Explorez tous les épisodes du podcast The EMS Lighthouse Project

The 2017 NEJM study, ALPS, compared amiodarone, lidocaine, and placebo for refractory shockable rhythms in adults with out of hospital cardiac arrest. They found no significant difference in survival to hospital discharge or functional survival between any of the arms. If that study has left you confused, you’re not alone. 

And you’re in luck. Tanner Smida joins us again to discuss his latest paper using something called target trial emulation to assess the difference in ROSC and survival to discharge between amiodarone and lidocaine. This is a great discussion of his paper, the methodology, and how we can put his results into the context of ALPS.

Citations:

1.Smida T, Crowe R, Price BS, Scheidler J, Martin PS, Shukis M, Bardes J: A retrospective ‘target trial emulation’ comparing amiodarone and lidocaine for adult out-of-hospital cardiac arrest resuscitation. Resuscitation. 2025;March;208:110515.

2. 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.

3.Hernán MA, Robins JM: Using Big Data to Emulate a Target Trial When a Randomized Trial Is Not Available: Table 1. Am J Epidemiol. 2016;April 15;183(8):758–64.

We just got a new paper that compares initial treatment with adenosine compared with diltiazem for the treatment of adults with SVT in the ED. Wouldn’t it be great if it turned out that diltiazem was just as effective, if not more effective, as adenosine without the crappy feeling? 

Yeah, that’d be great, but what do we do with statistically insignificant results. Is there, perhaps, a way to save this “insignificant” paper? Fear not, Bayes is here! 

Yes, that’s right, Dr. Jarvis is grabbing this new paper and diving straight back into that deep dark rabbit hole of Bayesian analysis. 

Citation:

1.     Lee CA, Morrissey B, Chao K, Healy J, Ku K, Khan M, Kinteh E, Shedd A, Garrett J, Chou EH: Adenosine Versus Fixed-Dose Intravenous Bolus Diltiazem on Reversing Supraventricular Tachycardia in The Emergency Department: A Multi-Center Cohort Study. The Journal of Emergency Medicine. 2025;August 1;75:55–64.

The next time you go to intubate a patient, should you give the sedation before the paralytic or the paralytic before the sedative? Does it matter? And what the hell does Bayes have to do with any of this? Dr Jarvis reviews a paper that uses Bayesian statistics to calculate the association between drug sequence and first attempt failure. Then he returns to Nerd Valley to talk about how to interpret 95% confidence intervals derived from frequentists statistics compared to 95% credible intervals that come from Bayesian statistics. 

Citations:

1.     Catoire P, Driver B, Prekker ME, Freund Y: Effect of administration sequence of induction agents on first‐attempt failure during emergency intubation: A Bayesian analysis of a prospective cohort. Academic Emergency Medicine. 2025;February;32(2):123–9. 

2.     Casey JD, Janz DR, Russell DW, Vonderhaar DJ, Joffe AM, Dischert KM, Brown RM, Zouk AN, Gulati S, Heideman BE, et al.: Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2019;February 28;380(9):811–21.

3.     Greer A, Hewitt M, Khazaneh PT, Ergan B, Burry L, Semler MW, Rochwerg B, Sharif S: Ketamine Versus Etomidate for Rapid Sequence Intubation: A Systematic Review and Meta-Analysis of Randomized Trials. Critical Care Medicine. 2025;February;53(2):e374–83.

We covered a paper in episode 81 that suggested treating atrial fibrillation with rapid ventricular response in the field could lower mortality. But it also drops BP a bit. Could pretreating these patients with calcium lower the risk of hypotension? Dr Jarvis puts on his nerd hat and uses Bayesian analysis to assess a new randomized, placebo-controlled study that looked at just this thing. Why is he going off on this Bayes thing? Because he’s been reading a couple of book on it and wanted to take it for a spin. 

Tables:

Charts:

Bayesian Distributions:

Citation:

1.     Az A, Sogut O, Dogan Y, Akdemir T, Ergenc H, Umit TB, Celik AF, Armagan BN, Bilici E, Cakmak S: Reducing diltiazem-related hypotension in atrial fibrillation: Role of pretreatment intravenous calcium. The American Journal of Emergency Medicine. 2025;February;88:23–8.

2.     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).

3.     Kolkebeck T, Abbrescia K, Pfaff J, Glynn T, Ward JA: Calcium chloride before i.v. diltiazem in the management of atrial fibrillation. The Journal of Emergency Medicine. 2004;May 1;26(4):395–400.

