The EMS Lighthouse Project

We know the literature on mechanical CPR devices on mortality in out of hospital cardiac arrest (we DO know this literature, right?), but what about in-hospital arrest? Dr. Jarvis reviews a recent paper that uses the AHA Get With The Guidelines - Resuscitation registry to assess the association between MCDs and mortality. Citations1. Crowley C, Salciccioli J, Wang W, Tamura T, Kim EY, Moskowitz A: The association between mechanical CPR and outcomes from in-hospital cardiac arrest: An observational cohort study. Resuscitation. 2024;May 1;198.2. Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R, et al.: Mechanical Chest Compressions and Simultaneous Defibrillation vs Conventional Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest: The LINC Randomized Trial. JAMA. 2014;January 1;311(1):53–613. Hardig BM, Lindgren E, Östlund O, Herlitz J, Karlsten R, Rubertsson S: Outcome among VF/VT patients in the LINC (LUCAS IN cardiac arrest) trial—A randomised, controlled trial. Resuscitation. 2017;June;115:155–62.4.  Perkins GD, Lall R, Quinn T, Deakin CD, Cooke MW, Horton J, Lamb SE, Slowther A-M, Woollard M, Carson A, et al.: Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. The Lancet. 2015;385(9972):947–55.5.  Wik L, Olsen J-A, Persse D, Sterz F, Lozano M, Brouwer MA, Westfall M, Souders CM, Malzer R, Van Grunsven PM, et al.: Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial. Resuscitation. 2014;June;85(6):741–8.6. Bonnes JL, Brouwer MA, Navarese EP, Verhaert DVM, Verheugt FWA, Smeets JLRM, Boer M-J de: Manual Cardiopulmonary Resuscitation Versus CPR Including a Mechanical Chest Compression Device in Out-of-Hospital Cardiac Arrest: A Comprehensive Meta-analysis From Randomized and Observational Studies. Ann Emerg Med Annals of emergency medicine. 2016;67(3):349-360.e3.7. Gonzales L, Oyler BK, Hayes JL, Escott ME, Cabanas JG, Hinchey PR, Brown LH: Out-of-hospital cardiac arrest outcomes with “pit crew” resuscitation and scripted initiation of mechanical CPR. The American Journal of Emergency Medicine. 2019;May;37(5):913–20.8. Koster RW, Beenen LF, Van Der Boom EB, Spijkerboer AM, Tepaske R, Van Der Wal AC, Beesems SG, Tijssen JG: Safety of mechanical chest compression devices AutoPulse and LUCAS in cardiac arrest: a randomized clinical trial for non-inferiority. European Heart Journal. 2017;October 21;38(40):3006–13.9. Primi R, Bendotti S, Currao A, Sechi GM, Marconi G, Pamploni G, Panni G, Sgotti D, Zorzi E, Cazzaniga M, et al.: Use of Mechanical Chest Compression for Resuscitation in Out-Of-Hospital Cardiac Arrest—Device Matters: A Propensity-Score-Based Match Analysis. JCM. 2023;June 30;12(13):4429.10. Youngquist ST, Ockerse P, Hartsell S, Stratford C, Taillac P: Mechanical chest compression devices are associated with poor neurological survival in a statewide registry: A propensity score analysis. Resuscitation. 2016;September;106:102–7.11.  S, Sulzgruber P, Datler P, Keferböck M, Poppe M, Lobmeyr E, Van Tulder R, Zajicek A, Buchinger A, Polz K, et al.: Mechanical chest compression does not seem to improve outcome after out-of hospital cardiac arrest. A single center observational trial. Resuscitation. 2015;November;96:220–5. 12. Morgan S, Gray JJ, Sams W, Uhl K, Gundrum M, McMullan J: LUCAS Device Use Associated with Prolonged Pauses during Application and Long Chest Compression Intervals. Prehospital Emergency Care. doi: 10.1080/10903127.2023.2183294 (Epub ahead of print).13.  Levy M, Yost D, Walker RG, Scheunemann E, Mendive SR: A quality improvement initiative to optimize use of a mechanical chest compression device within a high-performance CPR approach to out-of-hospital cardiac arrest resuscitation. Resuscitation. 2015;July;92:32–7.14.  Li H, Wang D, Yu Y, Zhao X, Jing X: Mechanical versus manual chest compressions for cardiac arrest: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med. 2016;December;24(1):10.15.  Sheraton M, Columbus J, Surani S, Chopra R, Kashyap R: Effectiveness of Mechanical Chest Compression Devices over Manual Cardiopulmonary Resuscitation: A Systematic Review with Meta-analysis and Trial Sequential Analysis. WestJEM. 2021;July 19;22(4):810–9.16.  Wang PL, Brooks SC: Mechanical versus manual chest compressions for cardiac arrest. Cochrane Database Syst Rev The Cochrane database of systematic reviews. 2018;20;8:CD007260.17.  Zhu N, Chen Q, Jiang Z, Liao F, Kou B, Tang H, Zhou M: A meta-analysis of the resuscitative effects of mechanical and manual chest compression in out-of-hospital cardiac arrest patients. Crit Care. 2019;December;23(1):100.

