Transcript Reality: Some Paramedics Are Good at ETI

(Almost) Everything You Know
About EMS Is Wrong
Amy Gutman MD
EMS Medical Director / [email protected]
Overview
• From the very new to the
very experienced, all
providers, administrators &
medical directors must
continually ask, “Does this
practice, procedure, or drug
improve outcomes?”
• Then ask… “Really?”
• When you get the answer…
ask again!
It is better to not understand something true, than to understand something false. Neils Bohr
“All of these are things in which some people
desperately wish to believe, despite the utter lack
of credible evidence of their existence”
Greaves I. Fluid resuscitation in prehospital trauma: J.R.Coll.Surg.Edinb. 2002.
Q: Does Prehospital Diuresis Help
Congestive Heart Failure?
Myth: Prehospital Diuresis Fixes CHF
• Historical prehospital CHF
treatment: O2, MSO4, diuretic
• Many SOPs include furosemide
for respiratory distress despite
few studies on effectiveness
• Rationale: utilize rapidly acting
medication to decrease work of
breathing
Reality: No Data Prehospital
Diuresis Effective or Safe
• Evaluation of prehospital use of
furosemide in patients with respiratory
distress. PEC 2006.
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144 pts receiving prehospital furosemide
59% CHF; furosemide “appropriate”
42% no respiratory dx; “inappropriate”
17% sepsis, dehydration, pneumonia;
“harmful”
Conclusion: Prehospital furosemide frequently
inappropriately administered & harmful
• MSO4 + furosemide resulted in
increased ETI, ICU admissions, longer
hospitalizations, higher mortality
• Many CHF pts taking furosemide;
boluses have little acute effect
Morphine and outcomes in ADHF: an ADHERE
analysis. EMJ.2011
Randomised trial of high-dose isosorbide
dinitrate plus low-dose furosemide versus highdose furosemide plus low-dose isosorbide
dinitrate in severe pulmonary edema. Lancet.
1998
Comparison of NTG, MSO4 & furosemide in
treatment of presumed prehospital pulmonary
edema. Chest. 1987
Reality: Other Modalities Have Greater
Immediate Benefit With Less Risk
• Hubble. Effectiveness of prehospital CPAP in the
management of acute pulmonary edema. PEC 2006
• All pts presenting to ED via EMS in 1 year with impression of
“pulmonary edema”
• Control: O2, nitrates, furosemide, MSO4, +/- ETI
• Intervention: CPAP +/- standard therapy
• Results:
• Pts on standard Rx 4 times more likely to be intubated/die
than those receiving standard therapy w/CPAP
• Intubation: 9% CPAP, 25.3% control
• Mortality: 5% CPAP, 23.2% control
Q: Are Tasers Deadly Weapons?
Myth: Tasers Kill Patients
• Electrical current disrupting voluntary muscle function
causing “neuromuscular incapacitation” via involuntary
muscle contractions
• High-voltage, short-pulse
• 3 microsec pulse followed by 100 microsec pulses
• Low-impedance current pathway across propelled barbs
• Multiple animal studies demonstrated safety, with
“clinically irrelevant” arrhythmia, QT prolongation,
acidosis
• Tasers attracted media attention for “contributing” to
deaths of violent individuals by police
Reality: Tasers “Less Lethal”,
Not “Non-Lethal”
• Increased VF / VT vulnerability:
• Cardiac disease, long QT,
pre-excitation
• Increased adrenergic tone
• Electrolyte abnormalities
• Acidosis
• Post-Taser
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•
•
•
Metabolic acidosis
QT prolongation
VT/VF secondary to “r on T”
Additive risk of death from
excited delirium
Reality: Conflicting Human Studies
• Taser-related death
series
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•
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37 males, 18-50 yrs
54% cardiac disease
84% illicit drugs
76% deaths from
“excited delirium”
• 27% TASER
“contributory” COD
• Vilke:
• No “clinically relevant ECG
changes” in 32 healthy
males post 5 sec taser
shock
• QT shortened / widened
“insignificantly” in 50%
• Low pH immediately post
shock
• Levine:
Strote. PEC. 2006
Vilke. AJEM. 2008
Levine. JEM. 2007
• QT short / wide,
tachycardia in 105
healthy police volunteers
after 5 sec taser shock
Reality: Tasers Less Lethal Than
Gunfire
• 218 individuals
subdued by police
with firearms vs
Tasers
• 1.4% mortality
(TASER group)
• 50% mortality
(firearm group)
Ordog GJ. AEM 1987; 16:73-78.