4.     Chivers T: Everything Is Predictable: How Bayes’ Remarkable Theorem Explains the World. Weidenfeld & Nicolson, 2024.

5.     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. New Haven, CT, Yale University Press, 2011.

Wrapping up a series of 5 episodes, Dr Jarvis finishes his discussion of mechanical CPR devices (MCDs) talking about papers from Utah, Vienna, Anchorage, and Cincinnati and then gives his take on how to interpret the literature and put it into practice.

Papers discussed:

1)    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.

2)    Zeiner 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.

3)    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.

4)    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. 2023;March 9;28(1):114–7.

5)    Grunau B, Reynolds J, Scheuermeyer F, Stenstom R, Stub D, Pennington S, Cheskes S, Ramanathan K, Christenson J: Relationship between Time-to-ROSC and Survival in Out-of-hospital Cardiac Arrest ECPR Candidates: When is the Best Time to Consider Transport to Hospital? Prehospital Emergency Care. 2016;September 2;20(5):615–22.

Last episode we described the literature showing no survival benefit to patients with the AutoPulse device. Fear not, I wasn’t ignoring the LUCAS, I just felt it deserved it’s own episode. We’ll cover the LINC and PARAMEDIC randomized controlled trials and the secondary analysis of LINC in shockable rhythms. 

I switched to a new production process using a new mic (Rode NT1) and started using ecamm to record. Yes, I know there is a bit of AV dysynchrony.. I’m working on it. I still have a lot to learn about ecamm but am optimistic about it. 

Citations on LUCAS device:

1. 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):53–61.

2. 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.

3. 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.

Citations on Jeff’s Tamiflu Rant

1. Jefferson T, Jones M, Doshi P, Spencer EA, Onakpoya I, Heneghan CJ: Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. BMJ. 2014;348:g2545.

2. Jefferson T, Jones MA, Doshi P, Del Mar CB, Hama R, Thompson MJ, Onakpoya I, Heneghan CJ: Risk of bias in industry-funded oseltamivir trials: comparison of core reports versus full clinical study reports. BMJ Open. 2014;4(9):e005253.

3. Jefferson T: The Tamiflu Story: Why We Need Access To All Data From Clinical Trials. Open Knowledge Foundation Blog.

Our story so far.. episode 92 looked at a study showing lower survival from in-hospital cardiac arrest in patients treated with mechanical compression devices. Episode 93 discussed an implementation study of implementing LUCAS devices in a system with high quality pit crew CPR also showing lower survival, despite spending lots of time in training on how to optimally apply the LUCAS to avoid prolonged compression interruptions and movement. 

Now we’re diving into the literature around AutoPulse, the load-distributing band device. We’ll cover two randomized controlled trials and one well-done observational study comparing AutoPulse to manual CPR. Don’t worry, LUCAS studies will be in the next episode.

Citations
1. Hallstrom A, Rea TD, Sayre MR, Christenson J, Anton AR, Mosesso VN, Van Ottingham L, Olsufka M, Pennington S, White LJ, et al.: Manual Chest Compression vs Use of an Automated Chest Compression Device During Resuscitation Following Out-of-Hospital Cardiac Arrest: A Randomized Trial. JAMA. 2006;June 14;295(22).
2. Ong MEH, Ornato JP, Edwards DP, Dhindsa HS, Best AM, Ines CS, Hickey S, Clark B, Williams DC, Powell RG, et al.: Use of an Automated, Load-Distributing Band Chest Compression Device for Out-of-Hospital Cardiac Arrest Resuscitation. JAMA. 2006;June 14;295(22).
3. 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.

Ever wonder what would happen to cardiac arrest survival after a system implements LUCAS devices and trains really hard to deploy them appropriately? Wonder no more. Dr Jarvis reviews a paper from the Austin/Travis County EMS System that will shed some light on the question. This is the second episode in a series on mechanical compression devices.  

Citations:

1.     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.

2.     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.

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. 