New Orleans implemented a blood program and assessed the impact of the program on mortality. Dr Jarvis dives into the details of the paper and then Dr Remle Crowe joins in for a discussion on why studying blood in the field is so difficult. Citation: Broome JM, Nordham KD, Piehl M, Tatum D, Caputo S, Belding C, De Maio VJ, Taghavi S, Jackson-Weaver O, Harris C, et al.: Faster refill in an urban emergency medical services system saves lives: A prospective preliminary evaluation of a prehospital advanced resuscitative care bundle. J Trauma Acute Care Surg. 2024;May;96(5):702–7.

We've reviewed several papers in the past that suggest there might be an advantage to using IV access compared to IO access for medications in cardiac arrest. Is that really a thing? Wouldn't it be great if we had some randomized controlled trials to help answer the questions?  Funny you should mention RCTs. Dr Jarvis reviews three (THREE!) new RCTs that compare IV to IO access in out of hospital cardiac arrest to try to shed some of that bright light of science on this question!Citations:1. Vallentin MF, Granfeldt A, Klitgaard TL, Mikkelsen S, Folke F, Christensen HC, Povlsen AL, Petersen AH, Winther S, Frilund LW, et al.: Intraosseous or Intravenous Vascular Access for Out-of-Hospital Cardiac Arrest. N Engl J Med.2. Smida T, Crowe R, Jarvis J, Ratcliff T, Goebel M: A retrospective comparison of upper and lower extremity intraosseous access during out-of-hospital cardiac arrest resuscitation. Prehospital Emergency Care. 2024;28(6):1–23.3. Nielsen N: The Way to a Patient’s Heart — Vascular Access in Cardiac Arrest. N Engl J Med. doi: 10.1056/NEJMe2412901 (Epub ahead of print).4. Ko Y-C, Lin H-Y, Huang EP-C, Lee A-F, Hsieh M-J, Yang C-W, Lee B-C, Wang Y-C, Yang W-S, Chien Y-C, et al.: Intraosseous versus intravenous vascular access in upper extremity among adults with out-of-hospital cardiac arrest: cluster randomised clinical trial (VICTOR trial). BMJ. doi: 10.1136/bmj-2024-079878 (Epub ahead of print).5. Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, Leroux B, Vaillancourt C, Wittwer L, Callaway CW, et al.: Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2016;May 5;374(18):1711–22.6.Daya MR, Leroux BG, Dorian P, Rea TD, Newgard CD, Morrison LJ, Lupton JR, Menegazzi JJ, Ornato JP, Sopko G, et al.: Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Circulation. 2020;January 21;141(3):188–98.7. Nolan JP, Deakin CD, Ji C, Gates S, Rosser A, Lall R, Perkins GD: Intraosseous versus intravenous administration of adrenaline in patients with out-of-hospital cardiac arrest: a secondary analysis of the PARAMEDIC2 placebo-controlled trial. Intensive Care Medicine. doi: 10.1007/s00134-019-05920-7 (Epub ahead of print).

