Archives for July 2013

Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Dilaudid – Start With 2 mg or Start With 1 mg?

ResearchBlogging.org
 
What is the proper interval before we should give another dose of opioid to patients who still have significant pain?

The authors of this study suggest that 3 to 5 minutes would be ideal, but that the ED (Emergency Department) is not a setting where that is practical.
 

Administration of small doses of intravenous opioids every 3 to 5 minutes until pain relief is achieved, as typically practiced in postoperative care settings, is highly appealing. However, this is simply not feasible in most EDs because of ubiquitous and progressive crowding.18,19

Taking into consideration the heightened risk of adverse effects associated with administration of too large or too rapid a dose of intravenous opioid, we wished to develop a modified titration strategy appropriate to the constraints of the ED.[1]

 

This would seem to make EMS the right people to administer opioids at theat ideal frequent rate of every 3 to 5 minutes. The main problem with having EMS do this seems to be the continuing refusal of many medical directors to do what is best for the patient.

Because of the staffing limitations of the ED, something that does not apply to EMS, the authors chose 15 minutes as the Do you want more pain medication? interval for their ED study.
 

The primary efficacy outcome was the difference in the proportion of patients in each arm who, when asked, declined additional pain medication at 60 minutes after receiving their first dose of intravenous hydromorphone. The primary safety outcome was use of naloxone as a reversal agent.[1]

 

One group received 2 mg hydromorphone intially and appears to have been asked an hour later if they wanted more pain medicine. The other group received 21 mg hydromorphone intially, was asked at 15 minutes if they want any more pain medicine and only appears to have been asked again an hour later if they wanted more pain medicine.

The outcome showed no statistically significant difference between the groups.

There was never any need for naloxone for any patient, but that should not be a surprise to anyone who has treated severe pain more aggressively than was treated in this study.

Only one patient had an oxygen saturation that dropped below 95%, but that was in the 1+1 group. It is not documented whether this was after the initial 1 mg, after a repeat dose of 1 mg, or after doses beyond the protocol (it is not clear if any doses were administered beyond the protocol).
 


Click on images to make them larger.
 

All patients received supplemental 2 L nasal cannula oxygen in response to a greater-than-expected incidence of oxygen desaturation in a previous study of the safety and efficacy of the 2 mg intravenous hydromorphone protocol.26 [1]

 

This is not unreasonable in an ED that is busy, but EMS should be able to more closely assess the oxygenation and avoid this medical intervention. In EMS, since we are usually with the patient at all times, it is easy to just get the patient to talk if the oxygen saturation drops below 94%, or the heart rate drops to something undesirable, or if hypotension develops (usually just a reaction to histamine when using morphine). When the patient talks, the patient ventilates and oxygenates. Problem solved. If the patient takes a nap, that is not a problem.
 

Do you want more pain medication? as the primary efficacy endpoint. This measure has a number of advantages and limitations. It is a simple, patient-centered index, with an immediate and unambiguous treatment strategy embedded within it. It invites the patient to take into account not only severity of pain but also other clinically relevant considerations, such as common opioid adverse effects that patients may find more unpleasant than partially attenuated pain.[1]

 

As much as we may think we know the patient’s pain level better than the patient, or the authenticity of the patient’s pain better than the patient, it is unlikely that we are right. Feel free to provide some research to contradict me, if you disagree.
 

Even after receiving the approximate equivalent of 14 mg morphine either all at once or in 2 equally divided doses, one third of patients still wanted additional analgesia. This is consistent with the work of other investigators, demonstrating similar and substantial interindividual variation in opioid requirement.10-12,35 [1]

 

We are sometimes discouraged from providing good patient care because of numbers that we might think are too much.

The problem is when not some numbers are too much.

The problem is when the patient’s pain is too much.
 


 

The mean level of pain was clearly lower at all times in the study.

With more attention to the patient’s pain and to the possible side effects, we can prove more aggressive pain management that is just as safe, if not more safe, than less aggressive dosing with opioids.
 

The difference between the conclusions we would have drawn according to a retrospective analysis indirectly comparing studies that appeared to constitute a valid comparison versus what we have concluded according to the current randomized clinical trial is a useful reminder of the hazards of using historical comparison groups, even if they are samples from the same population. Had we not performed a randomized trial to confirm our previous findings, we would have concluded that the 2 mg hydromorphone bolus protocol was superior to the 1+1 titration protocol.[1]

 

An initial 2 mg bolus does not appears to increase the benefits to the patients in this ED study.

In EMS our goal is usually to manage the pain before we move the patient.

In EMS an initial 1 mg hydromorphone, with 5 minute repeat doses would not appear to delay benefits, but the study’s end point was the need for more medicine at 1 hour, not the ability to adequately control the patient’s pain before moving the patient.

Footnotes:

[1] Randomized Clinical Trial of the 2 mg Hydromorphone Bolus Protocol Versus the “1+1” Hydromorphone Titration Protocol in Treatment of Acute, Severe Pain in the First Hour of Emergency Department Presentation.
Chang AK, Bijur PE, Lupow JB, Gallagher EJ.
Ann Emerg Med. 2013 May 16. doi:pii: S0196-0644(13)00201-1. 10.1016/j.annemergmed.2013.02.023. [Epub ahead of print]
PMID: 23694801 [PubMed – as supplied by publisher]

http://www.clinicaltrials.gov/ct2/show/NCT01311895 (NCT01311895

Chang AK, Bijur PE, Lupow JB, & Gallagher EJ (2013). Randomized Clinical Trial of the 2 mg Hydromorphone Bolus Protocol Versus the “1+1” Hydromorphone Titration Protocol in Treatment of Acute, Severe Pain in the First Hour of Emergency Department Presentation. Annals of emergency medicine PMID: 23694801

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Standards Of Care – Ventricular Tachycardia

 

Is it possible to write protocols that are based on good evidence, rather than on GOBSAT (Good Old Boys Sitting Around a Table) rules?
 

