Hot Topics in EMS

1. Hot Topics in EMS Robert B Dunne MD FACEP FAEMS Vice Chief, St John Hospital Medical Director Detroit East MCA

3. HOT TOPICS • Trauma Care • Opioid Overdose Response • Alternate Care • Behavioral Health Emergencies • Key for Cardiac Arrest

4. Best Practices for Trauma Care • Bleeding Control Update • Prehospital Blood Use • Management of Traumatic Cardiac Arrest • Resuscitative Techniques

5. 10 Golden Period Platinum10 minutes For critically injured patients, initiate transport to the closest appropriate facility within 10 minutes of arrival on scene.

6. Evidence Based Field Interventions • Limited, key field interventions: • Airway control • Oxygenation and ventilation support • Hemorrhage control • Spinal Immobilization • Rapid Transport to appropriate facility • Early Trauma Center Notification • Initiate IVs enroute NOT “scoop and run” Liberman M, Mulder D, Lavoie A, Denis R, Sampalis JS. Multicenter Canadian study of prehospital trauma care. Ann Surg. 2003;237(2):153–160

7. Hemorrhage Control • NOT JUST TOURNIQUETS • Packing • Recognizing Internal Bleeding • Rapid Transport – by any means • RTF concept is for everyday • Patients are saved in the OR • 10% of benefit from TQ Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: An overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006;60(6 Suppl):S3–S11

8. IV Fluids • No data has ever documented improved survival based upon prehospital IV fluid therapy • One study suggests increased mortality rate in hypotensive trauma patients given prehospital fluid • Protocols decreased IVF use – should eliminate • What about blood

9. TXA • Stabilizes Clots • Reduces bleeding – seen and unseen • Research – all cause traumatic bleeding • Crash 3 trial – sooner the better • Easy to use – 1 gram IV over 10 min The CRASH-3 trial collaborators, Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet. 2019; 10-14-2019

10. Pre-hospital Transfusion Criteria in TX • Two or more of the following: • Penetrating truncal mechanism • SBP <90 mmHg • HR >120 bpm • Patient’s receive up to 2 units of plasma and 2 units of pRBCs, starting with plasma • Other Systems in TX using whole blood Holcomb JB, Donathan DP, Cotton BA, Del Junco DJ, Brown G, Wenckstern TV, Podbielski JM, Camp EA, Hobbs R, Bai Y, Brito M, Hartwell E, Duke JR, Wade CE. Prehospital Transfusion of Plasma and Red Blood Cells in Trauma Patients. PrehospEmerg Care. 2014 Jun 16.

11. Pre-hospital transfusion in TX Table 4.  Multivariate logistic regression for mortality within the first 6 hours among those with critical ED disposition (admitted directly to the ICU, IR, OR or morgue) Holcomb JB, Donathan DP, Cotton BA, Del Junco DJ, Brown G, Wenckstern TV, Podbielski JM, Camp EA, Hobbs R, Bai Y, Brito M, Hartwell E, Duke JR, Wade CE. Prehospital Transfusion of Plasma and Red Blood Cells in Trauma Patients. PrehospEmerg Care. 2014 Jun 16.

12. Pre-hospital transfusion in MN Kim BD, Zielinski MD, Jenkins DH, Schiller HJ, Berns KS, Zietlow SP. The effects of prehospital plasma on patients with injury: a prehospital plasma resuscitation. J Trauma Acute Care Surg. 2012 Aug;73(2 Suppl 1):S49-53.