Citations
1. 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):53–61
3. 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/jcm12216918

3. 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/hc4501.098926

4.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)00141-5

5. 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.123.065561

7. 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:

1. 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)
2. 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.
3. Groombridge C, et al: A prospective, randomised trial of pre-oxygenation strategies available in the pre-hospital environment. Anaesthesia. 2017;72:580–4.
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.
5. 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.
6. 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.
7. Pourmand A, et al: Pre-oxygenation: Implications in emergency airway management. American Journal of Emergency Medicine. doi: 10.1016/j.ajem.2017.06.006
8. Solis 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.
9. 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.
10. 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 Attempt
11. Using Both Laryngoscope and Endotracheal Tube Insertions: A Secondary Analysis of Clinical Trial Data. Annals of Emergency Medicine. 2023;82(4):S0196064423002135.
12. 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 recommendations
3. 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 Compression
Technique. 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.

DSI (delayed sequence intubation) has been proposed as an alternative to RSI (rapid sequence intubation) for patients who can't tolerate interventions needed to properly pre-oxygenate patients. But does it work? There have been several observational studies (blatant bias acknowledgment: I wrote one of them!) suggesting it is safe and effective, but no randomized trials. Well, now we have one. Join Dr. Jarvis as he describes this RCT of DSI vs RSI in adult trauma patients presenting to an Indian ED.

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

In episode 69, we interviewed Tanner Smida about his very interesting paper using the ESO dataset. It looked at the association between survival from out-of-hospital cardiac arrest and the type of SGA used (iGel vs. KingLT). He found 36% higher odds of survival with iGel. 

The ink was barely dry on that paper before he published a follow-up paper looking at the same association but with a different dataset, this time CARES and the national US registry of OHCA. 

Citations: 
1. Smida T, Menegazzi J, Scheidler J, Martin PS, Salcido D, Bardes J. A retrospective comparison of the King Laryngeal Tube and iGel supraglottic airway devices: a study for the CARES surveillance group. Resuscitation. Published online April 2023:109812. doi:10.1016/j.resuscitation.2023.109812 
2. Smida T, Menegazzi J, Crowe R, Scheidler J, Salcido D, Bardes J. A Retrospective Nationwide Comparison of the iGel and King Laryngeal Tube Supraglottic Airways for Out-of-Hospital Cardiac Arrest Resuscitation. Prehospital Emergency Care. Published online January 18, 2023:1-13. doi:10.1080/10903127.2023.2169422

Man, did we have fun recording this one? I found myself in a hotel room in Ashland, Oregon, with Drs. Ed Racht, Maia Dorsett, and Ritu Sahni talking about Sepsis. We decided this would make for a great crossover episode with The EMS Show, minus our buddy Mikey V. Anytime I get together with this group of friends, I always have fun. We discuss a new sepsis trial, the OG sepsis paper, Dr. River's Early Goal Direct Therapy, and the cautionary tale of performance measures gone awry. We also hit on using EtCO2 as a surrogate for lactate in sepsis and collectively decided Dr. Dorsett is a rockstar. 

Citation: The National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury Clinical Trials Network. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. N Engl J Med. 2023;388(6):499-510. doi:10.1056/NEJMoa2212663

The cage match you've all been waiting for! iGel vs King LT in cardiac arrest. Which is associated with higher survival?

Airways-2 was an RCT of iGel vs. ETI in OHCA and found no difference. PART was an RCT of King LT vs. ETI in OHCA and found a slight difference favoring King LT. How about those patients just getting an SGA? How does the iGel compare to King LT? Dr. Jarvis interviews the amazing young researcher and medical student Tanner Smida about his new paper using the ESO dataset to answer this question. 

Citation: Smida T, Menegazzi J, Crowe R, Scheidler J, Salcido D, Bardes J. A Retrospective Nationwide Comparison of the iGel and King Laryngeal Tube Supraglottic Airways for Out-of-Hospital Cardiac Arrest Resuscitation. Prehospital Emergency Care. Published online January 18, 2023:1-13.

Remember AIRWAYS-2, the British RCT comparing iGel to ETI in adults with cardiac arrest? Have you wondered if those results would hold up in a different prehospital population? Wonder no more! Dr. Jarvis reviews the SAVE Trial, another RCT of adult, non-traumatic cardiac arrest, comparing iGel to ETI in Taiwan. 

Citation: Lee AF, Chien YC, Lee BC, et al. Effect of Placement of a Supraglottic Airway Device vs Endotracheal Intubation on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest in Taipei, Taiwan: A Cluster Randomized Clinical Trial. JAMA Netw Open. 2022;5(2):e2148871. doi:10.1001/jamanetworkopen.2021.48871

If one is good, two must be better, right? If it applies to cookies and ice cream, why not defibrillators? That’s the question the DOSED-VF trial set out to answer. We’ve covered this topic in episodes 12 and 27, including going over the pilot trial of DOSED-VF. But now the full meal deal is available. And you may have heard it was stopped early because… well, you’d best listen to find out. 