The Standard Of Care is what the popular kids are doing because of peer pressure, a lack of understanding of the available evidence, and a fear of law suits.

Peer pressure?

If we don’t do what everyone else is doing, we will harm patients?

Patient care is not a popularity contest, otherwise there would be no need for doctors. A majority of neighbors could come up with the Standard Of Care.

Is there any reason to discourage doctors from challenging the Standard Of Care?

Well . . . .

What will everyone hide behind, if we admit that the Standard Of Care may not be the best available care?

What will everyone hide behind, if we admit that the Standard Of Care may be bad care?

If we admit that, will memorization and application of a bunch of Standards Of Care be good for patients?
 

What about V Tach (Ventricular Tavhycardia)? The AHA (American Heart Association) writes guidelines for treatment, which are generally accepted as Standards Of Care and copied into EMS protocols. To the credit of the AHA, they do continually review the available evidence and revise their guidelines.
 


 

Many devotees of Standards Of Care whine about these changes. How can we be expected to provide care that doesn’t get us in trouble, if the definition of what doesn’t get us in trouble is constantly changing? It is as if we will be expected to understand what we are doing, rather than to just be expected to memorize and apply the Standards Of Care. It is as if we are expected to continue learning because we don’t know everything.

Amiodarone may be the ultimate standard Standard Of Care.

A Fib (Atrial Fibrillation)?

Give amiodarone.

A Flutter (Atrial Flutter)?

Give amiodarone.

V Tach?

Give amiodarone.

Wide complex tachycardia that could be anything?

Give amiodarone.

V Fib (Ventricular Fibrillation)?

Give amiodarone.

Sinus tachycardia (due to sepsis, or hemorrhage, or pain, or epinephrine, or dehydration, or anxiety, or fever, or . . . )?

Some people will still give amiodarone.

Why?

It’s the Standard Of Care. This is the excuse for not being competent. Just memorize some Standards Of Care, sprinkle them around liberally, and everything will be OK – but never, ever question the Standard Of Care.

This is no different from the protocol monkey, who is faced with the multiple choice protocol decision.

Tachycardia problem?

Tachycardia treatment.

Amiodarone vs. adenosine. Tough choice. Narrow = adenosine. Wide = amiodarone.

But does amiodarone do a good job of treating emergency patients?

Different studies show that amiodarone is only 29% effective at terminating V Tach,[1] only 25% effective at terminating V Tach, [2], and only 15% effective at terminating V Tach within 20 minutes, but if we don’t mind waiting an hour it can be as much as 29% effective.[3]

What else is available?

In the 2010 ACLS guidelines, procainamide is listed as Class IIa, LOE B, while amiodarone is only Class IIb, LOE B.

What does that mean?
 

Class IIa
Benefit >> Risk
It is reasonable to perform procedure/administer treatment or perform diagnostic test/ assessment.

Class IIb
Benefit Risk
Procedure/treatment or diagnostic test/assessment may be considered.[4]

 

There is much better evidence that procainamide is effective.
 

Procainamide and sotalol should be avoided in patients with prolonged QT.[5]

 

But that is a mistake.

Amiodarone is a potent QT segment prolonging drug.
 

Proarrhythmia
Like all antiarrhythmic agents, amiodarone I.V. may cause a worsening of existing arrhythmias or precipitate a new arrhythmia. Proarrhythmia, primarily torsades de pointes (TdP), has been associated with prolongation by amiodarone I.V. of the QTc interval to 500 ms or greater. Although QTc prolongation occurred frequently in patients receiving amiodarone I.V., torsades de pointes or new-onset VF occurred infrequently (less than 2%). Patients should be monitored for QTc prolongation during infusion with amiodarone I.V. Combination of amiodarone with other antiarrhythmic therapy that prolongs the QTc should be reserved for patients with life-threatening ventricular arrhythmias who are incompletely responsive to a single agent.
[6]

 

If the only advantage of amiodarone over procainamide is QT prolongation, but that advantage is not real, why should we prefer amiodarone to procainamide?

Footnotes:

[1] Amiodarone is poorly effective for the acute termination of ventricular tachycardia.
Marill KA, deSouza IS, Nishijima DK, Stair TO, Setnik GS, Ruskin JN.
Ann Emerg Med. 2006 Mar;47(3):217-24. Epub 2005 Nov 21.
PMID: 16492484 [PubMed – indexed for MEDLINE]

[2] Amiodarone or procainamide for the termination of sustained stable ventricular tachycardia: an historical multicenter comparison.
Marill KA, deSouza IS, Nishijima DK, Senecal EL, Setnik GS, Stair TO, Ruskin JN, Ellinor PT.
Acad Emerg Med. 2010 Mar;17(3):297-306.
PMID: 20370763 [PubMed – indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.