Q: Are EMT-Initiated Refusals Safe?
Myth: EMT-Initiated Refusals Are Safe
• Public Utility Models of
EMS care offer transport
to everyone who calls
delivering “care best for
the patient, not
necessarily the system”
• Risk of error when
dispatchers / EMTs
attempt to determine
who safely can be denied
transport
• Medico-legal conclusion:
eliminate risk by
providing every patient
requested care
Reality: EMT-Initiated Refusals
Often Unsafe
• Evaluation of protocols
allowing EMTs to determine
need for transport PEC. 2000
• 1,300 pts
• 79% required transport
• 15% told to go to ED via
alternative means
• 6% no transport
• Outcomes:
• 30/277 (11%) untransported
had critical event
• 7 (3%) required resuscitation
prior to EMS recall
• Medic determinations of
medical necessity. PEC. 2009
• 85 pts medics felt
transport unnecessary
• 15 (18%) admitted
• 5 (6%) admitted ICU
• Cone “ALS call-offs:
• 87% if BLS crew
cancelled ALS, pt needed
ALS interventions in ED
Data overwhelmingly does not support EMS determining if
patients require ambulance transport…except…
Reality: EMS Cannot
Transport Everyone
• “Prospective Evaluation of an EMS-Administered
Alternative Transport Protocol” PEC 2009
• Can experienced medics (10 yrs+) using guidelines
identify pts who can be safely alternatively transported
• 93 pts given taxi voucher
• Average time from taxi dispatch to ED 43 mins
• 10% transported by taxi admitted to hospital
• No emergent procedures or adverse events
• Conclusion: Experiences providers using SOPs may be
able to triage patients to alternative transport
Q: Are ALS Interventions Better than
BLS in Improving OOHCA Survival?
Myth: ALS Saves Lives in OOHCA
• Ontario Prehospital Advanced
Life Support Study
• 5,638 pts over 7 years
• Results:
• ALS more expensive with no
better outcomes than BLS + AED
• OOHCA ~1% EMS run volumes
• US & Canadian survival ~5%
• Of cities with higher survival,
almost all improvement
attributed to BLS
Myth: Two Medics Better Than
One in OOHCA
• Cities with more paramedics have worse pt outcomes
• Boston 10:100,000; 40% survival to admission
• Omaha 44:100,000; 3% survival to discharge
• Paramedics with OOHCA 4.68 cases / yr = 27% discharge
• Paramedics with OOHCA 1.63 cases / yr = 4% discharge
• 2 cities wth identical demographics, response times &
run volumes ~ only difference ALS vs BLS 1st response
• 38% ROSC BLS 1st response
• 13% ROSC ALS 1st response
Sayre. AEM 2006
Dunn. EMS Today 2007
Reality: ALS Does Improve Some
Outcomes
• ALS clinically & statistically
better outcomes for
respiratory distress, CP &
hypoglycemia vs BLS ONLY
if the intervention is ability
to initiate IV therapy
• Multiple studies show if
patient does not require IV
meds or BLS initiates CPAP,
dextrose & naloxone, BLS
patients have better
outcomes
Q: Are Paramedics Good At
Endotracheal Intubation?
Reality: Most Paramedics Are
“Inexperienced” Rather than ”Bad” at ETI
• Minimum required
training ETIs:
• Anesthesiologist: 400
• CRNA: 200
• Emergency Medicine:
100-200
• Paramedic USDOT: 5
• Research shows medic
students require at least
15-20 intubations to
attain basic proficiency
Bledsoe B. “The Future of Intubation”
2011.
