The EMS Lighthouse Project (FlightBridgeED, LLC.)

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.

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 and Mike Verkest are joined by a trio of guests to discuss the literature surrounding the Pfizer BionTech and Moderna Vaccines. Dr. Ritu Sahni, Dr. Veer Vithilani, and Dr. Remle Crowe round out the panel. This episode is nearly two hours in length, and we hope we answered any questions you might have in a non-biased way. Feel free to share this episode or any of the mRNA series of podcasts and live broadcasts we have done this month. We appreciate you listening.

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

Have you had patients recently with repeat EMS calls and lots of ED visits for nausea and vomiting? They say the only thing that works for them is scalding hot showers and that drug that starts with a "D." Did they happen to smoke a lot of weed? In this episode, Dr. Jarvis discusses cannabinoid hyperemesis syndrome and reviews an RCT comparing topical capsaicin cream (yes... the stuff of pepper spray fame) vs placebo.

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

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.

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

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.

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.

The debate has raged. In this corner, we have our established champion succinylcholine, or, as the oldsters call it, “because we’ve always done it this way.” In that other corner, we have the brash newcomer, rocuronium, or, as the youngsters call it, “OMG… what about the hyperK!.” Wouldn’t you just like an answer? Which is better? SAMU to the (potential) rescue. Our French colleagues published a Randomized Clinical Trial comparing FPS among pre-hospital patients undergoing intubation between succinylcholine and rocuronium. What did they find? Join Dr. Jarvis for a hot-off-the-presses podcast that will give you the down-and-dirty about this trial ON THE DAY IT WAS PUBLISHED! Take THAT Second Shift! If you like what you hear, please give us a 5-star rating on Apple Podcasts and tell your friends to subscribe. As always, we want to hear your feedback. You can reach us on Twitter at @EMSLighthouse and @DrJeffJarvis.

Remember Episode 12, where we reviewed a Houston paper on DSD that showed worse outcomes with DSD? At the end of that pod, I spoke about an ongoing RCT trial comparing DSD to standard therapy AND vector change defibrillation. Well, the pilot phase of that trial is over and has JUST been published. It has some surprising preliminary results. Join us and find out how that study is going. If you like what you hear, please give us a 5-star rating on Apple Podcasts and other premier podcast purveyors and tell your friends to subscribe.

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

Children are often considered to be just small adults, much to the dismay of pediatricians everywhere. But when it comes to peri-intubation cardiac arrest, is it true? We know that, in adults, peri-intubation hypoxia is a strong predictor of cardiac arrest. Is this true in pediatric patients?

This episode features another oral board case with Dr. Erin Lincoln (@ErinTWL) and a live discussion with Mike (@MikeVerkest), Jeff (@DrJeffJarvis), and special guest Dr. Peter Antevy (@HandtevyMD). Our live segment had lots of great listener questions, which led Peter and Jeff to explore safe intubation practices in depth. 

If you like what you hear, please give us a 5-star rating wherever you get your podcasts and tell your friends to subscribe. All of our podcasts are now also released in video format on the FlightbridgeED YouTube channel. Take a look, subscribe, and give us a ‘thumbs up.’ 

As always, we want to hear your feedback and questions/comments. You can reach us at @DrJeffJarvis or jeff.jarvis@flightbridgeed.com.

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!

In this episode, we look at 3 papers that try to answer the question about the airway in adult cardiac arrest. Put your seat belt on, this episode is nearly 2 hours so we broke it into 2 parts! We are joined By Eric Bauer from the FlightBridgeED podcast for a quick case review to start things off. Thank you for supporting the FlightBridgeED network of podcasts. We appreciate the subscriptions, comments, and ratings. Remember that reviews are key to helping keep us high on the charts where your friends and family can find us. We couldn’t make this podcast without you. Thanks for listening!

