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10/14/2019
1
Firehouse Expo 2019
EMS
Most Important Recent Articles
Corey M. Slovis, M.D.Vanderbilt University Medical Center
Metro Nashville Fire DepartmentNashville International Airport
Nashville, TN
Epinephrine
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
0%
10%
20%
30%
40%
50%
60%
Hundreds
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
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
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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
Adjusted AnalysisVF/pVT vs Non Shockable
Favors Placebo Favors Epinephrine
New Engl J Med 2018;379:711-21
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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
May 29, 2019
Resuscitation 2019;140:55-63
Does epinephrine affect shockable vs non-shockable rhythms differently?
• England’s PARAMEDIC-2 + Australian PACA combined
• 1518 VF/VT pts and 6330 AS/PEA pts
• These are the only 2 large randomized epi trials
• Compared 3919 epi pts to 3929 placebo pts
• ROSC, long term survival, and neuro outcomes compared
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4
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
33.37%
24.63%
ROSC
EpiPlacebo
48.74%
Epi
Resuscitation 2019;140:55-63
Placebo
7.39%
AS/PEA VF/VT
OR = 2.32OR = 6.52
0%
2%
4%
6%
8%
10%
12%
14%
1.6%
10.50%
Survival to Discharge
EpiPlacebo
12.41%
Epi
Resuscitation 2019;140:55-63
Placebo
0.43%
AS/PEA VF/VT
OR = 1.27
OR = 2.52
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
0.53%
8.81%
Favorable NeuroModified Rankin 0-3
EpiPlacebo
9.37%
Epi
Resuscitation 2019;140:55-63
Placebo
0.3%
AS/PEA VF/VT
Poor NeuroModified Rankin 4-5
Resuscitation 2019;140:55-63
AS/PEA⁃ 16 neurologically devastated patients with epi⁃ 4 patients with placebo
VF/VT⁃ 23 neurologically devastated patients with epi⁃ 12 patients with placebo
“There was insufficient evidence to suggest that favorable neurological outcomes at
discharge differed between treatments arms (p = 0.288) and it was not found to differ
according to rhythm type (p = 0.295)”Resuscitation 2019;140:55-63
Annals Emerg Med 2019 online August
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Resuscitation 2019 online May 1
• Is there a number of doses of epinephrine that after which, survival is no longer seen?
• 1 year retrospective review from London Ambulance Service
• 3151 cardiac arrest cases
• Epinephrine administered every 3-5 minutes
• VF/VT pts received epi beginning after 3rd shock
How does number of repeat doses of epinephrine affect survival?
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
1.7
Epinephrine Doses and SurvivalAsystole
32
1
10
Resuscitation 2019 online May 1
5
2.9
1 4
2.4
0
P < 0.001
0
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
1.7
Epinephrine Doses and SurvivalPEA
32
1
10
Resuscitation 2019 online May 1
5
4.5
1 4
6.1
0
P < 0.001
0
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
25
Epinephrine Doses and SurvivalVF/VT
32
1.7
10
Resuscitation 2019 online May 1
5
38
1 4
40.6
20.4
P < 0.001
1.52.1 03.9 2.4
9876
Epinephrine and SurvivalTake Homes
• Survival falls as time of the arrest and epinephrine doses increase
• No one survives after 10 doses
• Almost no one survives after 5 doses
• We need to establish limits on epinephrine doses and use patient history and ETCO2 also
• No ROSC after 5 doses = TOR?
Epinephrine in Cardiac ArrestTake Homes
• Epinephrine improves ROSC and Survival to Discharge
• Epinephrine effects are much more pronounced in non-shockable rhythms
• Epinephrine does not improve Neurologic Outcomes
• The increase in survival to discharge results in More Neurologically Devastated Survivors
• Decide: how long, how many epi doses
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Antiarrhythmics in VF
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?
What do you do after 3 unsuccessful shocks?