Wang H. Defining the learning curve for
paramedic student ETI. PEC 2005
Reality: Some Paramedics Are
Good at ETI
(Bledsoe 2010)
Author(s)
No of Intubations
(Misplaced/Total)
Misplaced Intubations (%)
2/39
5.1
Bozeman et al
1/100
1
Stewart et al
3/779
0.4
Sayre et al
3/103
2.9
Pointer
5/383
1.3
Jenkins et al
Jenkins WA. The syringe aspiration technique to verify endotracheal tube position. AJEM. 1994
Bozeman WP. EDD versus detection of ETCO2 level in emergency intubation. AEM. 1996
Stewart RD. Field ETI by paramedical personnel. Chest. 1984
Sayre MR. Field trial of ETI by basic EMTs. AEM. 1998
Pointer JE. Clinical characteristics of paramedics’ performance of ETI. JEM. 1988
Reality: More Attempt Leads to Improved
Success, But At What Cost?
• Prehospital ETI often requires
multiple attempts
• 1,941 cases of prehospital ETI:
• >30% required >1 attempt
• Cumulative success (arrest)
• 69.9%, 84.9%, 89.9%
• Cumulative success (nonarrest)
• 57.6%, 69.2%, 72.7%
Wang HE. How many attempts required
to accomplish out-of-hospital ETI. AEM.
2006
Reality: Paramedic Are Even
Worse at Pediatric ETI
• 1989 study of pediatric
cardiac arrests:
• ETI success rate: 64%
• 63 pediatric patients in
Milwaukee WI:
• ETI success rate: 78%
Aijian P. ETI of pediatric patients by paramedics.
AEM. 1989
Losek JD. Prehospital pediatric ETI performance
review. PEC. 1989.
Reality: The More You Do, The
Better You Do
• Rural Maine ETI success:
• 74% in medics with <5
annual ETI
• 86% in medics with >5
annual ETI
• Rural Pennsylvania 1 yr
study of 11,484 ETIs by
5,245 medics:
• 67% performed <2 ETIs
• 39% had no ETIs
Burton JH. ETI in a rural state: procedure utilization and
impact of skills maintenance guidelines. PEC. 2003
Wang HE. Procedural experience with out-of-hospital
ETI. CCM 2005.
Reality: Some Paramedics Are
Really Good at ETI
• San Diego:
• 1 UEI/264 PEDIATRIC
intubations (99%)
• Seattle/King County:
• 98.4% success
• Bellingham, WA:
• 20-year review
• 95.5% ETI success
• 0.3% UEI
Vilke GM. Out-of-hospital pediatric ETI by
paramedics: San Diego experience. JEM. 2002
Bulger EM. Analysis of advanced prehospital airway
management. JEM. 2002
Wayne MA. Prehospital use of succinylcholine: a 20year review. PEC. 1999
Myth Corollary: ETI Saves Lives in OOHCA,
Therefore We Must Make the Attempt
• 2000 LA study demonstrated outcomes for intubated
pediatric cardiac arrest patients were no better or often
worse than those managed with BVM
• 2010 ACLS guidelines: “If advanced airway placement
will interrupt chest compressions, providers may
consider deferring insertion of the airway until the
patient fails to respond to initial CPR and defibrillation
attempts, or demonstrates ROSC”
• 2010 NEMSIS data showed worse outcomes for ETI OOHCA pts
• MI: VF/VT survival to discharge decreased with field ETI
• CA: survival to discharge 4 X greater if BVM vs ETI
• NC: 5 x greater ROSC in non-ETI
Reality: Prehospital ETI Often
Worsens Outcomes
Mortality by Distance Category
OR (95% CI)
Nonintubated patient at any distance
Reference
OOH-ETI with distance < 10 miles
2.70
OOH-ETI with distance 10 miles - <20 miles
1.87
OOH-ETI with distance 20 miles - <30 miles
1.80
OOH-ETI with distance 30 miles - <40 miles
0.90
OOH-ETI with distance 40 miles - <50 miles
0.20
OOH-ETI and  50 miles
1.83
Helicopter
0.36
Reality: Alternative Airways Will Replace ETI
Within 10 Years (But ETI Will Never Go Away)
• Large body of research
demonstrates improved safety
profile, advanced airway
management success & better
patient outcomes using
alternative airways
management (i.e. VGI)
• www.theairwaysite.com is an
outstanding resource
Q: Is Spinal Immobilization Beneficial
& Necessary For Trauma Patients?