In this episode of the EMS LHP Podcast, Dr. Jarvis and Mike Verkest look at the data regarding responding to and from calls with lights and sirens…you may be surprised by the risks we are taking…do the benefits outweigh the risks? Tune in to find out! The EMS Lighthouse Project Podcast is the newest FlightBridgeED clinical podcast network show! Your feedback has been fantastic, and we appreciate the support! If you haven’t, please leave feedback and rate us on your favorite podcast app!

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

The final part of our coverage of some of the research from NAEMSP2020 in San Diego. If you missed any of the first three episodes, download them and listen. They were great! In this episode, we wrap up the series with outstanding discussions. We discuss the epidemiology of pediatric trauma activations with San Antonio’s Dr. Craig Cooley and finish up with a discussion with Dr. Henry Wang. Dr. Wang talks to us through an oral abstract he presented here on a secondary analysis looking at the impact of FPS in the PART trial comparing ET and King LT in cardiac arrest. As a bonus, he talked us through the original PART trial, where he was the principal investigator. As always, we want to hear your feedback. Let us know what you think: @DrJeffJarvis and @EMSLigthouse. Subscribe and give us an excellent rating on Apple Podcast.

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

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.

DSD is the current bright and skinny object. Many agencies (including mine) adopted it based on a few case series. Dr. Jarvis discusses a new paper on Houston Fire/EMS’ experience with DSD. Should we change our practice? Listen and find out. Thank you for the comments, reviews, and emails! If you haven’t, please go to your favorite podcast app and leave a rating and review! We appreciate it!

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.

Mike and Dr. Jarvis are joined by Drs. David Wampler and Emily Kidd to discuss their study on the performance characteristics of the VAN score for detecting large vessel strokes. Drs. Jarvis and Kidd run through a case of a patient with a stroke to discuss the thought process of an emergency physician.

More and more EMS research is being presented at the PCRF research forum at the EMS Expo. Dr. Jarvis sat with Dr. David Wampler at the EMS Expo 2019 in New Orleans. Dr. Wampler won the award for best research at EMS Expo 2019 for his research comparing inhaled isopropyl alcohol to oral ondansetron for nausea. He also discusses his other two posters. If you like hearing about the latest EMS research, subscribe to our podcast. If you like what you hear, please give us a 5-star rating on Apple Podcasts to help others discover the EMS LightHouse Project Podcast! As always, we want to hear your feedback. You can reach us on Twitter at @EMSLighthouse and @DrJeffJarvis.

In this episode, Dr Jarvis looks at the first secondary analysis from the PART trial of advanced airway management in cardiac arrest (King LT vs. ETI). The analysis looks at the impact of airway type and time to first epinephrine, with an expanded look at outcomes as a function of time to epi. We appreciate the subscriptions, comments, and ratings. Remember that reviews are key to helping keep us high on the charts where your friends and family can find us. We couldn’t make this podcast without you. Thanks for listening!

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.

VL vs. Augmented DL with Special Guest: Dr. George Kovacs. We’re starting a new format with this episode. We kick things off with a review of a paper: Brown CA, 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; 27: 100-108. After discussing the paper, we have a fantastic interview with Dr. George Kovacs (@kovacsgj) to discuss the differences between types of VL devices. He drops some great pearls on some tips for intubation success. Then Mike joins us for a discussion of the paper and interview. We hope you like the new format. Please drop us a line and let us know what you think! As always, please subscribe and give us a 5-star rating on Apple Podcasts. We’d love to hear your thoughts, questions, and suggestions. Join us on Twitter: @DrJeffJarvis, @EMSLighthouse

HAPPY NEW YEARS! We hope you are celebrating 2020 at the NAEMSP National Conference in San Diego. In this special episode of the EMS Collaborative, we discuss the wonderful world of Mobile Integrated Health (MIH) and ET3. It's a fascinating conversation filled with MIH history, MIH research, editorials, and, of course, checking to see if Dr. Sahni can qualify for Medicare. Check out this fun, entertaining, and witty podcast today! As always, THANK YOU for listening! Hawnwan Philip Moy MD (@pecpodcast), Scott Goldberg MD, MPH (@EMS_Boston), Jeremiah Escajeda MD, MPH (@jerescajeda), Joelle Donofrio-Odmann DO (@PEMems), Mike Verkest (@MikeVerkest), Ritu Sahni MD (@MD59), Jeffrey Jarvis MD (@DrJeffJarvis), and @FlightBridgeED!

