10/31/2018
1
EMS World Expo
The Most Important Recent Practice-Changing
EMS Articles for 2018Corey M. Slovis, M.D.
Vanderbilt University Medical CenterMetro Nashville Fire DepartmentNashville International Airport
Nashville, TN
Epinephrine
Anesth Analg 1963;42:599-606
• The two fathers of modern CPR
• Both anesthesiologists
• Baltimore City Hospital, Johns Hopkins, University of Maryland
• Used small dogs to evaluate drugs in CPR Anesth Analg 1965;44:746-52
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0.48
0.30
Epi Dosing and SurvivalCPC 1 - 2
1 Mg 2 - 5 Mgs
0.23
> 5 Mgs
OR
JACC 2014;64:2360-7
Resuscitation 2018;124:43-48
Could less than 1.0 mg be better dose of epinephrine?
• 2,255 pts from Seattle, 2008-2016• 554 (24.6%) VF/VT; 1,701 (75.4%) AS/PEA
• Before and after type study• VF/VT: 0.5 mg min 4, 8; AS/PEA: 0.5 mg Q 2 min• Evaluated ROSC, Discharge, CPC 1-2
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Low Dose Epinephrine
• Not a randomized trial
• Cross overs from either group
• 3.4 mg vs 2.6 mg in VF/VT; 3.5 mg vs 2.8 mg in AS/PEA
Reducing the dose of epinephrine in OOH cardiac arrests does not affect ROSC, hospital discharge frequency or neurologic outcomes in
either shockable or non-shockable rhythms
Epi improves ROSC
Summary as of 8/20/18
Survival benefits unproven
Give early, not late
Give after second shock in VF
Await London study
New Engl J Med 2018;379:711-21
• Large double blind placebo controlled trial
• 8,014 pts, UK EMS, adults ≥ 16 yo
• 4,015 pts, 1 mg epi Q 3-5 min
• 3,999 placebo receiving patients
What is the role of epinephrine in cardiac arrest?
The study evaluated 30 day outcomes and functional neurologic outcomes at
discharge and at 3 months
New Engl J Med 2018;379:711-21
Times and Dose
6.6 min Call to EMS arrival (median)
21.4 min Call to epinephrine or placebo
4.9 ± 2.5 mg Epinephrine dose (mean)
New Engl J Med 2018;379:711-21
0%
10%
20%
30%
40%
50%
60%
30.7
ROSC and EMS Transport
ROSC EMS Transport
11.7
Placebo Epi Placebo Epi
New Engl J Med 2018;379:711-21
36.3
50.8
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3
0%
1%
2%
3%
4%
5%
2.4%
30 Day Survival
Placebo
3.2%
Epinephrine
New Engl J Med 2018;379:711-21
OR = 1.39p = 0.02
NNT = 112
New Engl J Med 2018;379:711-21
30 Day Neurologic Outcomes
0.0
0.5
1.0
1.5
2.0
2.51.9%
Rankin 0 - 3
Placebo
2.2%
Epinephrine
New Engl J Med 2018;379:711-21
OR = 1.18CI = 0.86-1.61
0.00.10.20.30.40.50.60.70.80.91.01.11.21.31.41.51.6
1.35%
Favorable Neurologic OutcomeRankin 0 - 2
Placebo
1.29%
Epinephrine
New Engl J Med 2018;379:711-21
0%
10%
20%
30%
40%
50%
60%
17.8%
Severe Neurologic Disability (30 d)Rankin 4, 5
Placebo
31.0%
Epinephrine
New Engl J Med 2018;379:711-21
Adjusted AnalysisParamedic Witnessed
Favors Placebo Favors Epinephrine
New Engl J Med 2018;379:711-21
10/31/2018
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Adjusted AnalysisVF/pVT vs Non Shockable
Favors Placebo Favors Epinephrine
New Engl J Med 2018;379:711-21
Adjusted AnalysisMedical vs Traumatic
Favors EpinephrineFavors Placebo
New Engl J Med 2018;379:711-21
Positive Result Conclusion
Epinephrine in OOHCA arrest improves ROSC and likelihood
for hospital discharge
Neutral Result Conclusion
Epinephrine does not improve neurologically intact survival
in OOHCA
Negative Result Conclusion
Epinephrine in OOHCA just increases the likelihood of being neurologically
devastated without significantly increasing the number of neurologically
intact survivors
Antiarrhythmics in Cardiac Arrest
10/31/2018
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Resus 2018;132:63-72
• 14 randomized trials; 8 observational studies
• 1 additional pediatric observational study
• 1,213 pts studied with Amiodarone vs placebo
• 987 pts Amiodarone vs Lidocaine
• 19,517 pts Lidocaine vs placebo
How effective are antiarrhythmics in VF/pVT arrests?