Myth: “Spinal Motion Restriction”
Beneficial & Necessary
• Primary injury: time of trauma;
Keeping pt still does not reverse
damage
• Secondary injury: post-injury cord
inflammation, injury from bony
fragments, worsening primary
lesion. Restricting movement
limits potential for more damage
• Zero evidence restricting
movement if neurologically intact
spinal fractures does any good
(vast majority are stable fxs)
Myth: Spinal Immobilization
Beneficial & Necessary
• Gutman. Neck and Back Pain.
EMS: Clinical Practices & Systems
Oversight. 2009.
• No randomized prospective studies demonstrate ANY
aspects of immobilization prevent or lessen morbidity of
spinal injuries
• Baez asked 1,500 EMTs the following “beliefs” about
immobilization followed by a Cochrane Review (2006):
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Spinal immobilization prevents cord injury
Manual neck stabilization required until C collar applied
C collars inadequate to prevent cervical movement
KEDs reduce paraplegia
Cloth tape acceptable to secure pt
Prehospital skin breakdown does not occur
Reality: Spinal Immobilization
Hurts Patients
• Malayan C-Spine Study 5 yr
retrospective chart review
• 454 pts with SCI
• 0/120 Malayan pts
immobilized
• 334/334 New Mexico pts
immobilized
• Neuro disability less for
Malayan pts (11% vs 21%)
• Conclusion: immobilization
has no significant effect on
neurologic outcome
• 2002 Maine EMS spinal
clearance protocol
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16,019 trauma transports
7,014 immobilized
86 (0.01%) spinal fxs
12/86 not immobilized
11 stable fxs, 1 unstable
T-spine fx
• Unstable fx pt w/o
neurological deficits
• Conclusion: immobilization
has no significant effect
on neurologic outcome
Reality: Providers Can
Safely Clear C-Spines
• NEXUS (National Emergency XRadiography Study) criteria
minimizes unnecessary x-rays
• 34,069 pts
• 818 cervical fxs, all but 8
identified with clinical criteria
• NEXUS Exam Criteria:
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No midline c-spine tenderness
No intoxication
Normal alertness
No focal neurological deficit
No distracting injuries
• Canadian C-Spine Study
• 8,924 pts w/same
NEXUS results except:
• >65 yo greater risk
• Clearer MOI
• Injury above clavicles
greatest determining
factor for neck injury
Reality: Spinal Immobilization Has Serious
Consequences
• Pain / Anxiety
• Increased ICP & IOP
• Vomiting / aspiration
• Respiratory
decompensation
• Decubitus ulcers can
begin within 20 mins
• 15% reduction
respiratory capacity
Q: Does the ‘Golden Hour’ of Trauma
Improve Patient Outcomes?
Myth: The “Golden Hour” is a
Standard of Care
• R. Adams Cowley father of trauma
care & developer of Golden Hour
• PR tool promoting importance of
rapid surgical intervention in
trauma pts at newly opened U
Maryland “Shock Trauma”
• “Pts must arrive at a trauma center
within 1 hour of their injury in
order to have their best chance of
survival.”