Should we chill out with the non-shockable cardiac arrests? Another look at targeted temperature management. First, we knew early hypothermia after ROSC saved brains. Then, we learned that doing it in the field didn’t make a difference and that there was no difference between 33C and 36C. This month, the NEJM published the HYPERION trial of non-shockable arrests randomized to hypothermia (33C) or normothermia (37C). If you like what you hear, please give us a 5-star rating on Apple Podcasts and other premier podcast purveyors and tell your friends to subscribe.

We talk about headaches in this episode, specifically an RCT comparing haloperidol to placebo for benign headaches. Special guest Dr. Erin Lincoln (@ErinTWL), EM resident and paramedic, is joining us for this episode. Drs. Jarvis and Lincoln will go through an oral boards-type case of a 45-year-old woman with a headache. We’ll include a review of the literature on headache treatments, hit on why opioids aren’t recommended, and discuss the differential diagnosis of headaches and the red flags that will help find those “can’t miss” diagnoses. This is a new format for us. We want your feedback. Do you like the oral boards-style interview? Drop us a note on Twitter @DrJeffJarvis, or email jeff.jarvis@flightbridgeed.com. And don’t forget to give us a review on Apple Podcasts to help other like-minded clinicians find our show.

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

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).

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 

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.

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.

The FDA just granted EUA for the Johnson and Johnson vaccine against COVID. This is a big deal because it is a one-shot vaccination that is much more stable than the two mRNA vaccines. Dr. Jarvis provides a quick overview of the data submitted to the FDA for approval.

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

A variety of papers, including CRASH-2, suggest that TXA can decrease mortality if given early for patients at risk of significant hemorrhage but exclude patients with TBI. CRASH-3 was a large, multi-national, placebo-controlled randomized trial comparing TXA, 1 gm over 10 minutes, followed by a subsequent 1 gm infusion over the next 8 hours. So… what do we think of the paper’s results, and do we believe TXA should be given to TBI patients? The EMS Lighthouse Project Podcast is the newest FlightBridgeED clinical podcast network show! Your feedback has been fantastic, and we appreciate the support! If you haven’t, please leave feedback and rate us on your favorite podcast app!

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.

There has been a lot of talk about the benefits of TXA in major trauma with minor differences in outcomes. If you’re looking for a big treatment benefit for TXA, look no further than the very sexy nose bleeds. This is an easy and safe intervention that EMS can provide that makes a real difference in a growing number of patients. If you like what you hear, please give us a 5-star rating on Apple Podcasts and other premier podcast purveyors and tell your friends to subscribe.

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

Every other year, board-certified EMS physicians must take an open book quiz over 20-25 papers felt by the American Board of Emergency Medicine (ABEM) to be something all EMS physicians should know. Dr. Jarvis and Dr. Casey Patrick (@cpatrick_89) from Montgomery County Health District EMS gave a lecture reviewing the 2020 ABEM EMS LLSA articles at the Texas Chapter of NAEMSP meeting. We got together right after our lecture to record this podcast, going over these articles. Join us from the Cavalier Room at the Historic Menger Hotel (@mengerhotel) in downtown San Antonio, literally next door to the Alamo.

