubation the same
• Recurrent seizures the same
• Less hospital admissions with IM Versed(57.6% vs. 65.6%; p = 0.01)
Pediatric Care
• 45 EMS Crews; Simulated Peds Care
• 6 month old: AMS, SZ, Resp Arrest
• Crews used own equipment
• Two observers rated video observation
• Root cause analysis → 5 error themes
Acad Emerg Med 2012;19:37-47
• Don’t use peds equipment often
• Bags often sealed & tagged; not checked
• If stored with adult equip, not found
• If separate, often lacking equipment
Pediatric Error Themes Equipment Organization & Use
Acad Emerg Med 2012;19:37-47
Pediatric Error ThemesGlucose Measurement
Acad Emerg Med 2012;19:37-47
• Crews often forget to check glucose• Sepsis, AMS, OD:
all may be hypoglycemic
• Incorrect weight estimates
• Incorrect Broselow use
• Drug Calculation Errors
• 64% did not cross check dosages
Pediatric Error Themes Drug Administration
Acad Emerg Med 2012;19:37-47
they were often confused• If IV, IM, IN doses all different,
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Pediatric Error ThemesInappropriate CPR
Acad Emerg Med 2012;19:37-47
• Compressions with pulse present (<100 BPM)
• No pulse check per CPR
• Did not bring O2 to patients
• Could not find peds equipment
• Failed to use OPA in infants
• Poor ventilatory technique
Pediatric Error Themes O2 Delivery
Acad Emerg Med 2012;19:37-47
Expert Pediatric Emergency CareTake Homes
• We need to pay attention to paramedics
• Simulations great for diagnosing training
• Simulations great for teaching
• Pediatric EMS is rarely practiced
pediatric skills and skill retention
(1-2% for many services)
needs Anaphylaxis
• Online survey, 3357 NREMTs
• 98.9 recognized classic case
• Evaluated Epi use
• Evaluated routes of admin
Prehosp Emerg Care 2012 in press
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 in press
10/5/2012
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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!
Prehosp Emerg Care 2012 in press
with Benadryl as started with Epi (46.2%)
IM (38.9%)
• 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
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
In Summary
Atropine No, Epi Early
2 inches at 100-120 BPM
20 seconds or less for perishock pause
Mechanical CPR benefits still unproven
SGA’s may decrease cerebral flow and survivalFollow closely