1. John M. Gallagher, MD, FACEP
EMS
State of the art
John M. Gallagher, MD, FACEP
Medical Director
Wichita/Sedgwick County EMS System
Wichita, KS
Ryan Jacobsen, MD, FACEP
Medical Director
Johnson County EMS System
Olathe, KS

2. Disclosures
None

3. Objectives
1) Review several emerging issues in EMS 2) Develop critical thinking process to determine if a change in clinical practice is warranted 3) Provide real-time question/answer discussion with full time EMS Physicians.

4. Note
While some scientific work is presented here, this is not suggested to be a scientifically rigorous review of the concepts and should be taken only for what it is…evidence that we need to think about why we do what we do.

5. Note
These are emerging concepts. We don’t have answers yet as to what we should do. Data is sparse and often conflicting. So don’t expect clean “take-home” points from this talk. These challenges are what makes this job fun!

6. …SO Let’s have some fun…

7. Cervical Collars

8. Things we know about Long spine Boards
Causes pain
Increases radiation exposure
Increases admission rates
Worsens neurological outcomes
Causes tissue damage/pressure sores
Causes respiratory compromise
Worsens mortality in penetrating trauma
Doesn’t really “immobilize” spine
Is a slippery and ridiculous thing to anchor someone’s head to!
Redundant/unnecessary once on the ambulance cot

9. Good stuff about Long Spine Boards
Extrication/Movement device
ACS-COT/NAEMSP Position
Judicious use
ACEP Position
Backboards should not be used as a therapeutic intervention or as a precautionary measure either inside or outside the hospital or for inter-facility transfers. Spinal immobilization should not be used for patients with penetrating trauma.
PHTLS/ACS
Don’t place c-collars (or LSB) for patients with penetrating head/neck/face (or anywhere else)
Cochrane
No evidence to support

10. dogma Injured patients may have unstable cervical spine injury.
Additional movement of the cervical spine might result in additional damage to the spinal cord beyond that caused by the initial trauma.
The application of a C-collar may prevent potentially harmful movements of the cervical spine.
Spinal immobilization is harmless procedure and be applied to patients with a relatively low risk of injury.

11. Things WE Know About c-collars
They cause pain
They worsen mortality in penetrating trauma
They increase intubation attempts
They reduce mouth opening and make airway management more difficult
They don’t truly immobilize the C-spine
They can worsen high cord injuries (internal decapitation)
They increase radiation exposure
They increase ICP
They can cause pressure sores/tissue damage
It covers up injuries……….and that is bad

12. Good Stuff about c-collars
They can be bedazzled
They can be removed

13. Are there any benefits to C-collars?
Remind patients to limit motion?
Possibly support an unresponsive patients head during extrication and movement from “rolling around”?
Hospitals/Trauma Surgeons/Neurosurgeons/Ortho Spine surgeons love them

17. Benefit to c-collars?

18. What?! Remember, Odds Ratio of Death was 5.54!!! with immobilization!!
Remember, the two patients with unstable c-spines had normal neurological exams………..

19. Why Do We Put Cervical Collars On Conscious Trauma Patients?
Jonathan Benger and Julian Blackham
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine200917:44

20. EAGLES
“We might therefore consider discontinuing the use of the cervical collar in alert, cooperative trauma patients, even with a suspected C-spine fracture, unless consciousness deteriorates or if the application of a collar might provide the patient with a degree more comfort. It is certainly also time for EMS systems to remove collars from their protocols for the management of patients with penetrating trauma.”

21. Interpreting literature is challenging
Adults versus pediatrics?
Blunt versus penetrating?
Neuro deficits versus no deficits?
Brain Injury versus no brain injury?
Unconscious versus conscious?
Soft collars versus rigid collars?