Antiarrhythmics vs PlaceboAmiodarone, Lidocaine, Magnesium
Resus 2018;132:63-72
No proven benefits of antiarrhythmic therapy in cardiac arrest due to shockable rhythms
in OHCA when measuring survival to hospital discharge and especially when
evaluating favorable neurologic outcomes and long term survival.
Resus 2018; 132: 63-72
Do Antiarrhythmics Make A Difference?
Bicarbonate in CPR
Resuscitation 2017;119:63-9
How does bicarbonate administration during CPR affect outcome?
• 15,601 OOH cardiac arrests Vancouver
• 5,165 (37%) received IV bicarbonate
• Evaluated survival and good neuro outcome
• Also performed propensity scoring comparisons 0123456789
1011121314
12.3%
10.8%
Bicarb vs No BicarbUnadjusted, Unmatched
Resuscitation 2017;119:63-9
Survival Good Neuro
1.6%
Bicarb No Bicarb Bicarb No Bicarb
%
1.3%
10/31/2018
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Adjustment via propensity analysis required, as patients getting
bicarbonate usually are in arrest longer with refractory arrests and higher total doses of epinephrine
Bicarbonate in Cardiac ArrestResuscitation 2017;119:63-9
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.03.5%
2.8%
Bicarb vs No BicarbPropensity Analysis
Resuscitation 2017;119:63-9
Survival Good Neuro
2.2%
Bicarb No Bicarb Bicarb No Bicarb
%
OR=0.64 OR=0.59
1.8%
Bicarbonate in Cardiac ArrestsTake Homes
• Don’t routinely use
• Decreases survival and favorable neuro
• Generates CO2 and is hyperosmolar
• Use for pre-existing acidosis or OD(DKA, sepsis, methanol, EG, TCA)
• Great in Hyperkalemia
• 100,029 CPR patients, 349 hospitals
• 4,173 (4%) got D50W
• Compared D50 to no D50
• Looked at ROSC, discharge, neuro outcome
Critical Care 2015;19:160
Is glucose helpful or dangerous in cardiac arrest?
Do not use!
• Decreases survival to discharge ( 51%)
• Decreases neurological outcomes ( 67%)
• Has no benefits and is dangerous
Glucose is Bad in CPRUnless Patient Hypoglycemic
What do you do after 3 unsuccessful shocks?
We need to have a strategy for refractory VF
10/31/2018
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Refractory VFib
• Move pads Ant-Lat Ant-Post
• Consider Beta Blockade
• Consider Double Sequential Defibrillation (DSD)
• PCI
• ECMO
Resuscitation 2017;117:97-101
Is double sequential defibrillation (DSD) beneficial in refractory VF/pVT?
• 45 patients treated with DSD
• Retrospective observational study
• London Ambulance Service
• Compared to 175 who got standard defibrillation
• Only patients with ≥ 6 shocks compared
• 3 standard Ant-Lat defibrillations
• Anti-arrhythmic administration
• 3 standard Ant-Post defibrillations
• Double sequential defibrillation
• Done 3 – 4 seconds apart
Double Sequential ProtocolResuscitation 2017;117:97-101
0
5
10
15
20
25
30
35
40
45
50
55
60
35%38%
Standard vs DSD in VF/pVT
EMS ROSC
56%59%
Resuscitation 2017;117:97-101
%
STD STDDSD DSD
6.6% 7%
Discharged
STD DSD
Hosp ROSC
Double Sequential DefibrillationTake Homes
• Not a randomized trial
• Many pts got up to 10 shocks pre DSD
• The role of Double Sequential Defibrillation is not yet clarified and needs a randomized larger trial
10/31/2018
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Annals Emergency Medicine 2018;71:109-12
Is Dual Sequential Defibrillation (DSD) dangerous to the defibrillators?