Mike and Ritu bring Dr. Jarvis in the mix for the "cross-over episode of the century"…um, described by Mike as a ménage a trois…it's not like that…he just meant it’s a 3 for one…even that doesn't sound right. He is simply saying, how often do you get 2 AMAZING EMS Physicians on the same pod simultaneously!? We tackle DROPERIDOL!! Remember that medication? It was an amazing drug that lost its way. We talk about why and how it's making a comeback. Still considered one of the top 10 in the industry, we couldn’t do it without your support! Thank you for the comments, reviews, and emails! If you haven’t, please go to your favorite podcast app and leave a rating and review! We appreciate it!

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.

Dr. Jarvis and Mike Verkest were at the EMS Expo in Atlanta. We recorded some interviews from the FlightbridgeED booth on the exhibitor floor and then discussed them when Mike stopped by Casa Jarvis in Austin a bit later. There was so much goodness that we broke it up into two different episodes to keep these at a reasonable length.

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.

Ketamine-only intubation has been promoted by some as a safe approach to airway management in patients with anatomically or physiologically difficult airways. It turns out Dr. Jarvis has some thoughts on the subject. He uses a 2020 paper by Dr. Driver entitled “Success and Complications of the Ketamine-Only Intubation Method in the Emergency Department” to discuss this concept. 

If you like what you hear, please give us a 5-star rating wherever you get your podcasts and tell your friends to subscribe. All of our podcasts are now also released in video format on the FlightbridgeED YouTube channel. Take a look, subscribe, and give us a ‘thumbs up.’ 

As always, we want to hear your feedback and questions/comments. You can reach us at @DrJeffJarvis or jeff.jarvis@flightbridgeed.com. 

Thanks y’all!

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.

Mike and Jeff meet to discuss some airway papers from the National Emergency Airway Registry (NEAR) and float some merch ideas. If you like the show, please give us a like on YouTube and a 5-star rating wherever you get your podcasts. Drop your questions/comments/suggestions for future pods at: Jeff.jarvis@flightbridgeed.com or @DrJeffJarvis.

In this episode of the EMS LHP Podcast, Dr. Jarvis and Mike Verkest are joined by David Olvera to see what the literature says about ketamine for pain. Is it safer? Does it take care of pain any better? Tune in to find out! The EMS Lighthouse Project Podcast is the newest FlightBridgeED clinical podcast network show! Your feedback has been fantastic, and we appreciate the support! If you haven’t, please leave feedback and give is a rating on your favorite podcast app! We appreciate the subscriptions, comments, and ratings. Remember that reviews are key to helping keep us high on the charts where your friends and family can find us. We couldn’t make this podcast without you. Thanks for listening!

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

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.

In this episode of the EMS LHP Podcast, Dr. Jarvis goes solo and discusses an important paper regarding Airway and TBI. The Excellence in Prehospital Injury Care study (EPIC) published in May of 2019 in JAMA definitely sheds the bright light of science on current EMS Practice. Take a listen and tell us your thoughts! The EMS Lighthouse Project Podcast is the newest FlightBridgeED clinical podcast network show! Your feedback has been fantastic, and we appreciate the support! If you haven’t, please leave feedback and give us a rating on your favorite podcast app!

Dr. Jarvis had an opportunity to sit with Dr. Ben Bobrow at the Texas EMS Conference. Dr. Bobrow is the chair of Emergency Medicine at UT Houston. During his time in Arizona, Dr. Bobrow was instrumental in studying Traumatic Brain Injury and approaches to improved outcomes in cardiac arrest. If you know about the dangers of hypoxia and hypotension in TBI or the importance of minimally interrupted chest compressions and passive oxygenation in cardiac arrest, you should hear this interview. If you like what you hear, please give us a 5-star rating on Apple Podcasts and other premier podcast purveyors and tell your friends to subscribe.

And we’re back for part 2 of our coverage of some of the research from NAEMSP2020 in San Diego. If you missed part 1, be sure to download it and listen. It was great! As always, we want to hear your feedback. Let us know what you think: @DrJeffJarvis and @EMSLightouse. Subscribe and give us an excellent rating on Apple Podcast.