Back in episode 80 we discussed a feasibility study out of Salt Lake City that showed IM epi resulted in 3-minute faster administration in cardiac arrest. It was underpowered to show survival, however. Fortunately, the great folks in Salt Lake City is back with a larger bite at the statistical apple. Dr Jarvis discusses the background around what we know about epinephrine in cardiac arrest (briefly, for once), walks us through this new study, and puts it in context of modern clinical practice. Citations.1. Palatinus HN, Johnson MA, Wang HE, Hoareau GL, Youngquist ST: Early intramuscular adrenaline administration is associated with improved survival from out-of-hospital cardiac arrest. Resuscitation. 2024;August;201:110266.2. Perkins GD, Ji C, Deakin CD, Quinn T, Nolan JP, Scomparin C, Regan S, Long J, Slowther A, Pocock H, et al.: A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2018;August 23;379(8):711–21.3. Okubo M, Komukai S, Callaway CW, Izawa J: Association of Timing of Epinephrine Administration With Outcomes in Adults With Out-of-Hospital Cardiac Arrest. JAMA Netw Open. 2021;August 10;4(8):e2120176.4. Hubble MW, Tyson C: Impact of Early Vasopressor Administration on Neurological Outcomes after Prolonged Out-of-Hospital Cardiac Arrest. Prehosp Disaster Med. 2017;June;32(3):297–304.5.  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.

Do you give naloxone to patients who are in cardiac arrest? Should you? Can it possibly provide any benefit at all once you are already providing effective ventilations? Well, Dr. Jarvis certainly thought not. He might have even thought it out loud. Like, loudly out loud.  Based on two recent papers looking directly at this question, perhaps he needs to eat some crow and shine the bright light of science on his own damn practice. Citations:1. Strong NH, Daya MR, Neth MR, Noble M, Sahni R, Jui J, Lupton JR: The association of early naloxone use with outcomes in non-shockable out-of-hospital cardiac arrest. Resuscitation. 2024;August;201:110263.2. Dillon DG, Montoy JCC, Nishijima DK, Niederberger S, Menegazzi JJ, Lacocque J, Rodriguez RM, Wang RC: Naloxone and Patient Outcomes in Out-of-Hospital Cardiac Arrests in California. JAMA Netw Open. 2024;August 1;7(8):e2429154.3. Niederberger SM, Crowe RP, Salcido DD, Menegazzi JJ: Sodium bicarbonate administration is associated with improved survival in asystolic and PEA Out-of-Hospital cardiac arrest. Resuscitation. doi: 10.1016/j.resuscitation.2022.11.007 (Epub ahead of print).4. Wampler DA: Naloxone in Out-of-Hospital Cardiac Arrest—More Than 

Remember when we learned interruptions in compressions take a long time to recover blood pressure from? And how, to avoid these, we should do continuous compressions to avoid them. And ventilations aren’t all that important. Right? Right? Well, about that. Maybe the stories of the importance of continuous compressions were greatly exaggerated. Join Dr. Jarvis as he discusses the literature that led us to this point and some evidence that has led him to reconsider how his system approaches cardiac arrest. He’ll eventually get around to discussion a recent paper by Dr. Rose Yin that analyzes arterial pressures during cardiac arrest that was a catalyst for him to make changes in his arrest protocols. Citations:1. Yin RT, Berve PO, Skaalhegg T, et al. Recovery of arterial blood pressure after chest compression pauses in patients with out-of-hospital cardiac arrest. Resuscitation. 2024;201:110311. doi:10.1016/j.resuscitation.2024.110311 2. Azcarate I, Urigüen JA, Leturiondo M, et al. The Role of Chest Compressions on Ventilation during Advanced Cardiopulmonary Resuscitation. JCM. 2023;12(21):6918. doi:10.3390/jcm122169183. Berg RA, Sanders AB, Kern KB, et al. Adverse Hemodynamic Effects of Interrupting Chest Compressions for Rescue Breathing During Cardiopulmonary Resuscitation for Ventricular Fibrillation Cardiac Arrest. Circulation. 2001;104(20):2465-2470. doi:10.1161/hc4501.0989264.Kern KB, Hilwig RonaldW, Berg RA, Ewy GA. Efficacy of chest compression-only BLS CPR in the presence of an occluded airway. Resuscitation. 1998;39(3):179-188. doi:10.1016/S0300-9572(98)00141-55. Bobrow BJ, Clark LL, Ewy GA, et al. Minimally Interrupted Cardiac Resuscitation by Emergency Medical Services for Out-of-Hospital Cardiac Arrest. JAMA. 2008;299(10):1158-1165.6. Idris AH, Aramendi Ecenarro E, Leroux B, et al. Bag-Valve-Mask Ventilation and Survival From Out-of-Hospital Cardiac Arrest: A Multicenter Study. Circulation. 2023;148(23):1847-1856. doi:10.1161/CIRCULATIONAHA.123.0655617. Nichol G, Leroux B, Wang H, et al. Trial of Continuous or Interrupted Chest Compressions during CPR. N Engl J Med. 2015;373(23):2203-2214. doi:10.1056/NEJMoa1509139 8. Schmicker RH, Nichol G, Kudenchuk P, et al. CPR compression strategy 30:2 is difficult to adhere to, but has better survival than continuous chest compressions when done correctly. Resuscitation. 2021;165:31-37. doi:10.1016/j.resuscitation.2021.05.027 9. Zhan L, Yang LJ, Huang Y, He Q, Liu GJ. Continuous chest compression versus interrupted chest compression for cardiopulmonary resuscitation of non-asphyxial out-of-hospital cardiac arrest. Cochrane Anaesthesia C and ECG, ed. Cochrane Database of Systematic Reviews. Published online 2017. doi:10.1002/14651858.cd010134.pub2 10. Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation. 2004;109(16):1960-1965. doi:10.1161/01.CIR.0000126594.79136.61