[3] Intravenous amiodarone for the pharmacological termination of haemodynamically-tolerated sustained ventricular tachycardia: is bolus dose amiodarone an appropriate first-line treatment?
Tomlinson DR, Cherian P, Betts TR, Bashir Y.
Emerg Med J. 2008 Jan;25(1):15-8.
PMID: 18156531 [PubMed – indexed for MEDLINE]

[4] Table 3. Applying Classification of Recommendations and Level of Evidence
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 1: Introduction
Table 3

I have modified this table solely for the purpose of clarity of presentation, by modifying color and font. None of the words have been changed.

[5] Wide-Complex Tachycardia
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.3: Management of Symptomatic Bradycardia and Tachycardia
Tachycardia
Free Full Text from Circulation

[6] AMIODARONE HYDROCHLORIDE injection, solution
[Bedford Laboratories]

DailyMed
Warnings
FDA Label

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NAEMSP Position Paper on Spinal Immobilization

 

The current issue of Prehospital Emergency Care, the official journal of the NAEMSP (National Association of EMS Physicians), NASEMSO (National Association of State EMS Officials), NAEMSE (National Association of EMS Educators), and the NAEMT (National Association of EMTs) includes a position statement. A big deal is being made about the improvements, but that is because we have been so far in the Dark Ages with our management of potential spine injuries, that any improvement looks wonderful.

This may be the EMS equivalent of Why are you hitting your head against the wall? Because it feels so good when I stop.

Why are we still abusing our patients with potential spinal injuries? Unfortunately, the answer to this question is not as wise as Because it feels so good when we stop.
 

Utilization of backboards for spinal immobilization during transport should be judicious, so that the potential benefits outweigh the risks.[1]

 

What benefit?

Where is the evidence that this improves outcomes for patients with unstable spinal injuries?
 

However, the benefit of long backboards is largely unproven[1]

 

Largely?

Entirely?

There are no outcomes studies that show any benefit, but there are studies that show serious harm with back boards.[2],[3],[4]

Therefore, the risk/benefit ratio has either a question mark, or a zero as the benefit.

Real risk/?
 


Picture credit.

 

Plus

 


Picture credit from Voodoo Medicine Man.

 

Equals

 


Picture credit.

 
If there were some valid evidence of some benefit to backboarding patients, this position paper might have something positive, but it is only something that can be copied from a journal to be shown to the people who apparently ignore journals.

There is one positive.
 

Spinal precautions can be maintained by application of a rigid cervical collar and securing the patient firmly to the EMS stretcher, and may be most appropriate for:

  • Patients who are found to be ambulatory at the scene
  • Patients who must be transported for a protracted time, particularly prior to interfacility transfer
  • Patients for whom a backboard is not otherwise indicated[1]

 

A collar and no board?
 

This is still not supported by good evidence of improved outcomes, but there is evidence that it is much less likely to cause movement to an unstable spine than a back board or a KED (Kendrick Extrication Device).[5],[6]

Footnotes:

[1] EMS spinal precautions and the use of the long backboard.
[No authors listed]
Prehosp Emerg Care. 2013 Jul-Sep;17(3):392-3. doi: 10.3109/10903127.2013.773115. Epub 2013 Mar 4.
PMID: 23458580 [PubMed – in process]

Free Full Text in PDF Download format from NAEMSP.

[2] The cause of neurologic deterioration after acute cervical spinal cord injury.
Harrop JS, Sharan AD, Vaccaro AR, Przybylski GJ.
Spine (Phila Pa 1976). 2001 Feb 15;26(4):340-6.
PMID: 11224879 [PubMed – indexed for MEDLINE]
 

All but two patients had complete injuries at admission. One patient with incomplete injury and another that was neurologically intact had early complete cervical cord injuries after cervical immobilization.

 

Four of the five patients in the early group (mean age 56 years) developed neurologic worsening during application of cervical immobilization less than 24 hours after injury.

 

This paper was cited by the ACS (American College of Surgeons) as a justification for spinal immobilization for blunt trauma.

[3] Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed – indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.
 

RESULTS:
There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34).

 

[4] Spinal immobilisation for trauma patients.
Kwan I, Bunn F, Roberts I.
Cochrane Database Syst Rev. 2001;(2):CD002803. Review.
PMID: 11406043 [PubMed – indexed for MEDLINE]
 

The review authors could not find any randomised controlled trials of spinal immobilisation strategies in trauma patients. It is feasible to have trials comparing the different spinal immobilisation strategies. From studies of healthy volunteers it has been suggested that patients who are conscious, might reposition themselves to relieve the discomfort caused by immobilisation, which could theoretically worsen any existing spinal injuries.

REVIEWER’S CONCLUSIONS:
We did not find any randomised controlled trials that met the inclusion criteria. The effect of spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain. Because airway obstruction is a major cause of preventable death in trauma patients, and spinal immobilisation, particularly of the cervical spine, can contribute to airway compromise, the possibility that immobilisation may increase mortality and morbidity cannot be excluded.

 

[5] Cervical spine motion during extrication.
Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim RS.
J Emerg Med. 2013 Jan;44(1):122-7. doi: 10.1016/j.jemermed.2012.02.082. Epub 2012 Oct 15.
PMID: 23079144 [PubMed – in process]
 

RESULTS:
The results indicated a significant decrease in movement for all motions when the driver exited the vehicle unassisted with CC protection, compared to exiting unassisted and without protection. Decreases in movement were also observed for an event (i.e., Pivot in seat) during extrication with paramedic assistance and protection. However, no movement reduction was observed in another event (i.e., Recline on board) with both paramedic assistance and protection.