We need to have a strategy for refractory VF
Refractory VFib
• Move pads Ant-Lat Ant-Post
• Consider Beta Blockade
• Consider Double Sequential Defibrillation (DSD)
• PCI
• ECMO
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DSD
Acad Emerg Med 2018;00:1-8
• 40 yo, 40 min of VF, 7 shocks
• 8th was dual defibrillation < 1 second apart
• Patient D/C’d 24 d later, neuro intact at 1 yr
Prehosp Emerg Care 2015;19:554-7
First case report of neurologically intact survival after double sequential defibrillation for refractory VF
Acad Emerg Med 2018;00:1-8
• Matched case control comparison
• 205 patients with refractory VF (3 shocks)
• 64 DSD vs 64 Standard defibrillations
• 2 blinded observers; matched same year pts
• Same epi doses, downtimes, witnessed, bystander CPR
Is DSD more effective in refractory VF?
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%40.8%
16%
DSD vs Standard DefibrillationROSC and Survival to Discharge
STDDSD
23.3%
STDDRD
20%
ROSC Survival to D/C
Acad Emerg Med 2018;00:1-8
“Our current protocol of considering DSD after the third conventional defibrillation in out-of-hospital
cardiac arrest is ineffective”
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Resuscitation 2019;135:124-29
• No increase in ROSC
• No improvement on survival to discharge
PreHospital Emerg Care 2019 online August
Largest study to date evaluating DSD
• 310 patients, 71 (23%) received DSD
• Houston Fire Department and UT Health
• Evaluated ROSC, hospital admission, discharge
Effectiveness of DSD
ROSC
39.4%
Survival to Discharge
PreHospital Emerg Care 2019 online August
60.3%
OR = 0.6320.9%OR = 0.46
14.3%
DSD DSDSTD STD
DSD 2019 – 2020 Take Homes
No study has shown benefit of DSD and there is a consistent trend of inferiority
PCI S/P Cardiac Arrest
Resuscitation 2018;123:15-21
• 599 OHCA registry pts
• UPMC and Mercy Hospitals
• Early vs Later vs no Cath/PCI
• STEMI and no AMI pts
How valuable is PCI s/p cardiac arrest?
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0%
10%
20%
30%
40%
50%
60%
70%
65.6%
Survival to DischargeEarly PCI vs CCU
Early Cath Lab
31%
CCU Only
p = 0.0001
Resuscitation 2018;123:15-21
Early Coronary AngiographyTake Homes
• Early CCL essential to find intervenable lesions
• If PCI indicated: survival doubles with good neuro
• Non ST elevation AMI: intervenable lesions about 30% of time
• They, too, greatly benefit
• Be aggressive for high ROI
Doing Optimal “BCLS” •3643 pts; 2007-2009 ROC data
•150 EMS agencies from US and Canada
JAMA Cardiol 2019 online August14
What is the optimal depth and rate for closed chest CPR?
• 107 compressions per minute
• 1.85 inches depth of compressions
Optimal CPR is within 86 - 128 compressions/minute
and 1.5 - 2.2 inches
More than ½ of patients did not receive optimal CPR
(± 20% of target)
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1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
Survival with Optimal BLS
1.5 – 2.2 inches86 – 128 compressions
6.0%
Out of range
4.3%
JAMA Cardiol 2019 online August14
p = 0.0228% difference
High quality CPR is done less than 50% of the time in some of the best EMS services in the country, with
personnel who know they are having their CPR quality monitored
Supervising CPR
• 100 – 120 compressions/min
• 2 inches depth
• Allow full recoil
• Minimize interruptions
• Only 8 – 10 breaths/min
Our Job is to Ensure High Quality
Rotate your compressors every 2 minutes
Mechanical CPR
Prehosp Emerg Care 2018;22:338-44
How much additional benefit does mechanical CPR provide vs manual CPR?