13. Traumatic Arrest • NO ACLS needed • Compressions harmful • BVM • Vent Chest if needed • Stop Bleeding • Outcomes better than previously thought in the right patients • Protocols being updated Evans, Emerg Med Clin N Am 36 (2018) 19–40

14. Homework • Proper chest access (5th interspace mid axillary) • Good BVM • Prehospital US • Teach TQ the right way • Advocate for TXA and Blood

15. Alternate Care for EMS Patients • Alternative Transport Options • Alternative Destinations • Mobile Integrated Health Care • Community Paramedicine • Integrating Prehospital and Hospital Care

16. Manage Patients at Home • Know your data – how many do you “sign off” • All should get QA • Could some of those be better off at home (so they are not AMA) • Hypoglycemia • Overdose • Asthma • Opportunity to capture revenue WilliamsJG,BachmanMW,LyonsMD,etal. Improving decisions about transport to the emergency department for assisted living residents who fall. Ann Intern Med. 2018;168(3):179-186.

17. Alternative Transport Options • See and Defer (Lyft, Uber, Taxi, Van) – anything but an Ambulance • Call Center run by EMD’s • Staffing, Responders, Support • Selection

18. Transport to Alternative Destinations • Mental Health • Sobering Centers • Urgent Care • Psychiatric Facilities • How to Operationalize LangabeerJRII,GonzalezM,AlqusairiD,etal. Telehealth-enabled emergency medical services program reduces ambulance transport to urban emergency departments. West J Emerg Med. 2016; 17(6):713-720.

19. Community Health Outreach • Anticipating Problems • Need tight physician relationship • Telemedicine Capability • Partner with Health System • Frequent Users • Vulnerable Populations

20. Optimal Care for Opioid Overdose • Builds on other Programs • Opportunities for Intervention • Target frequent use areas • EMS based programs that reduce deaths • Take Home Narcan for Refusals • Hot Referrals • Early Medication Assisted Treatment

21. Use your Opioid Data

22. Special Topics: Opioids and Cardiac Arrest •  Resuscitation 81(1):42-6 · November 2009 • From a database of 32,544 advanced life support (ALS) • 15 /36 (42%) (95% confidence interval [CI]: 26-58) in cardiac arrest who received naloxone in the pre-hospital setting had an improvement in electrocardiogram (EKG) rhythm. • Of responders to naloxone, 47% demonstrated EKG rhythm changes immediately following the administration of naloxone. • Authors “Although we cannot support the routine use of naloxone during cardiac arrest, we recommend its administration with any suspicion of opioid use. “ • Smith G, Beger S, Vadeboncoeur T, Chikani V, Walter F, Bobrow B, Trends in Overdose-Related Out-of-Hospital Cardiac Arrests in Arizona, Resuscitation (2018), https://doi.org/10.1016/j.resuscitation.2018.10.019 • No change with Naloxone, treat as any arrest, avoid tunnel vision • No” pseudo arrest “, same incidence of PEA as all cause

23. Behavioral Health Emergencies • Strategies for Safe Restraint and Response • Crisis Response Teams • Recognition of Life-Threatening Behavioral Health Conditions

24. Behavioral Health Crisis Continuum A CONTINUUM OF CRISIS INTERVENTION NEEDS 23-hour Stabilization Mobile Crisis Team CIT Partnership EMS Partnership 24/7 Crisis Walk-in Clinic Hospital Emergency Dept. Crisis Respite Outpatient Provider Family & Community Support Crisis Telephone Line EARLY INTERVENTION RESPONSE Integration/Re-integration into Treatment & Supports Peer Support Non-hospital detox Care Coordination WRAP Crisis Planning Housing & Employment Health Care PREVENTION POSTVENTION TRANSITION SUPPORTS Critical Time Intervention, Peer Support & Peer Crisis Navigators

25. Goals for a crisis system • Decrease preventable interactions with • Law Enforcement • The Criminal Justice System • Emergency Departments • Increase rates of community stabilization • Availability of EMS to assist in stabilizationand ongoing support • Collaboration with community partners

26. The Problem of Recognition Hardest to recognize Best time to intervene Calm Irritable Verbal Physical Easiest to recognize Worst time to intervene

