Good afternoon, everyone. My name is Travis Murphy. I'm an ER intensivist based out of Miami, Florida. I work mostly in the cardiothoracic ICU mechanical circulatory support, but work closely with some of our EMS colleagues. So we'll be talking about critical care advancement in the pre-hospital transport of patients that are coming to us over the last 12 months. So I should mention briefly, there's a concurrent discussion going on right now about the SCCM guidelines and the recent update for RSI. So that's pertinent to pre-hospital management, certainly. And just briefly, overview of some recommendations regarding positioning, pre-oxygenation, whether or not to place an NG tube, not necessarily all things that pertain to what's happening in the back of an ambulance or the back of somebody's SUV, but things to consider and worth reviewing for all of us. So the first study I'll dive into was the arrest trial out of the United Kingdom based in the London area. So this is a prospective study, multi-center, open label, because it's hard to blind the geographic destination of these patients, comparing cardiac arrest centers. And really, the impetus for this was ILCOR recommendations for whether there really needs to be cardiac arrest centers of excellence. And so this study was designed to see if that designation and that bundle of care that's provided in such centers really has an impact in 30-day mortality in the out to three months. So ultimately, what they found is that there's not a big difference between bringing patients in non-stemic cardiac arrest, I should stress, to a designated cardiac arrest center versus a standard geographically closest ED. I should say that this is within the confines of Greater London, and so maybe not a whole lot of variability in the order you might see in the geographic differences in some of our practice areas. I can speak for myself from South Florida, there's definitely variability between hospitals and capabilities and approaches to cardiac arrest management within the ED and in the hospital at large. And so while these findings didn't really show a significant difference between bringing these patients to a cardiac arrest center or the standard of care, which is the geographically closest ED, there were some issues that I think you could take with the generalizability to this to your own local context. So in more dense urban centers, places with a lot of high-performing hospitals, this may ring true, but depending on where you practice, this may yet still be something worthwhile pursuing in your region. So subsequent, still kind of in the frame of cardiac arrest, is using supraglottic airways versus endotracheal intubation. This has been a subject of much study over the last several years, but this is a systematic review and meta-analysis of many of these trials. So they really sought to determine what's the best way to approach managing the airway in a hospital cardiac arrest. And there's some compelling data for each approach and different reasons behind them. So overall, this study found four RCTs, comparing them, over 13,000 patients, so a good cohort, and looking for meaningful outcomes like ROSC rate, time to definitive airway, and risks of aspiration, and then ultimately functional outcome, which is becoming a standard within cardiac arrest studies. Of these, many of these hospitals, the vast majority were paramedics placing these airways. The large-path success for ET tubes is, as we know, can be very variable. It's operator-dependent. It's a technical skill, especially in a time of crisis. So that's widely variable. There is some variability in the LMA-type devices used. Some were LMAs, really and truly. Some were the iGel, and one trial did use the King tube. So there are some differences there. Overall, there was a difference in ROSC rate and time to airway placement, which favored using supraglottic airway devices. And that, at least time to airway placement, that makes physiologic sense. It's something you just kind of drop. What was uncertain was the impact of this on functional outcome, whether getting a definitive airway with an ET tube or using a supraglottic device really had an impact on functional outcome. And one of the questions that I had that came out of reviewing this is whether the dye had already been cast for some of those things. This study wasn't really capable of digging down into whether each of these patients had other factors that were protective of neural outcome. So shockable rhythms, witnessed bystander arrest, bystander CPR, which may have already had an impact on at least the functional outcome, more so than the impact of which airway device was used. And what may have no effect is, based on the airway devices, survival and risk of aspiration. And the aspiration, you can conceivably think that if someone were to aspirate during this kind of event, it's likely to be at the moment of arrest or shortly thereafter, and not necessarily associated with the act of placing an airway. So another study that I found that had implications for those of you who decided to include EMS management among your already double background was the use of platelet inhibitors in STEMI alerts in an out-of-hospital context. So this was a large retrospective review of all of these studies. Over 10,000 patients were included, and a mix of using clopidogrel, ticagrelor, or other formulations. And looking at the impacts for these, they did find a significant benefit of administering this in the back of the ambulance in pre-PCI, so pre-stent placement, TIMI flow, and no significant difference in major bleeding. They also found that the patients who did receive one of these agents before getting to the cath lab tended to have lower rates of recurrent MIs and lower rates of stent thrombosis, but no significant events in major adverse cardiac events subsequently or those later outcomes. Variability in the stent might be a confounder that wasn't controlled for in these studies, but in doing a subgroup analysis of agents clopidogrel versus ticagrelor, there was no difference in whichever of those two platelet inhibitors were chosen. So looking at some other, moving beyond the heart to other organs of significance. So pre-hospital guidelines for the management of TBI were updated last year. I know Patrick was one of the authors for this. So this is an update of the original guidelines from 2007. And some big takeaways here that we'll dive into a little bit. A little bit into how to assess these patients, a little bit about the treatments that should be administered, and recommendations on how to go about the logistics of these cases. Overall, the recommendations found through this review of the literature and culmination of the findings make physiologic sense. And these are things that you're likely doing already. Things that are targeting a normal blood pressure, not too high, not too low. It's hard to say which blood pressure is going to be the best for a given patient. If somebody is already hypertensive, this wasn't really the model, the study to speak to what each individual patient's target would be. But speaking broadly, targeting normal tension, a saturation goal over 90% so as to avoid hyperoxia, a reasonable saturation goal. And a significant update is targeting normal capnea. So in saving the hyperventilation for the incidence of active herniation or signs of active herniation. Similarly with hyperosmolar therapy. The GCS was verified to be helpful in patients greater than two years old and otherwise recommended using appropriately sized devices. And I'll summarize nicely into an algorithm here. So something you could take home to the EMS directors and trauma teams back at your home institutions. So overall, sort of doubles down on the previous recommendations, but does go through and provide some more convincing evidence for the practice recommendations here. It does temper some of the recommendations for TXA. One of the other studies I'll mention talks about that briefly and continues to encourage coordination and getting these patients to the appropriate trauma facility. So some notable mentions of studies that were published last year. Studies that were published last year that one should be aware of are both essentially negative studies. The PATCH-ENDSX trial essentially found no significant difference in transfusion requirements for patients given TXA. And the PROCOAG trial, which is a major study in 12 different French trauma centers, found that administering pre-hospital four-factor PCC actually did not impact transfusion requirements in a favorable way and in fact increased adverse trauma. So something that should be avoided.

pre-hospital critical care

cardiac arrest

supraglottic airways

STEMI management

traumatic brain injury