Part pre-recorded, part LIVE! Dr. Jeff Jarvis, Dr. Jason Pickett, and Mike Verkest discuss the results of the Resuscitation Outcomes Consortium TXA in TBI Trial. Thanks for coming to the channel! Be sure to subscribe here and wherever you listen to podcasts!

Remember our podcast about amiodarone and lidocaine improving survival from arrest when given IV but not IO? Wait! There’s more. Another paper dropped looking at the same thing but with epinephrine instead of anti-dysrhythmics. Does this paper show the same thing? Is there something to this IV superiority thing? Dr. Jarvis breaks this new paper down. As always, please subscribe and give us a 5-star rating on Apple Podcasts. We’d love to hear your thoughts, questions, and suggestions. Join us on Twitter: @DrJeffJarvis, @EMSLighthouse

We are living in a COVID world. And I am a COVID doc. This is a special episode of the EMS Lighthouse Project Podcast. Since the Jarvis household is quarantined in our bunker in Central Texas, I brought the family together to discuss how such a short piece of RNA has changed our world. Oh, and we talk about the MMWR report from Singapore that, apparently, got the CDC to change its stance on the use of public face masks. If you like what you hear, please give us a 5-star rating on Apple Podcasts and other premier podcast purveyors and tell your friends to subscribe. Most importantly, stay safe out there. Thank you for stepping up and caring for others in these difficult times. We appreciate each one of you. I’ve never been prouder to be in EMS.

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

What if we told you that neither amiodarone nor lidocaine did any better in cardiac arrest when given by IO? What if we told you neither one improved survival when given by IV? Would you think I was smoking crack? Yeah, I would have thought that, too, until last week. I will quickly recap this important secondary analysis of the ALPS trial. As always, please subscribe and give us a 5-star rating on Apple Podcasts. We’d love to hear your thoughts, questions, and suggestions. Join us on Twitter: @DrJeffJarvis, @EMSLighthouse, @FlightBridgeED

This episode was a LIVE media broadcast discussing a double-blind trial of IM Droperidol, Ziprasidone, and Lorazepam for acute undifferentiated agitation in the emergency department. Join Mike and Jeff as they discuss the paper, take viewers' questions, and tease the newly released Standard of Care Podcast! Thank you for listening, sharing, rating, and reviewing all the FlightBridgeED podcasts! We appreciate you being on this journey with us!

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.

Ketamine is a wonder drug. Ketamine is a tool of systemic racism. Ketamine is impossible to overdose. Ketamine is an inappropriate drug used for inappropriate purposes. So much controversy. What should we believe? When in doubt, follow the data. Dr. Jeff Jarvis reviews a very timely paper just released in Annals of Emergency Medicine using the 2019 Data Collaborative data set that aims to describe the characteristics of patients getting ketamine as well as the potential deaths associated with it. As a bonus, Drs. Remle Crowe and Brent Myers join Dr. Jarvis for an interview about their paper and the controversies surrounding ketamine use.

And…we are back for part 3 of our coverage of some of the research from NAEMSP2020 in San Diego. If you missed parts 1 or 2, be sure to download them and listen. They were great! In this episode, we have two great interviews. We talk with Dr. Veer Vithalani of MedStar in Fort Worth, TX, about his work using EtCO2 to detect unrecognized BVM ventilation failures. We also chat with Drs. Casey Patrick and Rob Dickson from Montgomery County Hospital District EMS in Conroe, TX, about push-dose drugs, including epinephrine and nitroglycerin.

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

Have you ever given adenosine to a patient in SVT? Yeah? Did they like it? I didn’t think so. You’ve probably also given up trying to use the Valsalva maneuver because it doesn’t work very often. Wouldn’t it be great if there were a way to make the Valsalva more effective and, perhaps, avoid kicking the patient in the chest with adenosine? Dr. Jarvis reviews a paper in this episode that may offer just this. If you like what you hear, please give us a 5-star rating on Apple Podcasts and other premier podcast purveyors and tell your friends to subscribe.