• 2,999 pts, San Antonio EMS
• 2,236 manual vs 763 mechanical
• Measured ROSC, survival, neuro outcomes
• Prior Cochran reviews 2011, 2014: no benefit
• CIRC, LINC, PARAMEDIC: No benefits
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0
5
10
15
20
25
30
35
40
45
50
9%
44%
7%
BLS
Mechanical CPR vs Manual CPRPrehosp Emerg Care 2018;22:338-44
ROSC Survival
46%
Man Mech Man Mech
P=0.32
P=0.13
0
1
2
3
4
5
6
7
8
9
10
6%
Mechanical CPR vs Manual CPRPrehosp Emerg Care 2018;22:338-44
4%
CPC 1-2 Outcomes
P=0.036
Man Mech
Prehosp Emerg Care 2018;22:338-44
Results • Manual only CPR pts:
- Higher frequency of witnessed arrests
- More King Airways
• Mechanical CPR pts:
- Higher rates of bystander CPR
- More public AED use
- Higher doses of epi- More likely to have ETI
Mechanical vs Manual CPRTake Homes
• No differences in prehospital ROSC or survival to hospital
• Once adjusted logistic regression used: No difference in neuro outcomes
• ROSC, shockable rhythm and witnessed arrests are strongest predictors of survival with good neuro outcome
Mechanical CPR was not a significant predictor of
improved outcomesEMS Airways
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JAMA 2018;320:769-778
• 3,004 pts, 27 EMS agencies, ROC study
• Pragmatic crossover randomization, 13 clusters
• SGA vs ETI (only used LT)
• 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
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%
Hundreds
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;320:769-778JAMA 2018;320:779-791
Are SGAs superior to ETIs during out of hospital cardiac arrest?
• The AIRWAYS-2 Trial of 9296 pts
• Evaluated 30d neuro outcomes
• Also insertion success, regurgitation, and aspiration
• From 4 Brittish ambulance services
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0%
1%
2%
3%
4%
5%
6%
7%
8%6.8%
Good Neuro OutcomesRankin 0-3
JAMA 2018;320:779-791
6.4%
SGA ETI
p = ns
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100% 79%
Initial Ventilatory Success1-2 Attempts
JAMA 2018;320:779-791
87.4%
SGA ETI
or = 1.92
0%
1%
2%
3%
4%
5%
2.6%
Good Neuro OutcomesHad Airway Inserted
JAMA 2018;320:779-791
3.9%
SGA ETI
or = 1.57
SGA vs ETI Additional Finding
• No difference in regurgitation (26.1% vs 24.5%)
• No difference in aspiration (15.1% vs 14.9%)
SGA = ETI for airwaysSGAs more likely to be successful
JAMA 2018;320:779-791
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
• ETI focused services need to move to SGA for rescue after 1-2 failed ETI attempts and or for refractory hypoxia
10/14/2019
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Resuscitation 2019 online May 2019
Does a Supraglottic Airway improve time to epinephrine vs Endotracheal Intubation in cardiac arrest?
• 2652 pts, 1299 ETI vs 1353 SGA
• Pragmatic Airway Resuscitation Trial secondary analysis
• SGA previously shown to time to airway
• SGA also shown to first attempt success
• Hypothesis: earlier airway = earlier epi = survival 0
1
2
3
4
5
6
7
8
9
109.0
Median Time to EpinephrineResuscitation 2019 online May 2019
8.6
SGA ETI
p = ns
min
SGA patients were 8% more likely to receive epinephrine vs ETI
Resuscitation 2019 online May 2019
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10% 7.4%
6.1%
Survival to Discharge
> 10< 10
5.3%
> 10< 10
8.8%
SGA ETI
Resuscitation 2019 online May 2019
There was no significant association between airway strategy and time to
epinephrine administrationResuscitation 2019 online May 2019
SGA vs ETI and EpinephrineTake Homes
• Time to Epi is not affected by choice of ETI vs SGA
• The role of Epi remains unclear
• Earlier is better than later
• I believe ETI takes a lot of practice to be expert; SGA takes less practice and less experience
• ETI skills should not be the gold standard for EMS –oxygenation and ventilation are the gold standard
10/14/2019
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Hypotension
Annal Emerg Med 2017;70:522-30
How deleterious is hypotension in patients with traumatic brain injury (TBI)?
