The EMS Lighthouse Project FlightBridgeED, LLC.

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 (methoxyflourane) 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, aren’t you? Admit it, you are. Fortunately, there are breath actuated nebulizers. Maybe those things will work?
 
Dr Jarvis reviews a recent paper that compares the effectiveness of nebulized ketamine compared with IV ketamine. And he 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.

FAST24 | June 10 - 12, 2024 | Wilmington, North CarolinaFAST24 is our annual conference for pre-hospital and critical care transport professionals, including nurses, paramedics, and other disciplines. It features engaging workshops, talks by industry leaders, and focused sessions on air and surface critical care transport medicine. The event also offers a unique vendor experience, special guest appearances from notable talent in the industry, catered lunches, as well as relaxing and entertaining networking and social opportunities. Tickets are limited so don’t wait! Visit fbefast.com for more information.

What value does EtCO2 have when it comes to 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 when it comes to 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
 

FAST24 | June 10 - 12, 2024 | Wilmington, North CarolinaFAST24 is our annual conference for pre-hospital and critical care transport professionals, including nurses, paramedics, and other disciplines. It features engaging workshops, talks by industry leaders, and focused sessions on air and surface critical care transport medicine. The event also offers a unique vendor experience, special guest appearances from notable talent in the industry, catered lunches, as well as relaxing and entertaining networking and social opportunities. Tickets are limited so don’t wait! Visit fbefast.com for more information.

The debate about which drug to use for sedation prior to RSI will.. just.. 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. What we need is a systematic review and meta-analysis, preferably using a type of analysis that recognizes that this likely isn’t a black and white question and can bring some.. .nuance to it. That’s were 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 recommendations3. 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.

FAST24 | June 10 - 12, 2024 | Wilmington, North CarolinaFAST24 is our annual conference for pre-hospital and critical care transport professionals, including nurses, paramedics, and other disciplines. It features engaging workshops, talks by industry leaders, and focused sessions on air and surface critical care transport medicine. The event also offers a unique vendor experience, special guest appearances from notable talent in the industry, catered lunches, as well as relaxing and entertaining networking and social opportunities. Tickets are limited so don’t wait! Visit fbefast.com for more information.

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 control 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. The question for this podcast, however, is does it matter 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).

FAST24 | June 10 - 12, 2024 | Wilmington, North CarolinaFAST24 is our annual conference for pre-hospital and critical care transport professionals, including nurses, paramedics, and other disciplines. It features engaging workshops, talks by industry leaders, and focused sessions on air and surface critical care transport medicine. The event also offers a unique vendor experience, special guest appearances from notable talent in the industry, catered lunches, as well as relaxing and entertaining networking and social opportunities. Tickets are limited so don’t wait! Visit fbefast.com for more information.

Dr. Jarvis is joined by OG co-host Mike Verkest and Dr. Brent Myers from NAEMSP 2024. We talk about 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.


FAST24 | June 10 - 12, 2024 | Wilmington, North CarolinaFAST24 is our annual conference for pre-hospital and critical care transport professionals, including nurses, paramedics, and other disciplines. It features engaging workshops, talks by industry leaders, and focused sessions on air and surface critical care transport medicine. The event also offers a unique vendor experience, special guest appearances from notable talent in the industry, catered lunches, as well as relaxing and entertaining networking and social opportunities. Tickets are limited so don’t wait! Visit fbefast.com for more information.

Show Notes:EMS History is full of interventions we've rapidly adopted, often at great expense and withdisruption 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 compressiondevices, high-dose epinephrine, indiscriminate calcium administration in cardiac arrest. Do Ieven need to mention backboards?The next bright shiny thing promising to revolutionize cardiac arrest resuscitation is Head-UpCPR. It's certainly expensive and disruptive, but does it improve outcomes? What is theevidence?Dr. Jarvis has thoughts. He goes deep on this topic, using a recent paper on Head-Up CPR todiscuss how he evaluates new interventions for adoption. Oh, and he has thoughts on science ingeneral.
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 usingcirculatory 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 UpCPR: 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 UpCardiopulmonary Resuscitation Does Not Improve Outcomes. Annals of Emergency Medicine.2023;February;81(2):244–5.3. Jarvis J: Not so fast: More evidence needed in head-up CPR.ems1.com. Available athttps://www.ems1.com/ems-products/cpr-resuscitaCon/arCcles/not-so-fast-more-evidence-needed-in-head-up-cpr-ZK2O7yt5eb8jryYm/. Accessed December 9, 2023.4. Moore JC: Faster Cme to automated elevation of the head and thorax duringcardiopulmonary resuscitation increases the probability of return of spontaneous circulation.ResuscitaCon. 2022;Jan(170):62–9.5. Pepe PE, Scheppke KA, Antevy PM, Crowe RP, Millstone D, Coyle C, Prusansky C, Garay S, EllisR, Fowler RL, et al.: Confirming the Clinical Safety and Feasibility of a Bundled Methodology toImprove Cardiopulmonary Resuscitation Involving a Head-Up/Torso-Up Chest CompressionTechnique. Crit Care Med. 2019;March;47(3):449–55.6. Metro Fire Chiefs: First-In Responders Providing Neuroprotective (“Heads-Up”) CPR as theStandard of Care for Emergency Medical Services Systems.NFPA. Available at https://www.nfpa.org/-/media/Files/Membership/member-secCons/Metro-Chiefs/Urban-Fire-Forum/2023/UFF23_NPCPR-PosiCon-Statement.ashx. Accessed November 4, 2023.

FAST24 | June 10 - 12, 2024 | Wilmington, North CarolinaFAST24 is our annual conference for pre-hospital and critical care transport professionals, including nurses, paramedics, and other disciplines. It features engaging workshops, talks by industry leaders, and focused sessions on air and surface critical care transport medicine. The event also offers a unique vendor experience, special guest appearances from notable talent in the industry, catered lunches, as well as relaxing and entertaining networking and social opportunities. Tickets are limited so don’t wait! Visit fbefast.com for more information.