27. Rapid Chemical Sedation is Life-saving Use Team approach Goal; Rapid chemical restraint Prevent physical restraints when feasible Never allow hobble or prone restraint! Must monitor (Cardiac, Pulse ox, Temp) IV fluids, additional meds as needed (post radio) Transport to ED resus. Best evidence Versed 10mg IM 1st Line Ketamine 4-5mg/kg IM Close 2nd

28. Crisis Intervention Components • Call Taking and Dispatch • Law Enforcement, EMS and Medical Direction • Training • Coordination • Protocols – Sedation, Chemical Restraint. • Linkage to Mental Health • Evaluation and long term goals. • Community Intervention BEFORE the Crisis

29. What is really going on in Cardiac Arrest. • Airway Management • Drugs in Cardiac Arrest • CPR quality monitoring • Optimum Hospital Care

30. OHCA is a PrehospitalDisease 100 80 Survival reduced by ~7-10% each minute defibrillation delayed 60 Survival Rate (percent) 40 20 0 5 10 15 20 25 Time to Defibrillation(minutes) Win or Lose ON THE SCENE

31. Optimizing the System of Care • Define the System of Care • Create a Team • Measurement/Benchmarking/Feedback • Continuous Quality Improvement • Citizen Response • 911 Dispatch • EMS • Hospital

32. Lerner, Circulation, 2012

33. 911 Dispatch Lerner, Circulation, 2012

34. Citizen CPR

35. Community/Citizen Response • Culture change: everyone can respond • Metrics: • Bystander CPR Rate • Bystander AED Application Rate • Compare to national benchmarks • Set goal for annual increase • Celebrate saves • CPR rate from 14% to 35% • Call takers are big part of this

36. CPR Quality MOST important • Chest Compression CCF >80% • Compression rate of 100 to 120/min • Compression depth of ≥50 mm in adults with no residual leaning • At least one third the anterior-posterior dimension of the chest in infants and children) • Avoid excessive ventilation • Only minimal chest rise and a rate of <12 breaths/min • Watch CO2 waveform • CPR during transport – No circulation Meaney Circulation 2013

37. Live Feedback - can be simple

38. Follow up Feedback Picture monitor Feed back report

39. Follow up Feedback Picture monitor Feed back report Goal 90% CPR fraction

40. Special Topics: What about Mechanical CPR • Mechanical CPR is equivalent Manual CPR in terms of outcome. • Mechanical CPR is safer and may be useful in the RARE occasion that a patient needs transport during CPR. • Mechanical devices do have the risk of long CPR delays, a careful procedure for placing the device without interrupting CPR is essential.  The same transition will be needed at the hospital (most places just keep the mechanical CPR device on at the hospital until a clear prognosis is made) • Poole K, Couper K, Smyth MA, Yeung J, Perkins GD. Mechanical CPR: Who? When? How?. Crit Care. 2018;22(1):140. Published 2018 May 29. doi:10.1186/s13054-018-2059-0

41. Hyperventilation kills • Reduces CPR “density” • Increased intra-thoracic pressure, reducing venous return to the heart • Decreases coronary artery perfusion • Produces resp. alkalosis; which shifts Hgb-O2 dissociation curve to the left • Impairs cerebral blood flow

42. 2005 and on – Resp. Rate • 8 - 10 breaths per minute (one breath every 6 – 7 seconds!) • Recommend devices to time appropriate rates • Early use of a transport ventilator, or switch to a mechanical ventilator • Minimize respiratory acidosis and alkalosis • Always use waveform capnography (Circulation. 2005;112:IV-51 – IV-57.)

