Ep 71 - SGA Cage Match: Round 2

Atrial Fibrillation with rapid ventricular response is a common cause of EMS activations and ED visits. It is associated with chest discomfort, palpitations, and hypotension. Treatment is aimed at either rhythm control or rate control with rate control being the most common first line approach. EMS has the potential to treat this condition with medications such as diltiazem, metoprolol, or amiodarone. For those patients with hemodynamic instability, EMS can provide synchronized cardioversion. The question for this podcast, however, is does it matter if EMS treats A Fib or not. Dr. Jarvis recorded this episode in front of a live audience at the State of Jefferson conference in beautiful Ashland, Oregon with Mike Verkest, and special guest Dr Maia Dorsett. 

Citation:

Fornage LB, O’Neil C, Dowker SR, Wanta ER, Lewis RS, Brown LH: Prehospital Intervention Improves Outcomes for Patients Presenting in Atrial Fibrillation with Rapid Ventricular Response. Prehospital Emergency Care. doi: 10.1080/10903127.2023.2283885 (Epub ahead of print).

Dr. Jarvis is joined by OG co-host Mike Verkest and Dr. Brent Myers from NAEMSP 2024. We talk about an intriguing concept in cardiac arrest… giving the initial dose of epinephrine IM instead of starting an IV or IO. They discuss a 2021 paper that compared this approach to standard dosing in a feasibility study done in Salt Lake City. Those authors released some additional data from this study… this time about survival. We talk about the potential ramifications.

Citations:

Pugh AE, Stoecklein HH, Tonna JE, Hoareau GL, Johnson MA, Youngquist ST: Intramuscular adrenaline for out-of-hospital cardiac arrest is associated with faster drug delivery: A feasibility study. Resuscitation Plus. 2021;September;7:100142.

Show Notes:
EMS History is full of interventions we've rapidly adopted, often at great expense and with
disruption of existing processes, that later turned out to, how should I say this..... not work.
Want examples? MAST and high-volume crystalloids in trauma. Mechanical compression
devices, high-dose epinephrine, indiscriminate calcium administration in cardiac arrest. Do I
even need to mention backboards?
The next bright shiny thing promising to revolutionize cardiac arrest resuscitation is Head-Up
CPR. It's certainly expensive and disruptive, but does it improve outcomes? What is the
evidence?
Dr. Jarvis has thoughts. He goes deep on this topic, using a recent paper on Head-Up CPR to
discuss how he evaluates new interventions for adoption. Oh, and he has thoughts on science in
general.

Citations:
1. Moore JC, Pepe PE, Scheppke KA, Lick C, Duval S, Holley J, Salverda B, Jacobs M, Nystrom P,
Quinn R, et al.: Head and thorax elevation during cardiopulmonary resuscitation using
circulatory adjuncts is associated with improved survival. Resuscitation. 2022;October;179:9–
17.
2. Swaminathan A: Heads Up! There is No Association with Improved Outcomes for Head Up
CPR: Why We Must Read Past the Abstract.RebelEM. Available at https://rebelem.com/heads-
up-there-is-no-association-with-improved-outcomes-for-head-up-cpr-why-we-must-read-past-
the-abstract/.
3. Mohan M, Swaminathan AK: Heads Up! Data Dredging Coming Through: Heads Up
Cardiopulmonary Resuscitation Does Not Improve Outcomes. Annals of Emergency Medicine.
2023;February;81(2):244–5.
3. Jarvis J: Not so fast: More evidence needed in head-up CPR.ems1.com. Available at
https://www.ems1.com/ems-products/cpr-resuscitaCon/arCcles/not-so-fast-more-evidence-
needed-in-head-up-cpr-ZK2O7yt5eb8jryYm/. Accessed December 9, 2023.
4. Moore JC: Faster Cme to automated elevation of the head and thorax during
cardiopulmonary resuscitation increases the probability of return of spontaneous circulation.
ResuscitaCon. 2022;Jan(170):62–9.
5. Pepe PE, Scheppke KA, Antevy PM, Crowe RP, Millstone D, Coyle C, Prusansky C, Garay S, Ellis
R, Fowler RL, et al.: Confirming the Clinical Safety and Feasibility of a Bundled Methodology to
Improve Cardiopulmonary Resuscitation Involving a Head-Up/Torso-Up Chest Compression
Technique. Crit Care Med. 2019;March;47(3):449–55.
6. Metro Fire Chiefs: First-In Responders Providing Neuroprotective (“Heads-Up”) CPR as the
Standard of Care for Emergency Medical Services Systems.NFPA. Available at
 https://www.nfpa.org/-/media/Files/Membership/member-secCons/Metro-Chiefs/Urban-Fire-
Forum/2023/UFF23_NPCPR-PosiCon-Statement.ashx. Accessed November 4, 2023.

What would you say if I told you that Black patients were less likely to receive pain medication compared with white patients? My guess is you’d either question the methods, assume it isn’t possible, or ask why. Regardless of what your answer is, you’re going to want to listen to this episode. Mikey V returns to co-host a live episode from the ESO PCRF research forum where we interview Drs Remle Crowe and Jamie Kennel about their new research on this subject. I learned some things and I think you will, too. 