 As a special bonus, Dr. Jarvis explains the difference between odds and risk after falling into the statistical rabbit hole. Remember, this podcast also has a YouTube version complete with graphs and charts (oh, my!): https://www.youtube.com/@FlightbridgeedHEMS/playlists

Citations: 
1. Cheskes S, Verbeek PR, Drennan IR, et al. Defibrillation Strategies for Refractory Ventricular Fibrillation. N Engl J Med. 2022;387(21):1947-1956. doi:10.1056/NEJMoa2207304 
Other papers discussed in this episode: 
2. Mapp JG, Hans AJ, Darrington AM, et al. Prehospital Double Sequential Defibrillation: A Matched Case-Control Study. Braithwaite SA, ed. Academic Emergency Medicine. 2019;26(9):994-1001. doi:10.1111/acem.13672 
3. Beck LR, Ostermayer DG, Ponce JN, Srinivasan S, Wang HE. Effectiveness of Prehospital Dual Sequential Defibrillation for Refractory Ventricular Fibrillation and Ventricular Tachycardia Cardiac Arrest. Prehosp Emerg Care. 2019;23(5):597-602. doi:10.1080/10903127.2019.1584256 
4. Cabanas JG, Myers JB, Williams JG, De Maio VJ, Bachman MW. Double Sequential External Defibrillation in Out-of-Hospital Refractory Ventricular Fibrillation: A Report of Ten Cases. Prehosp Emerg Care. 2015;19(1):126-130. doi:10.3109/10903127.2014.942476 
5. Cheskes S, Dorian P, Feldman M, et al. Double sequential external defibrillation for refractory ventricular fibrillation: The DOSE VF pilot randomized controlled trial. Resuscitation. 2020;150:178-184. doi:10.1016/j.resuscitation.2020.02.010 
6. Ranganathan P, Aggarwal R, Pramesh C. Common pitfalls in statistical analysis: Odds versus risk. Perspect Clin Res. 2015;6(4):222. doi:10.4103/2229-3485.167092

Dr. Crowe returns to the EMS Lighthouse Project Podcast from our “vacation” in Mexico to discuss the impact of variations between pulse oximetry and blood gas values across races.

Citations:

1. Sudat SEK, Wesson P, Rhoads KF, et al. Racial Disparities in Pulse Oximeter Device Inaccuracy and Estimated Clinical Impact on COVID-19 Treatment Course. Am J Epidemiol. Published online September 2022:kwac164. doi:10.1093/aje/kwac164
2. Fawzy A, Wu TD, Wang K, et al. Racial and Ethnic Discrepancy in Pulse Oximetry and Delayed Identification of Treatment Eligibility Among Patients With COVID-19. JAMA Intern Med. 2022;182(7):730. doi:10.1001/jamainternmed.2022.1906

National guidelines for the management of seizures recommend midazolam 10 mg IM as first-line therapy. The big question is how often EMS follows this guideline or how well that guideline matches up to real-world use. Dr. Jarvis makes a road trip to ESO headquarters to discuss this paper using the ESO research dataset with newly minted Texan Mike Verkest and special guest Dr. Remle Crowe. As we get our nerd on, we go deep into the very interesting methodology used in this paper!

Citation: Guterman EL, Sporer KA, Newman TB, et al. Real-World Midazolam Use and Outcomes With Out-of-Hospital Treatment of Status Epilepticus in the United States. Annals of Emergency Medicine. Published online August 2022. doi:10.1016/j.annemergmed.2022.05.024

First, there was Episode 31: TXA for Epistaxis (the Zahed RCT from Tehran), then Episode 40: TXA for Epistaxis, Part Deux (the NoPAC trial), and now Episode 64: TXA for Epistaxis, Part Trois, another Iranian RCT.

 So, we have conflicting evidence, all from RCTs, about whether TXA works for epistaxis. Dr. Jarvis reviews the prior trials and then provides a more detailed analysis of the new evidence. He then discusses how he handles conflicting evidence. 