43. Recent Airway Trials • PART Trial - A total of 3,004 patients: • 1,505 assigned to the LT group, • 1,499 to the ETI group.  Time from EMS arrival to 3 min fatser • First pass success rate with an LT was 90.4 percent vs. 51.6 percent for the ETI. • 72-hour survival, was 18.3 percent in the LT group, and 15.4 percent in the ETI • AIRWAYS-2 Trial – Randomized ETI using direct laryngoscopy or an SGA • 4,410 patients were included in the ETI group • 4,886 were in the SGA group. • The SGA group was more likely to achieve ventilations within two attempts (87.4 percent vs. 79.0 percent)

44. Highlights of Local EMS protocols • Pediatric Airway • Orotracheal intubation under direct laryngoscopy may be performed in pediatric patients (14 years old and under) who are unable to protect their own airway (e.g., no gag reflex), require sustained positive pressure ventilation, and/or are in cardiac arrest ONLY when basic airway management techniques (e.g., 2-person mask ventilation with oropharyngeal airway) are ineffective. Per MCA selection, may be pre or post-radio. • DEMCA PEDS INTUBATION IS POST RADIO ONLY • Intubation in pediatric patients is HARMFUL, multiple studies. This protocol was changed 10 years ago. • Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: A controlled clinical trial. JAMA. 2000;283(6):783–790.

45. What About Drugs in Cardiac Arrest • Epinephrine trials pre 2010 ALS Outcomes = BLS Outcomes

46. Let’s Talk about Epi. • Hagihara, Akihito, Manabu Hasegawa, Takeru Abe, Takashi Nagata, Yoshifumi Wakata, and Shogo Miyazaki. 2012. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA, no. 11 ( 21). • Prospective, Non-Randomized, Observational Propensity Analysis • 417,188 OHCA Cases in Japan • In Japan, the use of epinephrine in OHCA increases the chance of ROSC, but does not increase survival with good neurologic outcomes at one month.

47. What About Drugs in Cardiac Arrest • Epinephrine most recent study • PARAMEDIC-2 - multicenter epi 1mg q3 – 5 minutes increased the chances of ROSC but came at a cost of more ICU usage, more severe neurological disabilities • No difference in survival with favorable neurological outcome compared to placebo. • Conclusion The use of epinephrine 1mg q 3 – 5 minutes should no longer be part of standard cardiac arrest protocols.  Epinephrine should be administered on a case by case basis by experienced providers who perceive that there is a benefit to be had.

48. What About Drugs in Cardiac Arrest • Calcium -  Administration of calcium and the subsequent elevation in serum calcium concentrations under these conditions may have further detrimental effects on the heart and vascular smooth muscle. The routine use of calcium in cardiac arrest is not recommended. • Stempien Ann Int Med review 1986 • Bicarb - SB administration is only recommended for cardiac arrest related to hyperkalemia or overdose of tricyclic antidepressant. • AHA 2010, Velissaris Review 2016

49. What About Drugs in Cardiac Arrest • What’s the glucose? STOP ASKING, dropped from H&T 2010 • Glucose - There is an no clear association between hypoglycemia and sudden cardiac death. Administration of dextrose is also associated with worse outcomes (Peng, et al). Glucose will almost always correct it self after ROSC. The fingerstick of a long non perfused finger gives no useful information. • Anti-Arrythmics • Kudencheck, NEJM 2016, randomized Amiodarone, Lidocaine and Placebo in Vfib/unstable Vtach – Equivalent no benefit • Magnesium – no benefit except MAYBE in Torsades

50. Highlights of Local EMS protocols • 5-1 Cardiac Arrest - Medications in Cardiac Arrests • Medications have never shown a survival benefit. • Epi should be at 5 min not 3, best current evidence • Bicarb and Calcium are harmful except in special cases • Bicarb in hyperkalemia or tricyclic OD, must document why • Calcium in Hyperkalemia ONLY • 5-1 Cardiac Arrest - Medical cardiac arrest patients undergoing attempted resuscitation should not be transported unless return of spontaneous circulation (ROSC) is achieved, transport is ordered by medical control or otherwise specified in protocol • There is no perfusion during CPR in transport • Only ROSC or special circumstances should be transported • Cheskes S, Byers A, Zhan C, Verbeek PR, Ko D, Drennan I, et al. CPR quality during out-of-hospital cardiac arrest transport. Resuscitation 2017;114:34–9.