What’s the best way to pre-oxygenate our patients prior to intubation? The evidence for this question has been mixed for some time. Dr Jarvis discusses the PREOXI Trial, which directly compares preoxygenation with non-invasive ventilation compared to a face mask to see which provides the best protection against peri-intubation hypoxia. This is an important trial that sheds light on a key component of our bundle of care to make intubation safer.Citations:Gibbs KW, Semler MW, Driver BE, Seitz KP, Stempek SB, Taylor C, Resnick-Ault D, White HD, Gandotra S, Doerschug KC, et al.: Noninvasive Ventilation for Preoxygenation during Emergency Intubation. N Engl J Med. (2024)Jarvis JL, Gonzales J, Johns D, Sager L: Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia. Annals of Emergency Medicine. 2018;72:272–9.Groombridge C, et al: A prospective, randomised trial of pre-oxygenation strategies available in the pre-hospital environment. Anaesthesia. 2017;72:580–4.Groombridge C, et al: Assessment of Common Preoxygenation Strategies Outside of the Operating Room Environment. Acad Emerg Med. 2016;March;23(3):342–6.Baillard C, et al: Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med. 2006;July 15;174(2):171–7.Ramkumar V, et al: Preoxygenation with 20-degree head-up tilt provides longer duration of non-hypoxic apnea than conventional preoxygenation in non-obese healthy adults. J Anesth. 2011;25:189–94.Pourmand A, et al: Pre-oxygenation: Implications in emergency airway management. American Journal of Emergency Medicine. doi: 10.1016/j.ajem.2017.06.006Solis A, Baillard C: Effectiveness of preoxygenation using the head-up position and noninvasive ventilation to reduce hypoxaemia during intubation. Ann Fr Anesth Reanim. 2008;June;27(6):490–4.April MD, Arana A, Reynolds JC, Carlson JN, Davis WT, Schauer SG, Oliver JJ, Summers SM, Long B, Walls RM, et al.: Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study. Resuscitation. 2021;May;162:403–11.Trent SA, Driver BE, Prekker ME, Barnes CR, Brewer JM, Doerschug KC, Gaillard JP, Gibbs KW, Ghamande S, Hughes CG, et al.: Defining Successful Intubation on the First AttemptUsing Both Laryngoscope and Endotracheal Tube Insertions: A Secondary Analysis of Clinical Trial Data. Annals of Emergency Medicine. 2023;82(4):S0196064423002135.Pavlov I, Medrano S, Weingart S: Apneic oxygenation reduces the incidence of hypoxemia during emergency intubation: A systematic review and meta-analysis. AJEM. 2017;35(8):1184–9.