CONCLUSION:
In this study, no decrease in neck movement occurred for certain extrication events that included protection and assistance by the paramedics. Future work should further investigate this finding.

 

There is a detailed evaluation of this paper in the article below by Dr. Brooks Walsh at Mill Hill Ave Command.

[6] In order to protect the c-spine, should we stop helping?
Mill Hill Ave Command
Saturday, December 15, 2012
Article

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Is Alternative Medicine Really ‘Medicine’? – Part I

 

A few weeks ago Science Friday interviewed Dr. Paul Offit about his new book, Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine. Unfortunately there is the false balance of including a proponent of invalid medicine alternative medicine as if there is some validity to using treatments that do not work.
 

All proceeds from the sale of Do You Believe in Magic? will be donated to The Children’s Hospital of Philadelphia.[1]

 


 

Dr. Offit mentions that the basis of acupuncture is the division of the body into 365 parts, because there are 365 days of the year. He did not mention whether leap years result in leap parts – parts that only exist in one out of every four years or perhaps only one quarter of a part. If we are going to be logically consistent, we need to update our approach when the basis of that approach is required to be updated.

There are also 12 meridians (places to put acupuncture needles) because there are twelve great rivers in China. Does that mean that practicing acupuncture in other countries would involve different numbers of meridians due to the different numbers of major rivers in other countries?
 

If you believe that human anatomy has nothing to do with rivers in China, or days of the year, they were making it up.[2]

 

Do you believe that human anatomy has anything to do with days of the year? Would someone lose body parts if living above the Arctic Circle, when the Sun does not set/rise for extended weeks? If not, why not?

Do you believe that human anatomy has anything to do with the major rivers in China?

Does the Three Gorges Dam[3] mean that human anatomy is now dammed up in that meridian?

What were the borders of China at the time? Did changes in the political boundaries of China result in anatomic changes?

Is acupuncture based on ancient wisdom?

Is ancient wisdom just another term for superstition?

Research that compares sham acupuncture with normal acupuncture and with expert acupuncture make it clear that the sham acupuncture is just as good as the expert acupuncture.[4],[5]

Sham acupuncture is placebo acupuncture.

Why doesn’t normal acupuncture work better than sham acupuncture?

Why doesn’t expert acupuncture work better than normal acupuncture?

Why doesn’t expert acupuncture work better than sham acupuncture?

Anything that does not work better than a placebo is a placebo.

Since the sham acupuncture works just as well as the expert acupuncture, that tells us that even the expert acupuncture is just an elaborate placebo.

Acupuncture is just a placebo.

What about other alternative medicine?

Is Alternative Medicine Really ‘Medicine’? – Part II – 7//2013

Is Alternative Medicine Really ‘Medicine’? – Part III – 7//2013

Footnotes:

[1] Do You Believe in Magic?: The Sense and Nonsense of Alternative Medicine
Paul A. Offit, MD
Web page with links to site to purchase the book.

[2] Is Alternative Medicine Really ‘Medicine’?
July. 05, 2013
Science Friday
Article/Podcast

[3] Three Gorges Dam
Wikipedia
Article

[4] A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain.
Cherkin DC, Sherman KJ, Avins AL, Erro JH, Ichikawa L, Barlow WE, Delaney K, Hawkes R, Hamilton L, Pressman A, Khalsa PS, Deyo RA.
Arch Intern Med. 2009 May 11;169(9):858-66. doi: 10.1001/archinternmed.2009.65.
PMID: 19433697

Free Full Text from PubMed Central

[5] Acupuncture for treatment of persistent arm pain due to repetitive use: a randomized controlled clinical trial.
Goldman RH, Stason WB, Park SK, Kim R, Schnyer RN, Davis RB, Legedza AT, Kaptchuk TJ.
Clin J Pain. 2008 Mar-Apr;24(3):211-8.
PMID: 18287826 [PubMed – indexed for MEDLINE]

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Not all mechanisms are created equal

ResearchBlogging.org
 

How do we determine which patients go to a trauma center?

Too often by MOI (Mechanism Of Injury).

Physiologic criteria are not too bad and involve some assessment of the patient.
 


 

Notice that the GCS (Glasgow Coma Score) is not just for a history of a loss of consciousness or for not being fully oriented.

Anatomic criteria are also not too bad and similarly involve some assessment of the patient.
 


 

Mechanism Of Injury is where the most disagreement arises and I have had some entertaining conversations with trauma doctors, but far more disagreement with those doctors who have only anecdotal trauma experience.
 

The MOI that accurately predicts trauma center need remains a controversial debate within the trauma community. One specific example of this controversy is the rollover mechanism. Single-center experience suggests rollover is not predictive of severe injury, while a review of a large government database suggests otherwise.13,14 [1]

 

This study excluded everyone who met physiologic or anatomic criteria in order to assess the ability of MOI alone to identify need for a trauma center.
 

Trauma center need was defined as death, Injury Severity Score (ISS) of more than 15, blood transfusion in the emergency department (ED), intensive care unit (ICU) admission, pelvic fracture, need for laparotomy/thoracotomy/vascular surgery within 24 hours of arrival, two or more proximal long bone fractures, or neurosurgical intervention during admission.[1]

 

Some of those duplicate anatomic criteria, but they appear to refer to pelvic fractures and pairs of long bone fractures that were not identified by EMS and were not documented by EMS as criteria for trauma activation.
 