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

In this episode, Dr. Jarvis discusses a paper that is hot off the press, and he’s excited to discuss it. The good folks up in Seattle, WA, and the Seattle FD looked at their cardiac arrest survival rates as a function of the number of intubation attempts needed to secure the airway. Results from this trial might help explain the 2.9% improved survival with King LT vs ETI that we saw in the PART trial. Join us to hear all the juicy details. As always, if you like the pod, give us a 5-star rating wherever you get your pods. If you have any questions, drop us a note: jeff.jarvis@flightbridgeed.com or @DrJeffJarvis. You can also follow the pod on Twitter @EMSLighthouseProject.

What is the impact of on-scene resuscitation vs intra-arrest transport on outcomes? Could the differences in first-pass success between ETI and King LT have accounted for the differences in outcome in the PART trial? How about differences in compression interruptions? In this episode recorded on the road in Bend, Oregon, Dr. Jarvis reviews three new papers addressing these questions. He then interviewed Petar and Amber Hossick about how Bend Fire Rescue has implemented tenets of improvement science to impact survival in their community.

Are you worried about what might happen in your jurisdiction if COVID breaks out in your nursing homes? You should be. Dr. Jarvis reviews a NEJM paper in this episode: Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility. Afterward, he’s joined by a special guest, Dr. Jason Pickett. Dr. Pickett is the deputy medical director for Austin-Travis County EMS, assistant local health authority for Austin Public Health, and the host of the EMS podcast with the longest name ever. As always, please subscribe and give us a 5-star rating on Apple Podcasts. We’d love to hear your thoughts, questions, and suggestions. Join us on Twitter: @DrJeffJarvis, @EMSLighthouse.

You’ve all seen it. Most of you have probably taken (or fired) a round or two in it. It’s the Great Twitter "VL vs. DL War." Everyone has their opinion. I certainly did. But now I’ve found peace by retreating from the madness. Ultimately, it’s WAY more about the training than the particular device used. To make his point, Dr. Jarvis reviews a randomized trial comparing AP Advance, CMAC, and King Vision. If you like hearing about the latest EMS research, subscribe to our podcast. If you like what you hear, please give us a 5-star rating on Apple Podcasts to help others discover the EMS LightHouse Project Podcast! As always, we want to hear your feedback. You can reach us on Twitter at @EMSLighthouse and @DrJeffJarvis.

We saw the amazing performance of Pfizer and Moderna's two mRNA COVID vaccines in their RCTs. As encouraging as trial performance is, we always want to know how those numbers hold up under large-scale, real-world pragmatic conditions. Well, we now have three new pieces of information on that. And, for the cherry on top, we get evidence of performance against asymptomatic infection! Dr. Jarvis does a quick review of the latest evidence on vaccine performance.

The EMS Lighthouse Project Podcast exists to foster knowledge translation from peer-reviewed scientific journals to the street. Join Mike Verkest and Dr. Jeff Jarvis as they shine the bright light of science on EMS practice in an informative and fun way. Remember that reviews are key to helping keep us high on the charts where your friends and family can find us. We couldn’t make this podcast without you. Thanks for listening!

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.

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).

Did y’all make it to NAEMSP 2020 in San Diego? If not, I’m sorry. It was awesome! If you did, you probably had a great time but still missed a lot. There’s just too much going on. Being the research nerds we are, we focused our time on the oral and poster presentations. We interviewed as many investigators as we could. In fact, we recorded more audio than we could fit in one episode. So… we’re cutting them into smaller chunks and will get them out faster than our regular every two-week release schedule. Join us as we sit down (or stand up, as the case may be) for some great interviews from NAEMSP. As always, we want to hear your feedback. Let us know what you think: @DrJeffJarvis and @EMSLightouse. Subscribe and give us an excellent rating on Apple Podcast.