There is evidence that clinician experience with intubation is associated with improved success rates and evidence that missed intubation attempts are associated with worse survival, at least in cardiac arrest. The recent Airway EBG paper recommends EMS agencies with low intubation proficiency should use SGAs instead of intubation in cardiac arrest. This all begs the question of whether agencies who intubate more often have higher success rates than those who do not. That’s precisely the question a new paper from Annals of Emergency Medicine attempts to answer. Join Dr. Jarvis to discuss the paper and his thoughts on integrating its findings into practice.Citations:1. Jarvis JL, Panchal AR, Lyng JW, Bosson N, Donofrio-Odmann JJ, Braude DA, Browne LR, Arinder M, Bolleter S, Gross T, et al.: Evidence-Based Guideline for Prehospital Airway Management. Prehospital Emergency Care. 2024;28(4):545–57.2. Murphy DL, Bulger NE, Harrington BM, Skerchak JA, Counts CR, Latimer AJ, Yang BY, Maynard C, Rea TD, Sayre MR: Fewer Tracheal Intubation Attempts are Associated with Improved Neurologically Intact Survival Following Out-of-Hospital Cardiac Arrest. Resuscitation. 2021;July 13;167(Oct 2021):289–96.3. Crewdson K, Lockey DJ, Røislien J, Lossius HM, Rehn M: The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis. Crit Care. 2017;December;21(1):31.4. Thomas J, Crowe R, Schulz K, Wang HE, De Oliveira Otto MC, Karfunkle B, Boerwinkle E, Huebinger R: Association Between Emergency Medical Service Agency Intubation Rate and Intubation Success. Ann Emerg Med. Published online: January 2024. doi: 10.1016/j.annemergmed.2023.11.005 (Epub ahead of print).5. Carlson JN, De Lorenzo R: Does Practice Make Perfect, or Is There More to Consider? Ann Emerg Med. Published online: January 2024. doi: 10.1016/j.annemergmed.2024.04.019 (Epub ahead of print).

Description: Let’s say you were looking for a safe and effective BLS option for analgesia. Something other than oral acetaminophen or ibuprofen. You want the Green Whistle (methoxyflurane), but you can’t get the Green Whistle (thanks, FDA!). How about sub-dissociative ketamine by nebulizer? Sounds great, but you’re worried about your colleagues getting stoned, right? Admit it, you are. Fortunately, there are breath-actuated nebulizers. Maybe those things will work? Dr. Jarvis reviews a recent paper comparing the effectiveness of nebulized ketamine with IV ketamine and gives a quick review of some other papers that paved the way for this one. Citations:1. Nguyen T, Mai M, Choudhary A, Gitelman S, Drapkin J, Likourezos A, Kabariti S, Hossain R, Kun K, Gohel A, et al.: Comparison of Nebulized Ketamine to Intravenous Subdissociative Dose Ketamine for Treating Acute Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind, Double-Dummy Controlled Trial. Annals of Emergency Medicine. (2024) May 2.2. Motov S, Mai M, Pushkar I, Likourezos A, Drapkin J, Yasavolian M, Brady J, Homel P, Fromm C: A prospective randomized, double-dummy trial comparing IV push low dose ketamine to short infusion of low dose ketamine for treatment of pain in the ED. Am J Emerg Med. 2017;August;35(8):1095–100.3. Motov S, Rockoff B, Cohen V, Pushkar I, Likourezos A, McKay C, Soleyman-Zomalan E, Homel P, Terentiev V, Fromm C: Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2015;September;66(3):222-229.e1.4. Motov S, Yasavolian M, Likourezos A, Pushkar I, Hossain R, Drapkin J, Cohen V, Filk N, Smith A, Huang F, et al.: Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2017;August;70(2):177–84.5.Dove D, Fassassi C, Davis A, Drapkin J, Butt M, Hossain R, Kabariti S, Likourezos A, Gohel A, Favale P, et al.: Comparison of Nebulized Ketamine at Three Different Dosing Regimens for Treating Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind Clinical Trial. Annals of Emergency Medicine. 2021;December;78(6):779–87.6.Patrick C, Smith M, Rafique Z, Rogers Keene K, De La Rosa X: Nebulized Ketamine for Analgesia in the Prehospital Setting: A Case Series. Prehospital Emergency Care. 2023;February 17;27(2):269–74.