 

How much risk of death is there for these mechanism-only patients? We do not know, but only 0.3% died in the hospital.

How many of them would have been triaged as trauma alerts by a good assessment?

The biggest problem with this paper is that it is not able to tell us whether these patients would have been triaged as trauma alerts without MOI criteria to point to for documentation.
 

The goal of every trauma center is to treat as many seriously injured patients as possible, while directing care of the less severely injured to community hospitals. To achieve this goal, the ACSCOT suggests that an overtriage rate of 50% is acceptable to maintain an undertriage rate of 5% or less.15[1]

 
 

Our overtriage rate of 77% was higher than that which is considered acceptable by the ACSCOT. The overtriage rate in this study is consistent with that noted in other studies, which used the 1999 guidelines for evaluating MOI in prehospital triage, which ranged from 75% to 91%.21–24 [1]

 
 

In 2006, our system stopped requiring trauma center transport of patients meeting Step 3 criteria.[1]

 

Step 3 is MOI.

Requiring medical command permission to fly patients meeting MOI criteria in Maryland led to an apocalyptic prediction from the top trauma doctor.
 

“Whenever someone says they want to ratchet it back,” says Dr. Thomas M. Scalea, physician in chief at Shock Trauma, “I tell them ‘OK, how many people can die next year to make that worthwhile?’”[2]

 

There have not been any reports of increases in the fatality rate with that change.

How did the MOI criteria do?

Wrong question. Since they eliminated the use of MOI criteria in this system, we have a strong hint.
 

Orthopedic operations were the most common procedures performed on those patients transported from the ED to the operating room (289 patients, 68%). Eighteen patients (4%) did require a laparotomy, thoracotomy, or vascular procedure directly from the ED. Of those requiring laparotomy (11 patients, 3%), 2 were to repair a liver laceration, 2 for splenectomy, and 4 were intestinal repairs/resection. Three nontherapeutic laparotomies were performed.[1]

 

Those numbers are better than what I would expect. I used to work in a trauma center that had less than 5% of trauma alert patients go to surgery in any kind of rush. Surgery is not the only criterion for whether the trauma center is an appropriate destination.
 

Significant MOI predictors of trauma center need include death in the same passenger compartment, ejection from the vehicle, extrication time of more than 20 minutes, fall from more than 20 feet, and pedestrian thrown/runover.[1]

 

Those are the criteria they think have some predictive value.

Here are the ones that are old wives’ tales.
 

Criteria that did not meet our definition of trauma center need were vehicle intrusion, vehicle rollover, speed of more than 40 mph, autopedestrian/autobicycle of more than 5 mph, and both of the motorcycle crash criteria.[1]

 

Separation of the motorcyclist from the motorcycle is not a bad sign, but it shows that the MOI criteria were written by someone who does not understand motorcycles. In a crash, remaining inside a car/truck is protective, but remaining attached to the outside of a motorcycle is almost as bad as being strapped to the outside of a car/truck. This is the reason motorcycles do not have seat belts. Motorcycles do not offer physical protection. The protection is in the increased maneuverability and the ability of the rider to avoid getting in trouble. A motorcycle crash at highway speed is only bad if you are hit, hit something, or if you are not wearing protective gear.

How much better would a good assessment be at correctly identifying patients who have critical injuries?

How much worse would a good assessment be at correctly identifying patients who have critical injuries?

A good assessment would require good education and good oversight.

As with other interventions, this should be studied prospectively.

Footnotes:

[1] Not all mechanisms are created equal: A single-center experience with the national guidelines for field triage of injured patients.
Stuke LE, Duchesne JC, Greiffenstein P, Mooney JL, Marr AB, Meade PC, McSwain NE, Hunt JP.
J Trauma Acute Care Surg. 2013 Jul;75(1):140-5.
PMID: 23940858 [PubMed – indexed for MEDLINE]

[2] Advantages of medevac transport challenged
Baltimore Sun
October 5, 2008
Article

Stuke, Lance E. MD, MPH; Duchesne, Juan C. MD; Greiffenstein, Patrick MD; Mooney, Jennifer L. MD; Marr, Alan B. MD; Meade, Peter C. MD; McSwain, Norman E. MD; Hunt, John P. MD, MPH (2013). Not all mechanisms are created equal: A single-center experience with the national guidelines for field triage of injured patients. Journal of Trauma and Acute Care Surgery, 75 (1), 140-145 DOI: 10.1097/TA.0b013e3182988ae2

.

Comment from Mike McEvoy on Apparent DNA Transfer by Paramedics Leads to Wrongful Imprisonment

 

Mike McEvoy, paramedic, nurse, firefighter, author, speaker…, provides an excellent comment on some of the problems we cause when we do not think about what we are doing – such as with the use of disposable medical gloves.[1]
 

Nothing spells ridiculous more than providers who hop out of their engine wearing gloves.

 

Often without having worn a seat belt while driving to the call.
 

Lord knows what germs they’re bringing as a gift to their soon to be patient.

 

With a good study, we could find out. Maybe ultraviolet coloring could be applied to the gloves, so that we could see everything that has been touched/contaminated with dirty gloves. Once the gloves are out of the box (on your hands, in a carrying case, in our pockets, et cetera), the gloves are dirty.
 