• 7,251 TBI pts ages 10 and older
• Statewide EMS database for Arizona
• Median age 40 yo; IQR 24-58 yo• 7.2% (539) of patients had BP < 90 mm Hg
• Evaluated time and depth spent hypotensive
“Dose of Hypotension
90 – SBP = Depth of Hypotension x Minutes
Hypotension “Dose”
10 minutes at 80 SBP = dose of 10 x 10 = 100
10 minutes at 70 SBP = dose of 10 x 20 = 200
Thus 10 minutes at 70 mm Hg increases mortality 20% over 10 minutes at 80 mm Hg
Annal Emerg Med 2017;70:522-30
Each 2 fold increase in hypotension dose, increased mortality by 20%
Depth and Duration of Hypotensionvs Mortality
Annal Emerg Med 2017;70:522-30
Hypotension in TBITake Homes
• Dramatically increases mortality
• 20% for each doubling of dose (time x 90-SBP)
• Avoid hypotension, treat hypotension
• Not clear if 90, 100, or 120 SBP is optimal s/p TBI
10/14/2019
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Depth and Length of Hypotension in TBI are both critical! Nausea
Annal Emerg Med May 2018;ePub ahead of print
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;ePub ahead of print
30%
Both
0%
10%
20%
30%
40%
50%
25%
45%
Rescue Antiemetic Need
Inhaled Isopropyl
Oral Ondansetron
Annal Emerg Med May 2018;ePub ahead of print
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
10/14/2019
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Ketamine
Am J Emerg Med 2017;ePub ahead of print
Is ketamine an effective therapy for delirious patients?
• Prehospital study of 49 patients
• All combative, very violent or out of control
• Only highest level agitation pts included
• Ketamine dosed at 5mg/kg IM
Ketamine For Agitation/Delirium5 mg/kg IM
• 4.2 min median time to sedation
• Sedation times varied 2.5-5.9 minutes (CI)
• 14% required 2nd dose
• 90% adequately sedated
• 57% (28/49) intubated during ED stay
• Hypersalivation 18%
• Vomiting 6%
• Emergence 2.4%
Am J Emerg Med 2017;ePub ahead of print
Complications of Ketamine
In 82% of patients, intubation time was less than 24 hours and the number one reason for ETI was
“Airway unprotected NOS”
Ketamine for Excited DeliriumTake Homes
• Great, great sedating agent
• Fast onset and 90% effective
• Patients may hypersalivate or vomit
• Many may need ETI - maybe
• Is it a primary drug or adjunct to benzos?
10/14/2019
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Narcotic ODs andNaloxone
Annal Emerg Med 2019 online July
What is the one year prognosis after a non-fatal narcotic OD?
• 17,241 non-fatal Massachusetts opioid ODs
• July 11, 2011 – Sept 30, 2015
• Followed for 1 year s/p OD
• Used 3 overlapping statewide databases
• Evaluated mortality 1 year post opioid OD
5.5% of patients died within 1 year of a non-fatal narcotic OD requiring an
ED visit
Deaths s/p Non-Fatal ODAnnal Emerg Med 2019 online July
Non-Fatal Narcotic ODTake Homes
• One in 20 will be dead in 1 year
• 20.5% of the deaths occurred within 1 month of OD
• Role of buprenorphine or naloxone prescriptions not studied
• We need to intervene or deaths will continue
Prehosp Emerg Care 2019 online March
How long after expiration is Naloxone still usable and bioavailable?
• Recommended shelf life is 1 - 2 years per manufacturer and FDA
• Auto Injector has 1 year “shelf life”
• IV and IN have 2 year “shelf lives”
• Samples came from fire trucks, ambulances, and PD
• Assays by mass spec and chromatography
10/14/2019
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Prehosp Emerg Care 2019 online March
Assays up to 27 years oldPrehosp Emerg Care 2019 online March
Naloxone is 90 - 99% effective over a quarter of a century!