• Zoll M and/or Physio-Control LP 15s
• Two DSDs: 1 Zoll & 1 LP @ 560 J synched
• Two DSDs with 2 LPs at combined 720 J
• All 4 DSDs done A-P
• One LP found to become nonfunctional
Dual Sequential DefibrillationTake Homes
• May not be more effective
• May damage defibrillator
• Is a crowd pleaser
ECMO
Resus 2018;132:47-55
• 100 transported VF/pVT pts
• University of Minnesota in Minneapolis
• All pts 3 shocks without ROSC
• Amiodarone 300 mg IV
• EMS transport with LUCAS device
Does ECPR really improve survival s/p refractory VF/pVT arrest?
EMS Cardiac Cath Labin less than 30 minutes
ECMO begun ASAP in CCL
Resus 2018;132:47-55
Declared Dead on CCL Arrival
• ETCO2 < 10 mm Hg
• PaO2 < 50 mm Hg
• Lactate > 18 mmol/L
• EMS CCL time > 90 min
10/31/2018
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hun
dre
ds
Fate of 100 Refractory VF/pVT pts
CCLResus
Good NeuroCPC 1
92%
CVICUAdmit
Poor Neuro
83%
7.2%
Resus 2018;132:47-55
48%
ECPR Complications
• Mean time on ECMO 3.5 days
• All patients developed MOSF
• Anoxic CNS insult #1 cause of death
• ¼ of pts will have CPR trauma
• Requires team of intensivists, surgeons, cardiologists
Resus 2018;132:47-55
Resus 2018;132:47-55
Does ECPR really improve survival s/p refractory VF/pVT arrest?
48% good neuro forShock resistant VF/pVT
Airways
JAMA 2018;320:769-778
• 3,004 pts, 27 EMS agencies, ROC study
• Pragmatic crossover randomization, 13 clusters
• King LT SGA vs ETI
• Secondary outcome: Favorable neurologic outcome
Is Endotracheal Intubation (ETI) superior to a Supraglottic Airway (SGA) in OOH Cardiac Arrest?
0%
5%
10%
15%
20%
18.3%
72 Hour SurvivalSGA vs ETI
SGA
15.4%
ETI
p = 0.04RR = 1.19
JAMA 2018;320:769-778
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0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
7.1%
Hospital Discharge-Favorable NeuroSGA vs ETI
SGA
5.0%
ETI
p = 0.02CI = 0.3%-3.8%
JAMA 2018;320:769-778
0%
10%
20%
30%
40%
50%
Hun
dre
ds
4.5%
Unsuccessful or ≥ 3 Attempts
Unsuccesful ≥ 3 Attempts
11.8%
SGA ETI SGA ETI
44.1%
18.9%
JAMA 2018;320:769-778
Additional Findings
• 2 x pneumothoraces with ETI (7.0% vs 3.5%)
• 2 x rib fractures with ETI (7.0% vs 3.0%)
• Airway misplacement or dislodgment (1.8% vs 0.7%)
• Only 51% ETI success rate
JAMA 2018;320:769-778
SGA vs ETITake Homes
• SGAs are easier to insert successfully
• SGA or ETI easily justifiable first airway
• Oxygenation must be focus (not ETI vs SGA)
• Hypoxia is our enemy
• I believe mandates ETI focused service to aggressively train to use an SGA as rescue after 1-2 fails and/or hypoxic patients
JAMA 2018;320:779-791
• 9,296 patients, pragmatic study
• 4 ambulance services, England
• Computer generated randomization
• SGA: I-Gel, ETI: Direct and Bougie
• Utilized modified Rankin Score
Is Endotracheal Intubation (ETI) really superior to a Supraglottic Airway (SGA)
for ultimate neurologic outcome?