Image credit.
 

There have been studies of the bacteria on the various interior surfaces of the ambulance.

It might shock those who think the Gloves on, scene safe, parrot phrase is a good idea.

If they knew how much bacteria they were carrying on their “clean” gloves, how might that change behavior?
 

In conclusion, data we obtained for a large national sample of wards and hospitals shows that although the rate of glove use is relatively low, gloves are still often worn when not indicated and vice versa. The rate of compliance with hand hygiene is significantly worse if gloves are worn for all types of hand hygiene moments, especially high-risk patient contacts and before patient contacts.[1]

 

It amazes me how quick readers are to criticize a magazine for pictures of firefighters without helmets, SCBA, or the proper tools yet, never have a seen a letter complaining about inappropriate use of medical PPE.

 

How many of us receive good education about appropriate use of disposable medical gloves?

How many of us throw them on the floor of the patient’s home or the emergency scene?

If we are disposing of a mess that we would put in biohazard bags, why is it appropriate to treat the mess as if it is clean?
 

Take a look at any EMS magazine. You’ll see providers carrying bags while wearing gloves, pushing stretchers while wearing gloves, hooking up oxygen while wearing gloves, writing out paperwork wearing gloves, talking on radios while wearing gloves, blah, blah, blah.

 


Image credit.
 

Bad training/education.

Mindless oversight by managers/supervisors who do not understand how gloves prevent infections and how glove spread infections.

Gloves are a temporary barrier.

Gloves are contaminated on the outside.

Gloves are usually more contaminated on the inside.
 

Gloves are for people, not equipment. Every one of these actions would be flagged in a hospital or health care facility and the employee counseled. Time to get with the program in EMS.

 

Hospitals are getting better. EMS is often far behind in infection control practices.

We claim that we work in unique circumstances, so the hospital rules do not apply. This is a mistake.
 

We work in occasionally unique circumstances. Because of that, we need to be better at not transmitting germs between patients or even from ourselves to our patients, or to ourselves.
 


Image credit.

Footnotes:

[1] Apparent DNA Transfer by Paramedics Leads to Wrongful Imprisonment
Fri, 05 Jul 2013
Rogue Medic
Article

[2] “The dirty hand in the latex glove”: a study of hand hygiene compliance when gloves are worn.
Fuller C, Savage J, Besser S, Hayward A, Cookson B, Cooper B, Stone S.
Infect Control Hosp Epidemiol. 2011 Dec;32(12):1194-9. doi: 10.1086/662619. Epub 2011 Oct 17.
PMID: 22080658 [PubMed – indexed for MEDLINE]

Free Full Text from Infection Control and Hospital Epidemiology.

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Un-extraordinary measures: Stats show CPR often falls flat

 

Does CPR (CardioPulmonary Resuscitation) save lives? CNN seems to think that CPR does not work. This article misrepresents the evidence of the results of CPR.

For example, this quote of Dr. David Newman suggest that only one patient a year survives CPR to be discharged from his hospital.
 

In fact, out of the hundreds of CPR patients who have come to St. Luke’s Hospital in New York, Newman recalls no more than one individual a year making a full recovery.[1]

 

Is one person per year out of all patients who receive CPR what Dr, Newman really means?

Of all of the patients who received prehospital CPR, does only one patient a year survive?

I have not asked Dr. Newman, because I wanted to write something quickly, but I do not have any reason to believe that this is what he meant.

What Dr. Newman probably meant is that of the patients who come to his hospital with CPR in progress, only about one per year will survive.

What is the difference?

If the patient does not have ROSC (Return Of Spontaneous Circulation – get a pulse back) prior to transport by EMS, the chances of resuscitation are less than 1%.
 

Yet despite advancements, the overall effectiveness of CPR remains disappointingly low — although the practice still has its defenders.[1]

 

While we do need to improve our resuscitation methods, there has been dramatic improvement with the focus on exactly what the author is criticizing – CPR. The less we do that is not based on evidence, the better the outcomes.

Continuous fast and deep chest compressions are effective.

This month the LAS (London Ambulance Service) reported their change in resuscitation rates from 2007 to 2012.
 

In 2010 a number of further initiatives were introduced. One such initiative focussed on the crucial role that bystanders play. More than 30,000 members of the public were trained by the LAS to recognise cardiac arrest and deliver bystander intervention. This training, reflected in an increase in bystander CPR rates during this time, along with an increase in the number of community access automated defibrillators placed in London, may have positively contributed to reducing the time between collapse and effective intervention.[2]

 

A big part of what they changed was the focus on having bystanders perform CPR.

What was the change in resuscitation rates?
 

Survival to hospital discharge rates for those meeting the Utstein comparator criteria improved dramatically, increasing from 12% to 32% from 2007 to 2012.[2]

 

In 2007 the survival to discharge was 12% – not great, but not as bad as the author would have us believe.

In 2012, after increases in bystander CPR and a focus on continuous fast and deep compressions, the survival to discharge increased to 32%.
 

1/3 of patients survived to hospital discharge.
 

Not just 1/3 of patients who had bystander CPR, but 1/3 of all patients.

Bystander CPR increased from 55.4% in 2007 to 64.6% in 2012, but what is probably more important is the quality of CPR. No longer were pauses for IVs, intubation, or moving the patient considered acceptable. There is still no evidence that any pause for anything other than defibrillation improves outcomes – not for ventilation, drugs, intubation, or transport to be the one patient per year surviving to discharge after arriving with CPR in progress.
 