• This “Golden Hour” concept
repeated so often that it has been
“willed” into truth
Reality: No Data Behind the
Golden Hour
• 2001 AAEM found no data supporting
‘Golden Hour’
• “Nobody wants to talk about this false
notion…because it shakes the roots of
EMS & trauma care.” B Bledsoe MD
• Little evidence in “Platinum 10 Minutes”
• Applies only in setting of hemodynamically unstable trauma
pts in which EMS should “be on scene <10 mins” before
transporting patient to ED for surgical intervention
• Often results in shoddy assessment, care & packaging
• Benefit of rapid surgical intervention for trauma pts
“obvious”, but no data identifies optimum time frame
Myth Corollary: Lights & Sirens Save Lives
• North Carolina
• 43.5 sec savings with
lights & siren vs without
• Syracuse
• “L&S reduce response by
average of 106 secs”
• Unlikely clinically relevant
• Philadelphia
• Pt outcomes when EMS
strictly limited use of lights
& sirens
• “No adverse outcomes
identified related to nonlights & siren transport”
Is ambulance transport time with lights and siren
faster than that without? 1995
Do warning lights and sirens reduce ambulance
response times? PEC 2000
Patient outcome using medical protocol to limit
“lights and siren transport. PDM 1994
Reality: Faster is Better For Some
Medical Emergencies
• 4 min response associated
with increased survival in
OOHCA If:
• Unwitnessed arrest
• No bystander CPR
• No AED
• However, rapid response
less important than
appropriate scene care &
destination facility
• 9,273 OOHCA pts (OPALS)
• 4% survival if <6 min to
defibrillation
• “Steep decrease in 1st 5
mins of survival curve,
beyond which levels off”
• ALS 8 min response not
assoc w/ improved survival
• 4 mins response improves
survival in pts with high
mortality risk
Reality: Response Recommendations
Based on Conjecture not Science
• 8 mins goal for 90% responses
to “save most persons in need”
• Time to travel between 2 points
determined by speed. Speed
affected by traffic, road / vehicle
conditions, operator experience
• Shorter response intervals not
without safety & monetary costs
Blackwell. Lack of association between prehospital response times and patient outcomes. PEC 2007
Bailey. Considerations in establishing EMS response time goals. PEC 2003
Q: People Survive Cardiac Arrest on TV All
The Time Just Like Real Life…Right?
Myth: The Dead Will
Rise
• Researchers watched 2 yrs of ER,
Chicago Hope & Rescue 911
• 65% OOHCA in children or teens
• 75% survived arrest
• 67% survived to discharge
• Los Angeles:
• 2,021 consecutive OOHCA pts
• 1.4% survived neuro intact
• 6.1% survival bystanderwitnessed VF
• 2.1% survival bystander CPR
• 3.2% survival witnessed arrest &
bystander CPR
• 1% survival w/o bystander CPR
CPR on television. Miracles and misinformation.
1996
Cardiac Arrest Resuscitation in Los Angeles:
CARE- LA. 2005
Reality: Despite 30+ Years & Expenditure of
Billions of Dollars, Majority of Dead Remain Dead
• No change in traumatic arrest
survival since Crimean war
• Some improvements in medical
OOHCA
• Bystander CPR / Early AED
• Effective compressions
• Is there a benefit in saving the
very very few vs the safety
risk to EMS, public & financial
expenditure?
Q: Fluid Resuscitation Raises Blood
Pressure & Saves Trauma Patients
Myth: Aggressive Fluid Resuscitation
Saves Trauma Patients
• Known for decades, but recent military
studies changed trauma resuscitation
• Hypotensive resuscitation during active
hemorrhage: impact on in-hospital
mortality, J Trauma 2002.
• Hypotensive resuscitation strategy
reduces transfusion requirements &
severe postoperative coagulopathy in
trauma pts with hemorrhagic shock. J
Trauma 2011.
• Effect of plasma & RBC transfusions on
survival in pts with combat related
traumatic injuries, J Trauma 2008.
• Early aggressive use of FFP does not
improve outcome in critically injured
trauma patients, Ann Surg 2008.
Reality: Consensus Statement from the
European & American Trauma Surgeons
• IV en route unless entrapped or delay in transport
• Only 2 IV attempts or 1st attempt IO
• Transfer should not be delayed to obtain IV access
• Saline or blood products as 1st line fluids
• 250cc NS boluses titrated against presence or
absence of radial pulse (caveats: penetrating torso
injury, head injury, infants)
Greaves I. Fluid resuscitation in prehospital trauma care: A consensus view. Coll.Surg.Edinb. 2002.
Prehospital EKGs ~
What Are Your “Myths”?
Myths: Prehospital EKG
• If you're close to the ED, a 12-lead is
a waste of time
• Closest hospital not necessarily
most appropriate!
• ED must repeat ECG to confirm
STEMI
• Nothing magic about the ED's EKG
• Serial ECGs extremely important
• If ST elevation resolves by ED arrival,
it's not a STEMI
• If elevation resolves, pt still has
an occlusion. Why else would the
segment elevate in the 1st place?