0%
1%
2%
3%
4%
5%
6%
7%
8% 6.4%
All Randomized PatientsRankin 0-3
SGA
6.8%
ETI
p = nsCI = 0.6%-0.3%
JAMA 2018;320:779-791
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0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
3.9%
Received Advanced Airways (81%)Rankin 0-3
SGA
2.6%
ETI
OR = 1.57CI = 1.18%-2.07%
JAMA 2018;320:779-791
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
4.2%
First Airway UsedModified Rankin 0-3
SGA
2.0%
ETI
OR = 2.06CI = 1.51%-2.81%
JAMA 2018;320:779-791
Additional Findings
• SGA significantly better for ventilation within 2 attempts (87.4% vs 79%)
• No overall differences in vomiting or aspiration
• More pre-intubation vomiting/aspirations vs more seen post SGA insertion
• 2 x loss of SGAs than ETI
JAMA 2018;320:779-791
Take Home
The choice of using an I-Gel as a supraglottic airway vs endotracheal intubation should be
service chosen –
Neither proved clearly superior
But SGAs easier to use successfully
Resus 2018 Aug 30;epub ahead of print
How many endotracheal intubations during cardiac arrest does it take
to be competent at ETI?
Resus 2018 Aug 30;epub ahead of print
• How long to become “Qualified”- ETI < 60 sec during CPR- No complications
• How long to become “Highly Qualified”- ETI < 30 sec during CPR- No complications
• CPR interruptions must < 10 sec
• Required a 90% success rate
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Resus 2018 Aug 30;epub ahead of print
• First study to prospectively evaluate
• Began with 1st year Korean ED residents
• Utilized video review of ETIs
• Direct laryngoscopy only, no video DL
90% successful ETI < 60 secrequires at least 137 patient
attempted intubations
Resus 2018 Aug 30;epub ahead of print
Expertise in ETI during CPR
90% successful ETI < 30 secrequires at least 243
attempted intubations
Resus 2018 Aug 30;epub ahead of print
Expertise in ETI during CPR90% ETI Success < 30 sec
Number RequiredResus 2018 Aug 30;epub ahead of print
90% ETI Success < 30 secDays Required
Resus 2018 Aug 30;epub ahead of print
Becoming an expert in invasive airway management requires years,
not months, and hundreds of invasive airway attempts
ETI Expertise during CPRTake Home
10/31/2018
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JAMA May 2018;319:2179-89
Does routine Bougie use improve likelihood of first pass endotracheal intubation success?
• 757 patients randomized, Hennepin Med Center
• Bougie first vs ETT with Stylet
• Done with Mac blades and Storz C-MAC
• 58% DL; 21% all video; 20% video passage
• ½ (380) of pts had difficult airway characteristics
JAMA May 2018;319:2179-89
• Difficult vs All vs WNL airways
• Difficult = 1 or more:- Body fluids obscuring view- Airway obstruction or edema- Obesity, short neck- Small mandible, large tongue- Cervical spine immobilization
Bougie vs ETI with StyletComparison Groups
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
96%
82%
Bougie vs ETI with Stylet
Difficult
98%
87%
JAMA May 2018;319:2179-89
Bougie BougieETT ETT
99%
87%
WNL Airway
Bougie ETT
All
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
100%
78%
Most Difficult Airways
C Spine Immobilized
96%
75%
JAMA May 2018;319:2179-89
Bougie BougieETT ETT
97%
60%
Incomplete glottic views
Bougie ETT
Obese
Bougie Use for ETITake Homes
• Use bougie’s more
• They are central to airway management
• Start with a bougie on difficult airwaysor go to one quickly after first look
Circulation 2018;137:2114-24
Does post-resuscitation hyperoxiaadversely affect neurologic outcome?
• 280 pts, multicenter prospective trial
• 38% (105 pts) were hyperoxic: PaO2 > 300
• All pts comatose, ventilated, received TH
• 55% overall survival, 70% overall poor neuro
10/31/2018
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0%
10%
20%
30%
40%
50%
60%
70%
80%
Hun
dre
ds
77%
Poor Neurologic OutcomeCirculation 2018;137:2114-24
65%
P=0.035
Hyperoxia No Hyperoxia
Hyperoxia and Poor Neurologic OutcomeAdjusted Relative Risk
Circulation 2018;137:2114-24
Each hour of hyperoxiais independently associated
with a 3% increase in poor neurological outcome
Oxygenation S/P Arrest Once ROSC Obtained
• Maintain O2 saturation below 100%
• Aim for 95-96%
• Await further refinements
100% by non-rebreather s/p arrest in normotensive patients is no longer good care
STEMI
Prehosp Emerg Care 2018 Mar 29:1-7
How important is minimizing EMS response and on-scene time with STEMI patients?
