I went down to Baltimore, Maryland to attend the annual JEMS EMS Today Conference. This is the second time I have been, and I was very glad I went. The speakers are always absolutely first rate. It is good to surround yourself with people who are on the leading edge of EMS. I always like finding out what the latest is, both in research and technology.
This years’s conference was dominated by the new AHA guidelines. The message was Compressions, compressions, compressions. Allow full chest recoil when doing CPR and NO hyperventilation. Ventilate your codes at 8-10 times a minute.
Here are some of my notes:
Studies show half the time in CPR compressions don't get done.
When you stop compressions, all blood flow ceases.
Studies show paramedics, doctors and nurses all ventilate at rates from 30-40 a minutes.
High ventilation rates screw up the intrarthoracic pressure preventing effective blood flow.
Normal people breathe through negative pressure. We ventilate people with positive pressure. Too much positive pressure inhibits blood return.
Our ventilations should be fewer and less both in terms of volume and duration.
Studies showed uninterrupted compressions increased survival by 300%.
Anything that interrupts compressions is bad.
You can delay intubation for patients in vfib. They should have a good supply of oxygenated blood in their body that will last for five minutes or so. You could monitor their status by using a nasal end tidal CO2 cannula while using a bag mask.
When you do intubate try to keep compressions going while you pass the tube. If you need to stop compressions, stop only for a brief moment
In a study when pigs were put into arrest, 6 of 7 pigs survived when they were ventilated 6 times a minute, only 1 of 7 survived when they were ventilated at 30 times a minute.
Keep tidal volume to 400 on ventilations.
There are two ways to hyperventilate: Too many respirations and too much volume in a single respiration.
Most pulses that emerge after a shock don't show up for 60 seconds. So keep doing compressions.
One speaker joked “Keep doing compressions until the patient wakes up, grabs you hand and insists you stop.”
There are fewer v-fib codes today than several years ago because of the better cardiac care people receive from their doctors. Most codes are sicker people.
Epi has a IIb rating because they cannot do a study where epi is used against a placebo. No ethics board would allow it. Without such a study, there can be no Level I rating. Its one of the quirks of the evidence rating system.
One of the reasons, cardiac arrest discharge from hospital rates are so low is because the post resuscitation care at the hospital is so poor -- it often consists only of trying to make a person a DNR.
Other notes:
On cardioversion -- if the patient can remember what you look like after you have cardioverted them, don't cardiovert because they probably don't need it.
I asked the Dr. responsible for the tachycardia algorithm about the new phrase “Seek Expert Consultation,” and he said, it means if you don't have to give a patient drugs, don't, wait for the hospital.
On Intubation, a doctor said the FDA would not approve intubation today based on existing studies that show how badly it is being done and its negative effect on patients. A group of doctors said for people to keep intubating, their program needs a solid QI program and people need to go to the ER if they are not getting enough tubes. One doctor said, "a misplaced tube is a travesty. It means, your patient would have done better in a Yellow Cab."
They said never intubate a child unless you absolutely have too.
The adult IO is great for cardiac arrest, it may not have a place in trauma.
Studies have shown that morphine actually helps the surgeon do an abdominal evaluation. We should be giving morphine to patients with abdominal pain.
In trauma, we should practice permissive hypotension – the BP can be kept around 70 for trauma patients and fluid should only be administered if the pressure gets below 40.
Gunshot wounds to the head without neuro deficits, do not need cspine.
Magnesium is great for severe asthma -- 2 grams in 100cc over 1-10 minutes.
Instead of doing one breathing treatment followed by another, do a continuous treatment, which is basically dumping two treatments in the neb to begin with.
CPAP for CHF is outstanding.
Be very cautious with lasix. Never start with Lasix and never give it unless you are also giving nitro because lasix's initial action is as a vasoconstrictor.
For anaphylaxis, give epi IM in the thigh
Everyone intubated should have end tidal Co2 monitoring.
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And here are my awards for the two best products from the EXPO:
Vida Care Easy IO
RESQPOD
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The conference will be held again in Baltimore next year. Since EMS is now relying on evidence-based medicine, each new study will shape our direction. As one doctor said, what you are learning today, will be different tomorrow.