NaloxoneUse it but respect it
ACS
Acute Hypotension with NTG5 Causes
• Right Ventricular AMI
• Relative or Absolute Volume depletion
• Viagra, Levitra, Cialis
• Bezold-Jarisch Reflex
• Drug Sensitivity (valvular dsx, idiopathic)
• 1,466 STEMIs, 56% received NTG
• Montreal Quebec EMS 2010-2012
• Evaluated BP changes in Inf vs Non-Inf AMIs
• BP < 90 or BP > 30mm Hg s/p NTG
Prehosp Emerg Care 2016;20:76-81
How dangerous is NTG in Inferior AMI?
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0%
5%
10%
15%
20%
25%
STEMI BP Changes Post NTGPrehosp Emerg Care 2016;20:76-81
BP < 90 BP > 30mm Hg
8.2%
InfNot-Inf InfNot-Inf
23.4%
P=NS
P=NS8.9%
23.9%PreHospital Emerg Care 2019 online
How safe is NTG in r/o AMI and does it effectively relieve pain?
• Prospective study, 780 pts, suspected STEMI
• LA County EMS and UCLA
• “Suspected STEMI” by ECG plus paramedic
• 0.4 mg SL NTG, up to 2 more doses
• BP < 100 mm SBP pts excluded
-14
-12
-10
-8
-6
-4
-2
0
NTG in suspected STEMIMedian BP Fall
NTG
-10 mm Hg
No NTG
-3 mm Hg
PreHospital Emerg Care 2019 online
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
NTG in suspected STEMISystolic BP fall > 30 mm Hg
NTG
5.3%
No NTG
6.7%
PreHospital Emerg Care 2019 online
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
NTG in suspected STEMIPain Relief
NTG
2.6%
No NTG
1.4%
PreHospital Emerg Care 2019 online
P < 0.0001
Hypotension from NTG
•Borderline BPs
• Increasing Tachycardia
10/14/2019
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NTG for r/o AMI
•NTG is safe in AMI
•NTG is safe in Inferior AMI
•NTG relieves Anginal pain in ACS
• Respect NTG but use it
Fluids in EMS
N Engl J Med 2018;378:819-28
Is LR or NSS more advantageous in non-critical ED patients admitted to the hospital?
• 13,347 adult ED patients, 1 hospital
• Pragmatic, multiple cross overs
• ED pts admitted to non ICU beds• 1,089 ml LR (Plasma-Lyte) vs 1,071 ml NSS medians
• Hospital free days and major adverse kidney events
Major Adverse Kidney Events
• Death
• New Renal Replacement Therapy
• Final serum Cr > 200% baseline
0
5
10
15
20
25
30
Major Kidney Events
N Engl J Med 2018;378:819-28
Hosp Free Day Major Kidney Event
25d
5.6%
P=0.01
25d
4.7%
Getting a median of about 1100 cc of NSS or LR (mean 1600 cc) results in a significant increase of renal dysfunction at 30 days
when saline is used vs a balanced electrolyte solution of LR or Plasma-Lyte
10/14/2019
22
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 N Engl J Med 2018;378:829-39
N Engl J Med 2018;378:829-39
0%
2%
4%
6%
8%
10%
12%
14%
16%
18% 15.4%
Major Adverse Kidney Events
NSS
N Engl J Med 2018;378:829-39
14.3%
LR
P=0.04
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
11%
12%
Hundreds
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
10/14/2019
23
Role of Epinephrine remains unclear
Summary
Five doses seems like enough
Antiarrhythmics are not of great value
DSD: NO
SGA = ETI, SGAs easier
Ensure optimal BCLS
Summary
NTG is safe in Inferior AMI
Isopropyl for Nausea
Plasma is great – longer runs
LR appears superior to NSS