• 550 pts from Charlotte NC, Mecklenburg EMS
• Mean 911 to PCI time 81.8 min (SD = 20)
• Evaluated mortality at one year
• Survival was evaluated vs 911 to PCI time
• Multivariate analysis: age, sex, BP, prior AMI etc.
10/31/2018
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For every one minute increase in time to PCI, the odds of survival
decrease by 3%
Mortality for STEMI increases by 30% for every 10 minute delay
J Emerg Med 2018;55:71-7
How good is our software in diagnosing *** STEMI ***
• San Diego EMS 2012 data
• False notifications were evaluated
• Significant with new monitors
• 6 mos pre and post new algorithm
• Decreased false positives: 64% to 28%
True STEMI
Before• False STEMI = 150/234
After• False STEMI = 40/138
J Emerg Med 2018;55:71-7
Non STEMI “STEMIs”What To Beware Of
• RBBB
• LBBB
• Atrial Fibrillation
• Benign Early Repolarization
• Pacer
• Poor Quality ECG
STEMI IdentificationTake Homes
• Beware most common false positives
• BBB and Poor Quality are our enemies in prehospital alerts
10/31/2018
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STEMI Evolution
EMS ECG
ED ECG 12 minutes later
• 83 prehospital ECGs with STEMI
• 217 EMS agencies; UPMC Medical Control
•All patients went to cath lab
Prehosp Emerg Care 2014;18:174-179
How often does a prehospital STEMI arrive with a resolved ECG?
0
10
20
30
40
50
60
70
80
90
100 n = 83 78.3% (65)
STEMI Resolution
Total AMI
ED STEMI
21.6% (18)
ST Resolution
Prehosp Emerg Care 2014;18:174-179
• 1 in 5 prehospital STEMIs have ECG changes
• There was no difference in % occlusion in those
• Patients without STEMI resolution are more
Prehosp Emerg Care 2014;18:174-179
that resolve prior to ED arrival
with and without ST resolution of STEMIECG changes
likely to have multivessel disease
10/31/2018
17
ST segment resolution of a STEMI still
equals a STEMI and mandates rapid
transport to coronary catheterization
ST Segment Resolution = NO STEMI
Prehosp Emerg Care 2018;Jan 16:1-8
Do serial 12 leads during EMS transport add any useful information in diagnosing a STEMI?
• 728 STEMI transports, Quebec EMS
• Used BLS-EMTs transmitting Q 2 minutes
• 24 minute average transport time (15-38)
• “Persistent” STEMI vs “Evolution” vs “Loss”
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
Dynamic STEMI ECGs15.7% (114 / 728)
No STEMI STEMI STEMI No STEMI
Prehosp Emerg Care 2018;Jan 16:1-8
4.5%
STEMI No (multiple changes)
7.7%8.0%
Results
• 84.3% of STEMIs were persistent
• 15.7% of STEMIs were dynamic
• 8% of STEMIs not evident on first ECG
Prehosp Emerg Care 2018;Jan 16:1-8
STEMI Evolution
• 12.3 min was median time from No STEMI
• Females had more dynamic changes then men
• Longer transports = more dynamic changes
Prehosp Emerg Care 2018;Jan 16:1-8
Some STEMIs stay persistent
Some STEMIs “come and/or go”
Prehosp Emerg Care 2018;Jan 16:1-8
10/31/2018
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No STEMI STEMITake Homes
One ECG begets another
EMS and STEMI Take Homes
• Time = muscle
• Time = survival
• Minimize all intervals
STEMI No STEMITake Homes
A STEMI is a STEMI if seen even just once!!
Anaphylaxis
True Definition of Anaphylaxis
• Reduced BP after exposure to known
• Acute onset of skin or mouth symptoms
• Involvement of 2 or more systems:– Skin– Mucous membranes– Respiratory– Cardiovascular– Gastrointestinal
allergen
plus wheezing or hypotension/tachycardia
Pediatrics 2017;139:e20164006
Epinephrine is the drug of choice
10/31/2018
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The #1 cause of death in anaphylaxis is the failure to give epi in a timely manner
Prehosp Emerg Care 2018;22:452-6
• 471 anaphylaxis pts, NC database, 2010-13
• All patients had “allergic reactions”
• Anaphylaxis: either hypotension and/or respiratory distress
How often is epinephrine administered to patients < 18 yo with anaphylaxis?