More Prehospital EKG Myths
• It's easy to identify STEMI
• Identifying true ST segment
elevation easy but deciding
between STEMI and STE-mimics
difficult
• Impossible to identify STEMI
with a LBBB
• It’s hard, but doable. Perform
serial ECGs as you can see
evolutions in the ST segments
Q: Does Trendelenburg Position
Improve Blood Pressure?
Myth: Trendelenburg Position
Improves Blood Pressure
• During WWI, Trendelenburg popular to
increase cardiac output & perfusion
• In 1967, Los Angeles researchers
evaluated the Trendelenburg & found it
did not provide any benefit in improving
circulation
• In 1980 British researchers: “Our study
failed to document any consistent
beneficial or detrimental effect of
Trendelenburg positioning in acutely ill
normo- or hypotensive patients.”
• 30+ studies show Trandelenburg
increases venous pressure, but does not
raise SBP significantly
Trendelenburg Complications
• Cardiogenic shock
• Pulmonary edema
• Aspiration
• Visual loss increased IOP
(2-10 x nml)
• 25% decreased SV
• 35% decreased CO
• No change in MAP or HR
Malloy BL. Implications for postoperative visual loss:
steep trendelenburg position & effects on IOP. AANA
J.2011.
Popescu WM. A pilot study of pts with clinically severe
obesity undergoing laparoscopic surgery. J
Cardiothroacic Vasc. Anes. 2011.
Zorko N. Influence of the Trendelenburg position on
haemodynamics: comparison of anaesthetized patients
with ischaemic heart disease and healthy volunteers. J
Int Med Res. 2011.
Q: Do “Code” Medications Save Lives?
Myth: Resuscitation Medications
Improve Outcomes in Cardiac Arrest
• 2002: bretylium, isoproterenol & high-dose epinephrine
removed from guidelines
• 2005: lidocaine largely replaced by amiodarone
• 2010: atropine essentially removed
• 2012: epinephrine, vasopressin & many antiarrhythmics
being questioned in research trials
• 2009 JAMA editorial: “The best available observational
evidence indicates that epinephrine may be harmful to
patients during cardiac arrest”
Reality: Epinephrine Ineffective
• 2003 Norway researchers evaluated ACLS medications
vs none in a 6 year trial
•
ROSC rates improved (32% control vs. 21% placebo), but no change in survival to
discharge or favorable neurological outcome
• 2006 Australian researchers evaluated epinephrine
against placebo
• Higher ROSC in the epinephrine vs placebo group (24% vs 8%),
but no significant improvement in survival to discharge
• 2012 Japanese researchers evaluated epinephrine vs
nothing or nothing in 400,000 patients
• ROSC improved (18% vs. 5%) but 1 month survival unchanged &
neurological outcomes worse
Current ACLS Research
• “Amiodarone, Lidocaine or
Placebo for OOHCA Due to VF
or VT (ALPS)”
• University of Washington
• Enrollment of 500+ patients
• 2012 meta-analysis of 6 trials
comparing epinephrine vs
vasopressin found no
improvement in sustained
ROSC, long-term survival or
good neurological outcome
• Insignificantly higher long-term
survival in asystole patients
Q: Are Thrombolytics Like tPA Are
Standard of Care For Ischemic Strokes?
Myth: tPA Does Not Produce Clinical
Improvements in The Majority of Stroke Pts
• 750,000 ischemic stroke annually
• 2-3% of these receive tissue plasminogen activator (tPA)
• Data shows relative improvement in 37% of pts, with
5% risk for an adverse outcome
• EM physicians sharply divided on the issue of whether
or not tPA is an appropriate treatment modality
• ACEP’s & AAEM’s official policies reflects that split, do
not take a position on whether or not tPA should be
used, and thus do not set a standard for care
• But what about the AHA?
Myth: AHA Provides Unbiased Data
• AHA: “Research continues to
accumulate in support of the
effect of thrombolytic therapy
when given to carefully selected
patients within 3 hrs of the
onset of acute ischemic stroke.”
• Conflict of interest?