22. Final thoughts on c-collars
Don’t be afraid of removing the collar during airway management
Don’t be afraid to manage the spine manually if a collar isn’t appropriate
Don’t ever apply a collar to a patient with penetrating trauma
Don’t ever cover up a wound/hemorrhage/lac
Elevate the head of the bed in patients with head injuries (think ICP reduction)
Don’t ever cause more pain/discomfort by applying the collar
Use your clinical judgement/decision-making rules to judiciously apply c-collars to appropriate patients

23. What do you do with all of this info?
Review the literature
Discuss with Medical Director
Engage your local trauma surgeons/ED docs/Flight Services
Engage your providers
Institute Selective Spinal Clearance Protocols (Canadian C-spine/NEXUS)
Don’t be the first……………Don’t be the last to change.

24. STUFF

26. CPR Duration

27. How long do you run a code…

29. Nagao 2016 Japanese study Single service system
Everyone participates in data collection
Study includes 283,183 cardiac arrests
Adults only, collected from
Fire based
3 responders on a medical unit
Different cultural norms
No TOR protocols
Stigma of death

30. This study looks at the opposite of what we typically have asked:
When is it appropriate to discontinue my resuscitation? vs
How long must I resuscitate until I can predict no additional survivors?
The risk of using population data on the individual

31. Graph of every case in the study. Duration of efforts along the bottom
Graph of every case in the study. Duration of efforts along the bottom. Shaded by prehospital ROSC or no prehospital ROSC

33. Only 0.7% (1,606/241,943) of the cases not achieving prehospital ROSC went on to have favorable neurological outcome.

35. Categories Shockable Rhythm Non-Shockable Rhythm Bystander CPR
Bystander, Shockable
Bystander, Non-Shockable
No Bystander CPR
No Bystander, Shockable
No Bystander, Non-Shockable

39. What this paper tells us
Demonstrates that most survivors are discovered early, but there is a small “tail” of late survivors that can be realized with longer resuscitations efforts
Suggests that if durations are extended to as long as 59 minutes we might be able to catch all potential survivors
Re-affirms that advanced airways are associated with worse outcomes
Suggests that there might not be as clean of a separation between shockable and non-shockable arrests as we previously thought

40. What this paper doesn’t tell us
DOESN’T tell us when it’s reasonable to stop a resuscitation
DOESN’T reveal any benefit of transporting patients in cardiac arrest
DOESN’T address the concepts of response times or Lights/Siren use
DOESN’T break out cases of public AED use
DOESN’T discus manual vs mechanical CPR

41. So what Should we do??? We don’t know
We like the idea of catching extra survivors
…but we would have to extend thousands of resuscitations to catch a very small number of survivors
…this takes a toll on our systems (not just financially but emotionally)
It becomes a very challenging medical, financial, and ethical question.

42. Ketamine

44. Prospective, observational, open-label study
Undifferentiated agitation in the EMS environment requiring chemical sedation
5mg/kg IM ketamine OR Haldol 10mg IM
Hypothesis: Ketamine better than Haldol for chemical restraint in patients with “severe agitation”
Excluded <18 y/o, pregnant, AND “profound agitation”??
Used a formal Altered Mental Status Scale

47. Complication rate in Ketamine group was 49% (27/55 patients)
Complication rate of Haldol group was 5% (4/82 patients)
Intubation rate in ketamine group 39% (25/64 patients)
Intubation rate in Haldol group 4% (3/82 patients)

49. 49 patient retrospective case series
5mg/kg IM ketamine for agitation
29% intubation rate
36 patient retrospective case series
4mg/kg IM ketamine for agitation
22% intubation rate

50. 52 patients retrospective case series
4mg/kg IM ketamine for agitation
4% intubation rate

51. Issues that need resolved
Provider weight estimation accuracy? Only half of the weights in ketamine patients recorded
Ideal dosing?
Ideal route?
With or without benzos?
Role of Haldol/Droperidol/atypical anti-psychotics with/without benzos?
Why the disparity in EMS studies when compared to in-hospital experiences on complication rates?
How do you maintain proficiency?
Other uses for ketamine? (sub-dissociative dosing/analgesia)

52. John M. Gallagher, MD, FACEP
EMS
HOT TOPICS
John M. Gallagher, MD, FACEP
Medical Director
Wichita/Sedgwick County EMS System
Wichita, KS
Ryan Jacobsen, MD, FACEP
Medical Director
Johnson County EMS System
Olathe, KS