Only 32.4% of patients received epinephrine
Age < 10 Epi use by almost 3x
Prehosp Emerg Care 2018;22:452-6
Atrial Fibrillation
Acad Emerg Med 2018;in press August
• 450 pts, double-blind, placebo controlled
• 3 groups of pts from 3 Tunisian hospitals
• High dose vs Low dose vs Placebo
• MgSO4 9 grams vs 4.5 grams vs Placebo
• Given over 30 minutes
Is Magnesium effective for rate control in “Rapid” Atrial Fibrillation?
10/31/2018
20
Measured effectiveness as HR < 90or rate lowering by > 20%
Acad Emerg Med 2018;in press August
0%
10%
20%
30%
40%
50%
60%
70% 59.5%64.2%
EffectivenessHR < 90 or HR > 20%
9 Grams 4.5 Grams
43.6%
--
Acad Emerg Med 2018;in press August
High Dose Mg Low Dose Mg Placebo
This paper is not what it seems
Acad Emerg Med 2018;in press August
• Essentially all patients got other rate control agents
• 45-50% received Digoxin
• 30% received Diltiazem
• 20% received Beta Blockade
Magnesium for Rate Control in AFTake Homes
• Adjunct? – maybe; Primary – NO
• 2.5 grams or 4.5 grams?
• 9 grams = lots of flushing (10-15%)
• Was very safe, < 1% hypotension
• Read this paper carefully
Annal Emerg Med May 2018;72:184-93
How effective is inhaled isopropyl alcohol vs oral ondansetron for nausea?
• 120 subjects
• 41 isopropyl vs 41 oral ondansetron vs 40 both
• Placebo controlled with inhaled or oral placebo
• Used visual analog nausea scale
• Also evaluated rescue antiemetic therapy
0%
5%
10%
15%
20%
25%
30%
35%32%
9%
Mean Nausea Decrease
Inhaled Isopropyl
Oral Ondansetron
Annal Emerg Med May 2018;72:84-93
30%
Both
10/31/2018
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0%
10%
20%
30%
40%
50%
25%
45%
Rescue Antiemetic Need
Inhaled Isopropyl
Oral Ondansetron
Annal Emerg Med May 2018;72:184-93
27.5%
Both
Inhaled Isopropyl for Nausea Take Homes
• Inhaled alcohol pad isopropyl alcohol works better than oral ondansetron
• Use it first line, before IV even started
N Engl J Med 2018;378:829-39
Is LR or NSS more advantageous in ED patients admitted to the ICU?
• 15,802 adult pts from 1 hospital• Pragmatic, multiple cross overs
• ED pts who were then ICU admitted• 1,000 ml LR/Plasma-Lyte vs 1,020 ml NSS median• Compared mortality, new RRT, persistent Cr 2 x
PlasmaLyte / Normosol
Na 140 meq/L
Cl 98 meq/L
Osm 294 mOsm
pH 7.4
Acetate 27 meq/L
Gluconate 23 meq/L
K 5 meq/L
Mg 3 meq/L
N Engl J Med 2018;378:829-39 N Engl J Med 2018;378:829-39
10/31/2018
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0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
11%
12%
Hun
dre
ds
11.1%
10.3%
Death, Renal Replacement Therapy and Cr 2 x
Mortality
2.9% 2.5%
N Engl J Med 2018;378:829-39
NSS NSSLR LR
6.6% 6.4%
Cr
NSS LR
RRT
p < 0.6
p < 0.08
p < 0.06
Balanced Crystalloids vs NSSTake Homes
• Same cost, same color, same manufacturers
• NSS is hyperchloremic and acidotic
• LR (or Plasma-Lyte) appears safer in 29,000 pts
• I see no benefit to routine NSS
Love it s/p vomiting with dehydration
Epinephrine’s role still unclear
Summary
No routine bicarbonate in CPR
No routine D50 in CPR
Double Sequential??
ECPR if done early
SGAs are excellent
Summary
Bougies are great
Expertise in ETI takes time
Beware 100% O2
Time = Muscle
ECGs change
Summary
Anaphylaxis = Epi!
Magnesium is an adjunct in AF
Sniffed isopropyl for nausea
Love Lactated Ringers
10/31/2018
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VanderbiltEM.com