Here's a link to future ESO PCRF research forums:

https://www.eso.com/events/research-forum-pcrf/

Citation:

Crowe RP, Kennel J, Fernandez AR, Burton BA, Wang HE, Van Vleet L, Bourn SS, Myers JB: Racial, Ethnic, and Socioeconomic Disparities in Out-of-Hospital Pain Management for Patients With Long Bone Fractures. Annals of Emergency Medicine. doi: 10.1016/j.annemergmed.2023.03.035 (Epub ahead of print).

Have you heard that you’re supposed to decrease the dose of your sedative when performing RSI on hypotensive patients? First, avoid the question about why you haven’t addressed the hypotension before intubating.. maybe there’s a reason. Maybe. But, regardless of why, intubate you will. What about those doses? I’ve been hearing for years that I should be dropping the dose of sedation prior to RSI. But what evidence are these recommendations based on?

We review a paper today that is aimed at providing some evidence on this question. Oh, and I offer a gratuitous plug for the ESO/PCRF Research Forum nerdvanna. Here’s the URL for more information:

https://www.eso.com/events/research-forum-pcrf/

Citation:

Driver BE, Trent SA, Prekker ME, Reardon RF, Brown CA: Sedative Dose for Rapid Sequence Intubation and Postintubation Hypotension: Is There an Association? Annals of Emergency Medicine. June 2023 (Epub Ahead of Print)

Also discussed:

Pappal RD, Roberts BW, Mohr NM, Ablordeppey E, Wessman BT, Drewry AM, Winkler W, Yan Y, Kollef MH, Avidan MS, et al.: The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department. Ann Emerg Med. 2021;77(5):532–44.

Y’all know I have thoughts on epinephrine in cardiac arrest. And perhaps might have heard me say epinephrine “saves the heart at the expense of the brain”. I’ve also said I don’t have an issue with any epinephrine in arrest, just how we give it currently and have wondered if less epi might do the trick. We review the One and Done paper recently published from North Carolina that looks at this question.

Citations

1.      Ashburn NP, Beaver BP, Snavely AC, Nazir N, Winslow JT, Nelson RD, Mahler SA, Stopyra JP: One and Done Epinephrine in Out-of-Hospital Cardiac Arrest? Outcomes in a Multiagency United States Study. Prehospital Emergency Care. 2022;September 26;27(6):751–7.

2.      Fernando SM, Mathew R, Sadeghirad B, Rochwerg B, Hibbert B, Munshi L, Fan E, Brodie D, Di Santo P, Tran A, et al.: Epinephrine in Out-of-Hospital Cardiac Arrest. Chest. 2023;August;164(2):381–93.

We’ve spoken a lot recently about intubation First Pass Success, including what the definition is. We’ve also discussed different papers about the impact the type of laryngoscope, video or direct, has on first pass success. There’s a new paper out that directly compares video vs direct laryngoscopy. Join us to discuss the DEVICE trial.

Citations Prekker ME, Driver BE, Trent SA, et al. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. N Engl J Med. Published online June 16, 2023 Jarvis JL, McClure SF, Johns D. EMS Intubation Improves with King Vision Video Laryngoscopy. Prehosp Emerg Care. 2015 Ducharme S, Kramer B, Gelbart D, Colleran C, Risavi B, Carlson JN. A pilot, prospective, randomized trial of video versus direct laryngoscopy for paramedic endotracheal intubation. Resuscitation. 2017 Pourmand A, Terrebonne E, Gerber S, Shipley J, Tran QK. Efficacy of Video Laryngoscopy versus Direct Laryngoscopy in the Prehospital Setting: A Systematic Review and Meta-Analysis. Prehosp Disaster Med. 2023 Brown CA, Kaji AH, Fantegrossi A, et al. Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study. Acad Emerg Med. 2020 Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation: a Cochrane systematic review and meta-analysis update. British Journal of Anaesthesia. 2022

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What even IS FPS? There's been a long running argument about the definition of FPS. And by argument, I mean mostly established in the literature with some people just not liking it. FPS is successful ET passage through the cords within 1 attempt at laryngoscopy or when the blade passes the teeth.

That definition worked well when we were using direct laryngoscopy where the hard part of intubation was visualization and the easy part of tube passage. But does it still hold in an age of VL where visualization is easy and tube passage is the hard part.

We discuss a paper on this episode that proposes a new definition, perhaps better meeting the needs of the VL era.

Citation:

Trent SA, Driver BE, Prekker ME, et al. Defining Successful Intubation on the First Attempt Using Both Laryngoscope and Endotracheal Tube Insertions: A Secondary Analysis of Clinical Trial Data. Annals of Emergency Medicine. Published online April 2023:S0196064423002135. doi:10.1016/j.annemergmed.2023.03.021

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Citations: 1. Levin JH, Pecoraro A, Ochs V, Meagher A, Steenburg SD, Hammer PM. Characterization of fatal blunt injuries using post-mortem computed tomography. J Trauma Acute Care Surg. 2023;Publish Ahead of Print. 2. Sakles JC, Ross C, Kovacs G. Preventing unrecognized esophageal intubation in the emergency department. JACEP Open. 2023;4(3):e12951. 3. Chrimes N, Higgs A, Hagberg CA, et al. Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies*. Anaesthesia. 2022;77(12):1395-1415.

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Citation: 1. Bandyopadhyay A, Kumar P, Jafra A, Thakur H, Yaddanapudi LN, Jain K. Peri-Intubation Hypoxia After Delayed Versus Rapid Sequence Intubation in Critically Injured Patients on Arrival to Trauma Triage: A Randomized Controlled Trial. Anesthesia & Analgesia. 2023;136(5):913-919.

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