• Genentech, the manufacturer of
tPA, donated $11 million to the
AHA in the decade prior to AHA
recommending tPA for stroke
• Most of the association’s stroke
experts have ties to the
manufacturer of tPA
Myth: Many Studies Have Shown the
Absolute Benefits of tPA for CVA
• 6 multi-center thrombolytic trials since 1980s in US,
Europe, Australia & China
• NINDS trial 1st & only to demonstrate a positive benefit
• Only “sound” study not sponsored by a drug company
could not duplicate NINDS
• All strokes treated at 29 Cleveland-area hospitals
over a 1 year
• 1.8% (70:3948) received tPA
• Results strikingly different & negative from NINDS
• Rate of symptomatic ICH 16% (compared to 7% in
control group); with 6 fatal bleeds
Katzen. Use of tPA for acute ischemic stroke: The Cleveland area experience. JAMA. 2000
N.I.N.D.S rt-PA Stroke Study Group. TPA for acute ischemic stroke. NEJM. 1995.
Myth: tPA for Stroke is
Highly Recommended
• Extremely limited role of tPA in acute
ischemic stroke
• Thrombolytics limited to EDs with a neuroradiologist reading
CT & a neurologist administering / monitoring therapy
• “Since the NINDS trial there has not been a second
randomized, double-blinded, placebo-controlled study to
validate its findings. There is insufficient evidence at this time
to endorse the use of intravenous tPA in clinical practice…”
(ACEP, 2010)
• Following public scrutiny, the AHA recently withdrew
statements that tPA for stroke “saves lives.”
Reality: NINDS Trial Results
• In 624 pts, tPA (white) or
placebo (black) given to pts
w/i 3 hrs of CVA SSX with (-)
head CT
• tPA pts more likely to have
minimal /no disability at 3
mo (50% vs 38%)
• ICH w/i 36 hrs in 6% of tPA
pts vs 0.6% of placebo pts
(significant)
• Mortality 3 mo 17% in tPA
group vs 21% in placebo
group (insignificant)
Myth: Leading EM Physician Groups
Endorse tPA for Stroke
• CAEP guidelines: “thrombolytics…
restricted to use in the context of
formal research protocols, or in a
closely monitored program”
• “It is the position of the AAEMEM that
objective evidence regarding the
efficacy, safety & applicability of tPA
for acute ischemic stroke is insufficient
to warrant its classification as a
standard of care.”
• ACEP Poll: 40% would not use tPA,
even in ideal pt under ideal conditions
Additional References
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Stankus JL. Does Standard of Care for Acute Ischemic Stroke in the ED Include tPA? A Legal Perspective. 2010.
Lerner. “The Golden Hour: Scientific Fact or Medical ‘Urban Legend’?” AEM 2001
Turner J. The Costs & Benefits of Changing Ambulance Response Time Performance Standards. University of Sheffield. 2006
Hunt. Is ambulance transport time with lights and siren faster than that without? Annals of EM 1995
Brown. Do warning lights and sirens reduce ambulance response times? PEC 2000
Kupas. Patient outcome using medical protocol to limit “lights and siren transport. PDM 1994
Bledsoe B. EMS Myth Busting: A Logical Approach to A Safer Reality . 2010
Boullthiet T, Dean B. FireEMS Blogs Network. The Trandelenburg Myth. 2010
Brian Bledsoe. The Current Slant on the Trandelenburg Position. 2011.
Taylor J, Failure of Trendelenburg position to improve circulation during clinical shock. Surgery, Gyn & Obstetrics. 1967
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Summary
• What we know & do in EMS is
often based upon anecdotal
evidence, politics, medical
director mindset & available
resources rather than evidencebased practice and evaluation of
risk:benefit ratios
• Despite this, every day the job
is performed well by
overworked, underpaid &
underappreciated providers
• It’s time to treat our patients
based more on science than on
myth & ritual procedures
connecting the street with the
science
Thank You For The Great Job You
Do Every Day!
[email protected]
• “We are there for the
good of the patient,
not for the good of
the protocol, not for
the good of the
medical director, and
not for the good of
the company”- Rogue
Medic