As a special Thanksgiving treat, we bring a “Live” panel discussion featuring Drs. Jeff Jarvis, Jason Pickett, Heidi Abraham, and Taylor Ratcliff. Skillfully (and tactfully) moderated by the awesome Ginger Locke. Recorded 11/26/19 at the Texas EMS Conference in Fort Worth, Texas. Topics include epinephrine and advanced airways in cardiac arrest, paramedic degrees, intubation with paralytics vs. “sedation assisted intubation,” whole blood, IV push nitroglycerine for CHF, POCUS, and discussing clinical errors. This was a ton of fun to record. We hope you enjoy it as much as we did. Happy Thanksgiving! If you like what you hear, please give us a 5-star rating on Apple Podcasts and tell your friends to subscribe. You can reach us on Twitter at @EMSLighthouse and @DrJeffJarvis.

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

In this episode, we continue from part 1 and look at 3 papers that try to answer the question about airway in adult cardiac arrest. Thank you for supporting the FlightBridgeED network of podcasts. We appreciate the subscriptions, comments, and ratings. Remember that reviews are key to helping keep us high on the charts where your friends and family can find us. We couldn’t make this podcast without you. Thanks for listening!

The EMS Lighthouse Project Podcast exists to foster knowledge translation from peer-reviewed scientific journals to the street. Join Mike Verkest and Dr. Jeff Jarvis as they shine the bright light of science on EMS practice in an informative and fun way. Remember that reviews are key to helping keep us high on the charts where your friends and family can find us. We couldn’t make this podcast without you. Thanks for listening!

December 4, 2001. A bad day, indeed. That’s the day the FDA issued a black box warning for droperidol, citing evidence of QT prolongation, Torsades de Pointes, and death. This was a surprise warning because droperidol had been extensively used by emergency medicine and anesthesiology for decades without apparent problems. Since this bad day, we’ve essentially been without droperidol. Fortunately, it’s back! Before we use it again, we should look at what got this drug on the FDA’s radar. Dr. Jarvis reviews the literature about the “evidence” behind the warning and describes how his systems will be bringing droperidol back into practice.

Ketamine has been getting a lot of attention recently in the media. It's probably safe to say it’s had a bad year. We like ketamine. We felt bad it’s been having a rough year so we wanted to do something that would lift its spirits. Fortunately, Dr. David Barbic and his colleagues from Vancouver, BC published a wonderful, randomized trial comparing ketamine to a combination of haloperidol plus midazolam for undifferentiated agitation in the ED. This was the amazingly titled RACKED trial (Rapid Agitation Control with Ketamine in the ED). It has direct and important implications for EMS and is something all emergency providers should know about. Dr. Jarvis reviews the trial and then invites Dr. Barbic himself on the show to discuss this study. If you like the show, please give us a like on YouTube and a 5-star rating wherever you get your podcasts.

This episode was recorded LIVE on Facebook with a ton of fun interactions. Dr. Jeff Jarvis and Mike Verkest look at a recent paper that described stroke patients who underwent RSI had worse outcomes than their non-RSI counterparts! …do the benefits outweigh the risks? Tune in to find out! The EMS Lighthouse Project Podcast is the newest FlightBridgeED clinical podcast network show! Your feedback has been fantastic, and we appreciate the support! If you haven’t, please leave feedback and rate us on your favorite podcast app!

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.

LIVE from a virtual Texas EMS Conference; we bring you a session moderated by Mike featuring Drs. Jeff Jarvis, Jason Pickett, and Heidi Abraham. This is the highly anticipated Part Deux of a session we all did at the Texas EMS Conference in Fort Worth in 2019… back before “the situation” when we could all meet in person like civilized humans. We discussed various topics, including the new DEA rules about controlled substances, the latest AHA guidelines, and many other goodies. But mostly, we just had fun.

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

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.