Citation: Hosseinialhashemi M, Jahangiri R, Faramarzi A, et al. Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial. Annals of Emergency Medicine. 2022;80(3):182-188. doi:10.1016/j.annemergmed.2022.04.010

COVID sucks, no doubt about it. Vaccination has been a game changer for how we live through the pandemic, but we still need therapeutics for those breakthrough cases and the unvaccinated amongst us. Paxlovid is a novel anti-viral agent that showed promise in an initial industry-sponsored trial among unvaccinated patients with the delta strain. But does it hold up in the real world where vaccination is common, and omicron has pushed delta to the wayside? Dr. Jarvis reviews the initial RCT and a recent Israeli observational trial where more than 75% of patients were vaccinated. He also covers the contraindications for its use. Finally, he’ll no doubt massacre the almost impossible-to-pronounce generic names for the drugs in Paxlovid.

Citations: Najjar-Debbiny R, Gronich N, Weber G, et al. Effectiveness of Paxlovid in Reducing Severe Coronavirus Disease 2019 and Mortality in High-Risk Patients. Clinical Infectious Diseases. Published online June 2, 2022:ciac443. doi:10.1093/cid/ciac443 2.Hammond J, Leister-Tebbe H, Gardner A, et al. Oral Nirmatrelvir for High-Risk, Nonhospitalized Adults with Covid-19. N Engl J Med. 2022;386(15):1397-1408. doi:10.1056/NEJMoa2118542

Our good friends at Montgomery County Hospital District EMS in suburban Houston brings us a nice feasibility study about the use of esmolol for refractory v-fib. Dr. Jarvis discusses why this is a helpful study. 

If you like the show, please give us a 5-star rating wherever you get your podcasts. Did you know our podcast is on YouTube, too? Check us out and subscribe on the FlightBridgeED channel. Drop your questions/comments/suggestions for future pods at Jeff.jarvis@flightbridgeed.com or @DrJeffJarvis.

Dr. Jarvis interviewed several EMS industry leaders, discussing why we should use Red Lights & Sirens as a clinical intervention and only as indicated. This podcast is part of the first-ever national EMS quality improvement effort led by NEMSQA (https://www.nemsqa.org/lights-and-siren).

Join us for interviews with Drs. Doug Kupas, Lawrence Brown, Michael Redlenner, and Mike Taigman to hear about The Case Against Lights & Sirens. Did you know all of our podcasts are also available in video versions? Check them out on the FlightBridgeED YouTube channel.

During my FAST22 talk, I received a great question about what to make of two different papers, seemingly on the same topic, that give different results. In this case, it was about the Prague study Mike and I spoke about on the last episode (E59) and the one from Minneapolis (the ARREST trial). It was a great question that I’ll discuss in this episode. I’ll also talk more about the ARREST trial.

 If you like the show, please give us a 5-star rating wherever you get your podcasts. Did you know our podcast is on YouTube, too? Check us out and subscribe on the FlightBridgeED channel. Drop your questions/comments/suggestions for future pods at Jeff.jarvis@flightbridgeed.com or @DrJeffJarvis.

Mikey V. and Dr. Jarvis get together again “live” from Planet Hollywood in Las Vegas for FAST22! We took the opportunity to sit down and discuss two papers on cardiac arrest. Should we stay and play, or should we load and go? In other words, should we work our arrests to a conclusion where we find them or rapidly transport them? In a paper from Prague, we discuss whether early transport with LUCAS directly to the cath lab for ECMO and PCI improves survival.

As a foretaste of a pod to come, we’ll discuss the apparent contrasting results between the Prague ECMO study and one from Minneapolis (The ARREST trial) in a future episode. If you like the show, please give us a 5-star rating wherever you get your podcasts. Did you know our podcast is on YouTube, too? Check us out and subscribe on the FlightBridgeED channel. Drop your questions/comments/suggestions for future pods at: Jeff.jarvis@flightbridgeed.com or @DrJeffJarvis

Y’all have had lots of questions about using sodium bicarbonate in cardiac arrest after we ran an interview with Dr. Menegazzi about an abstract he presented showing a benefit with bicarb. You wanted more, so here it is! Dr. Jarvis reviews a paper from British Columbia from 2017 that looks at just this thing!

If you like the show, please give us a 5-star rating wherever you get your podcasts.
Did you know our podcast is on YouTube, too? Check us out and subscribe to the FlightBridgeED channel.