What about in the US, since the author interviewed American emergency physicians?
 

Despite decades of research, median reported rates of survival to hospital discharge are poor (7.9%) and have remained virtually unchanged for 3 decades (9,10).[3]

 

That does not look good, but that includes everyone – even those who did not get any bystander CPR. The CNN article is suggesting that bystander CPR does not work, so what are the results for patients who did have bystander CPR?
 

Although 36.7% of OHCA events were witnessed by a bystander, only 43.8% of these arrests involved persons who received bystander CPR, and only 3.7% of those persons were treated with an AED before the arrival of 911.[3]

 

The problem is not too much CPR.

The problem is not enough CPR.
 

Patients who received bystander CPR had a higher rate of overall survival (11.2%) than those who did not receive bystander CPR (7.0%; p<0.01). Improving community bystander CPR rates is an important step towards improving OHCA survival.[3]

 

That is not great, but it is far from useless. We can increase our survival to discharge rate to over 30% – several places in the US already exceed 30%. The most famous of these is Seattle, which historically has the highest bystander CPR rate in the US.

1/9 patients survived to discharge with bystander CPR.

1/14 patients survived to discharge without bystander CPR.

This includes the patients who are unlikely to survive no matter what is done for them.

That is more than a 50% increase in the survival rate. That is not insignificant. If we can improve the quality of CPR, the rate of bystander CPR, and the quality of EMS treatment, we can save a lot of lives.

CPR, especially without the ventilations, does save lives.

If we limit the analysis to patients who meet Utstein criteria, the numbers improve to 30%.
 

Click on image to make it larger.
 

The figure above shows site-specific and aggregate Utstein survival rates for out-of-hospital cardiac arrest events by participating emergency medical services agency for October 1, 2005- December 31, 2010. Utstein survival refers to survival to hospital discharge of persons whose cardiac arrest events were witnessed by a bystander and had an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia. Results varied by agency; the overall Utstein survival rate was 30%.[3]

 

Why use the Utstein criteria?
 

The Utstein criteria are designed to permit standardisation between the many reports of cardiac arrest available in literature and hence allow for direct comparisons of the presented data. In addition, the Utstein criteria can be used as a predictor of survival as it is this group of patients that has the greatest chance of a positive outcome.[2]

 

If you witness a cardiac arrest, that person probably meets Utstein criteria. You should call 911 (or whatever the emergency number is where you are) and then begin fast and deep compressions. Continue until someone can take over for you or until help arrives. If you get tired and can switch with someone else, do so as many times as necessary to be able to continue fast and deep compressions.
 

[youtube]ILxjxfB4zNk[/youtube]
 

Footnotes:

[1] Un-extraordinary measures: Stats show CPR often falls flat
By Madeleine Stix, CNN
July 10, 2013 — Updated 1118 GMT (1918 HKT)
CNN
Article

[2] Increases in survival from out-of-hospital cardiac arrest: A five year study.
Fothergill RT, Watson LR, Chamberlain D, Virdi GK, Moore FP, Whitbread M.
Resuscitation. 2013 Apr 11. doi:pii: S0300-9572(13)00207-4. 10.1016/j.resuscitation.2013.03.034. [Epub ahead of print]
PMID: 23583613 [PubMed – as supplied by publisher]

[3] Out-of-hospital cardiac arrest surveillance — Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005–December 31, 2010.
McNally B, Robb R, Mehta M, Vellano K, Valderrama AL, Yoon PW, Sasson C, Crouch A, Perez AB, Merritt R, Kellermann A; Centers for Disease Control and Prevention.
MMWR Surveill Summ. 2011 Jul 29;60(8):1-19.
PMID: 21796098 [PubMed – indexed for MEDLINE]

Free Full Text from Morbidity and Mortality Weekly.

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Do Paralytics Improve Outcomes Following Resuscitation?

ResearchBlogging.org
 

This study will get some people excited because of an impressive p value for an odds ratio of improved cardiac arrest outcomes – 7.23 (1.56–33.38) p = 0.01.

NMBs (NeuroMuscular Blockers/Blockade) are paralytic drugs that are used to prevent movement by the patient. Does this study truly show that immediate use of NMBs improves neurologically intact survival from cardiac arrest?
 

Side effects of therapeutic hypothermia include an increased risk for arrhythmia, infection or bleeding, and shivering.6 [1]

 

NMBs could cause worse outcomes from therapeutic hypothermia use following ROSC (Return Of Spontaneous Circulation).
 

the American Heart Association (AHA) has recommended minimizing the use of NMB in post-CA patients or avoiding it altogether.11 [1]

 

Is this enough to get the AHA to change their minds?
 

We included patients who were 18 years of age or older who had suffered OHCA with sustained ROSC (defined as the presence of palpable pulses for >20 min) and who were comatose (not following commands) upon presentation to the NPARC hospital.[1]

 

That is an unusual definition of comatose. It would be interesting to know how many patients had a GCS (Glasgow Coma Score) of at least 8, but were not following commands. Many people are taught that a low GCS means that we should intubate. The mnemonic Less than 8 – intubate, is taught as if it is a substitute for a thorough assessment.