What value does EtCO2 have when predicting survival from cardiac arrest? We all know a sharp spike in EtCO2 is associated with ROSC, but what about persistently elevated levels? What does this mean for decision-making regarding the termination of resuscitation? Join Drs. Jeff Jarvis, Remle Crowe, and Heidi Abraham for the first episode of “Between Two Nerds,” a subgenre of the EMS Lighthouse Project podcast suggested in episode 82 by Dr. CJ Winckler, as they run through a new paper that may shed some light on this question. Citation:1. Smida T, Menegazzi JJ, Crowe RP, Salcido DD, Bardes J, Myers B: The Association of Prehospital End-Tidal Carbon Dioxide with Survival Following Out-of-Hospital Cardiac Arrest. Prehospital Emergency Care. 2024;April 2;28(3):478–84.2. Levine RL, Wayne MA, Miller C: End-Tidal Carbon Dioxide and Outcome of Out-of-Hospital Cardiac Arrest. N Engl J Med. 1997;337:301–6.3. Page, J. The Magic of 3 AM. PennWell Books. Tulsa, OK. 2017 

The debate about which drug to use for sedation before RSI will... not… die. Advocates for both ketamine and etomidate approach the argument with near-religious zeal. There have been studies. We’ve even covered some here. We need a systematic review and meta-analysis, preferably using an analysis that recognizes this likely isn’t a black-and-white question. That’s where our friend Bayes comes in. Dr. Jarvis is joined by Drs Remle Crowe and CJ Winkler to discuss this paper and what in the hell Bayesian analysis actually is. We get some nice book recommendations in the process. Plus, we check in with ChatGPT for answers.Oh, BTW... don't take zoological advice from Dr. Winkler. Contrary to his thoughts, Giraffe's do NOT, in fact, have larger hearts than elephants. Citations:1. Koroki T, Kotani Y, Yaguchi T, Shibata T, Fujii M, Fresilli S, Tonai M, Karumai T, Lee TC, Landoni G, Hayashi Y. Ketamine versus etomidate as an induction agent for tracheal intubation in critically ill adults: a Bayesian meta-analysis. Crit Care. 2024 Feb 17;28(1):48. doi: 10.1186/s13054-024-04831-4. PMID: 38368326; PMCID: PMC10874027.2. Russotto V, Myatra SN, Laffey JG, et al. Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries. JAMA. 2021;325(12):1164-1172.Bonus book recommendations3. Heller J. Catch-22. New York, NY: Simon & Schuster; 1961.4. McGrayne SB. The Theory That Would Not Die. How Bayes’ Rule Cracked The Enigma Code, Hunted Down Russian Submarines & Emerged Triumphant From Two Centuries of Controversy. Yale University Press; 2011.5. Salsburg D. The Lady Tasting Tea: How Statistics Revolutionized Science In The Twentieth Century. Henry Holt & Company; 2001.

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 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. However, the question for this podcast is whether it matters 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 discuss 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.

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):244–5.4. 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, 2023.5. 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):62–9.6. 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 CompressionTechnique. Crit Care Med. 2019;March;47(3):449–55.7. 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-FireForum/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 asking 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 before RSI. But what evidence are these recommendations based on? Today, we reviewed a paper 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. Perhaps you 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 reviewed 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 the definition. We’ve also discussed different papers about the impact the type of laryngoscope, video or direct, has on first-pass success. A new paper compares video vs. direct laryngoscopy directly. Join us to discuss the DEVICE trial. Citations: 1) 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 2) Jarvis JL, McClure SF, Johns D. EMS Intubation Improves with King Vision Video Laryngoscopy. Prehosp Emerg Care. 2015 3) 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 4) 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 5) 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 6) 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

What even is FPS? There's been a long-running argument about the definition of FPS. By argument, I mean mostly established in the literature, with some people 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 was tube passage. But does it still hold in the 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 that perhaps better meets 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

A new study describes the utility of post-mortem CT panscans in patients who died either in the field or in the ED to identify mortal and potentially mortal injuries. This paper has a couple of surprising findings that can help EMS focus our efforts on caring for these patients. 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.