Drop your questions/comments/suggestions for future pods at:
Jeff.jarvis@flightbridgeed.com or @DrJeffJarvis

Citations:
1. Kawano T, Grunau B, Scheuermeyer FX, et al. Prehospital sodium bicarbonate use could worsen long-term survival with favorable neurological recovery among patients with out-of-hospital cardiac arrest. Resuscitation. 2017;119:63-69. doi:10.1016/j.resuscitation.2017.08.008

Join us for a joint release of the first episode of The Pediatric EMS Podcast. We collaborated with the great folks from the PEC podcast and MedicMindset to introduce this new podcast. We discuss the assessment and management of pediatric pain.

Do y'all treat a-fib? Have you wondered what the best method of rate control is? Should you use diltiazem or metoprolol? How about the best pad placement for electrical Cardioversion? Should you go anterior-posterior or anterior-lateral? Great questions! Dr. Jarvis reviews two recent papers to help shed the bright light of science on these two questions.

We’re back with the second part of our interviews with researchers from the NAEMSP 2022 conference in San Diego. In this episode, Dr. Jarvis interviews Dr. Brian Miller from Fort Worth, Texas, about his work on “MCD Walk,” i.e., the case of the migratory Lucas device, Dr. Sarah Frances McClure from UT San Antonio about the impact of EMS leadership engagement on a medic’s decision to get vaccinated against COVID-19, and finally Dr. Jim Menegazzi from Pitt about sodium bicarb in EMS Witnessed cardiac arrest.

Abstracts:

“MCD Walk” – Mechanical Compression Device Migration Leading to Inadequate Compression Depth.

Kerby Johnson, BS, NRP

William Gleason, BS, LP

Brian Miller, MD, FACEP, FAEMS

Veer Vithalani, MD, FACEP, FAEMS

Office of the Medical Director, Metropolitan Area EMS Authority, Fort Worth, Texas

EMS Leadership Presence Positively Influences EMS Provider’s Decision to Receive the COVID-19 Vaccine

Sarah Frances McClure, DO, FAWM, NRP

Bryan Everitt, MD, NRP

Mark Sparkman, MD

David Wampler, PhD, LP

Courtney Wenzell, EMT-P

University of Texas Health Science Center at San Antonio, Dept of Emergency Medicine & San Antonio FD

Sodium Bicarbonate Use in EMS-Witnessed Out-of-Hospital Cardiac Arrest

Sara M. Niederberger

Remle Crowe, PhD, EMT

David D. Salcido, PhD

James J. Menegazzi, PhD

University of Pittsburgh School of Medicine, Dept of Emergency Medicine, & ESO

If you like the show, please give us a 5-star rating wherever you get your podcasts.

Did you know our podcast is on YouTube, too? Check us out and subscribe on the FlightBridgeED channel.

Drop your questions/comments/suggestions for future pods at:

Jeff.jarvis@flightbridgeed.com or @DrJeffJarvis

NAEMSP in Sunny San Diego… Just. SO. MUCH. GREAT. RESEARCH. Dr. Jarvis interviewed a small sample of the great work presented. There was so much we broke it into two parts. This episode features interviews with Dr. Amber Rice from Tucson, Arizona, discussing a secondary analysis of the EPIC trial looking further into the impact of hypotension on TBI, Dr. Veer Vithalani from MedStar in Fort Worth, TX discussing how he used his CAD and ePCR data to determine which calls could safely get a BLS response, Dr. Erin Lincoln from Austin discussing her work on disparities in analgesia, and Dr. Henry Wang on his latest secondary analysis of the PART trial, this one looking at the impact of airway type (LT or ET) on ventilatory rates.

Are you still giving Calcium in undifferentiated cardiac arrests? Not those with hyperkalemia or hypocalcemia… you know, when it’s actually indicated. Be honest, now… nobody’s looking. If you are, join us for this episode, where we review a randomized, double-blind, placebo-controlled clinical trial of calcium vs placebo in out-of-hospital cardiac arrest.

Do you even bougie, bro? Do you use the bougie on every intubation? If so, why? Do you think it improves first-pass success? Well, I certainly did. At least before this trial was released. Join me to discuss this randomized controlled trial of bougie vs no bougie for intubation. I suspect the results will surprise you!

Dr. Jarvis and Mike Verkest return for part 2 of our interviews with some great researchers at the Prehospital Care Research Forum at the EMS Expo in Atlanta. In this episode, we interview Kevin Collopy on his RCT comparing ketamine and etomidate for RSI, Sean McAllister on Sepsis using the ESO dataset, and David Page about PCRF and his work on comparing Mexican and American EMT training. If you like the show, please give us a like on YouTube and a 5-star rating wherever you get your podcasts.