Maybe not following commands is the right metric to use for administration of NMBs, but we might want to describe this level of consciousness with a term other than coma. There is a lot of connotation associated with coma that might complicate decisions about treatment. If we use NMBs for patients with ROSC and a motor score of less than 6, will some people start to use a motor score of less than 6 for intubation with NMBs? RSI (Rapid Sequence Induction/Intubation) is the use of NMBs to facilitate intubation. A better question is How many of us will do this?, rather than Will any of us will do this?
 

Continuous neuromuscular blockade is associated with decreased mortality in post-cardiac arrest patients - Fig 1
 

Impressive.

So why am I suggesting caution?
 

Compared to those who did not receive sustained NMB, patients with 24-h NMB had shorter intervals from collapse-to-ROSC (13 min [IQR: 9–25] versus 22 min [IQR: 13–30]; p = 0.04) and higher baseline blood pH values (pH = 7.30 [IQR: 7.26–7.36] versus 7.22 [IQR: 7.12–7.31]; p = 0.04). There was a lower incidence of chronic obstructive pulmonary disease in patients with NMB compared to patients without NMB (0% versus 22%; p = 0.02).[1]

 

Time to ROSC demonstrates one of the problems with small numbers. The IQRs (InterQuartile Ranges) do not show that much difference, but the median times to ROSC are much farther apart. 22 minutes is in the middle of the 13-30 minute IQR for control patients, but 13 minutes is much quicker than the middle of the IQR for NMB patients.

Why does this matter?

The control patients appear to be evenly distributed around 22 minutes from collapse to ROSC, but the NMB patients had an uneven distribution that masks a tendency toward much quicker ROSC.
 

It is also odd that the group with the smaller numbers has a narrower IQR. Is this because of some uncontrolled variable in choosing which patients received early, sustained NMB treatment?
 

This is a post hoc analysis of data collected for a study with a different hypothesis, so the best that can be stated is that immediate NMB use (continued for 24 hours) is a promising treatment for further study.

Another big problem with this study is that it is so small. 18 patients received NMBs. The authors started the paper by mentioning that there are 400,000 cardiac arrests in the US each year. We need to demonstrate benefit on much more than 18 patients, regardless of p value, if we are going to start using this treatment outside of controlled trials.
 

There were 77 (69%) patients documented to have received NMB at any point within the first 24 h following ROSC. A portion of these patients (18/111, 16%) patients had NMB initiated immediately and sustained for a minimum duration of 24 h following return of circulation.[1]

 

This is not really a study comparing NMB use with absence of NMBs. This is a study comparing immediate NMB use that was continued for at least 24 hours against control group patients – most of whom received NMBs, but did not meet the full criteria for inclusion in the study group.

How different were the treatments? We do not know.

59 out of the 111 patients in the No NMB group received NMBs.

53% of the No NMB group did receive NMBs, just not for at least 24 hours and/or not immediately following ROSC. Correction – 15:20 7/08/2013.

59 out of 93 patients in the No NMB group received NMBs.

63% of the No NMB group did receive NMBs, just not for at least 24 hours and/or not immediately following ROSC.
 

The following is the main limitation pointed out by the authors.
 

An important limitation of this observational study is the uncertainty about why NMB was used in certain patients. It is possible that patients with more intact reflexes, shivering or spontaneous movement were more likely to receive NMB than patients with less vigorous neurological examinations. Thus, the possibility remains that patients without sustained NMB were less responsive (i.e., worse neurological status) and therefore did not clinically require continued therapy therefore creating selection bias. Finally, whether heavy sedation in the post-CA period would confer similar results is possible but has yet to be explored.[1]

 

Is a good physiologic explanation is leading them to minimize the weaknesses of this study? I don’t know, but they are not recommending anything other than more study, which is a reasonable conclusion for this study.

Unfortunately, the abstract presents a different conclusion – a conclusion that assumes too much.

I would discuss the physiology that is the basis for this study, but with no clear evidence of benefit and a lot of evidence that the data are misleading, there is no reason to spin tales about any possible mechanism(s).

The hypothesis is still essentially untested.

Footnotes:

[1] Continuous neuromuscular blockade is associated with decreased mortality in post-cardiac arrest patients.
Salciccioli JD, Cocchi MN, Rittenberger JC, Peberdy MA, Ornato JP, Abella BS, Gaieski DF, Clore J, Gautam S, Giberson T, Callaway CW, Donnino MW.
Resuscitation. 2013 Jun 21. doi:pii: S0300-9572(13)00331-6. 10.1016/j.resuscitation.2013.06.008. [Epub ahead of print]
PMID:23796602[PubMed – as supplied by publisher]
 

The National Post-Arrest Research Consortium (NPARC) is a clinical research network conducting research in post-cardiac arrest care. The network consists of four urban tertiary care teaching hospitals and was established to evaluate treatment strategies for individuals who are successfully resuscitated after out-of-hospital cardiac arrest. The current investigation is a post hoc analysis of a prospectively conducted NPARC trial evaluating mitochondrial injury in post-cardiac arrest patients (NIH 3UL1RR031990-02S1).

Salciccioli JD, Cocchi MN, Rittenberger JC, Peberdy MA, Ornato JP, Abella BS, Gaieski DF, Clore J, Gautam S, Giberson T, Callaway CW, & Donnino MW (2013). Continuous neuromuscular blockade is associated with decreased mortality in post-cardiac arrest patients. Resuscitation PMID: 23796602

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