Thank y'all appreciate you having me. It's exciting being here in San Antonio We're talking about some of the new literature that's come out over the last year that applies to pre-hospital critical care Transport and care. I don't have any conflicts of interest. I'm not sponsored by anybody as Dr. Don talked about I work at UT Health San Antonio both in the medical ICU and the emergency department And I sit on some boards and committees, but shouldn't have any biases the first one actually Sticks to me because I can remember when I was a field medic It felt like every time as soon as I arrived to the emergency department patient received calcium and or sodium bicarbonate despite it be it outside of the AHA guidelines and This study that was published in JAMA December 2021 so just at the end of that year I actually looked at the efficacy of it the effect of intravenous or interactive calcium versus saline and ROSC for out-of-hospital cardiac arrest better known as COCA trial was performed in Denmark It was double blind and placebo controlled randomized clinical trial. It was either IV or IO To administer the medication or the placebo and it was specifically for out-of-hospital cardiac arrest So after the first dose of epinephrine was given the patients were at that time Randomized one-to-one to either receive the saline placebo or five millimoles of calcium chloride Which equaled 735 milligrams of calcium chloride They were still in cardiac arrest after the second dose of epinephrine Then they received an additional dose of either the placebo saline or the calcium chloride Patients that were excluded were pediatric patients less than 18 years old traumatic arrests Pregnancy or suspicion of pregnancy based on physical findings if they had already received epinephrine outside of the trial Or if there was a clinical indication for calcium such as suspected hypocalcemia or hyperkalemia Primary outcome that was measured was sustained ROSC for at least 20 minutes The secondary outcomes I would argue were actually more important at least from a patient viewpoint Survival at 30 days and survival at 30 days of favorable neurological outcome They enrolled 391 patients it was just shy of the 400 they wanted they had to stop early because of kovat Pretty equal between the two 198 saline versus 193 calcium 68 years old median age Heavily male at 71% a good amount actually got bystander CPR at 86% Unfortunately, not as much received bystander ad use at 7.5% and a low incidence of shockable rhythms of v-fib or v-tach Io was the predominant route of administration at 60% pretty quickly to get medications on board at 17 minutes and Almost three quarters received two doses of either the placebo or the calcium Results With the primary outcome of actually getting ROSC Overall the results show that there was not benefit to given calcium and there was a trend towards harm with 19% ROSC in the calcium group versus 27 the saline risk ratio 0.72 survival at 30 days 5.2 percent for calcium versus 9.1 for saline and then again probably most importantly 30 days with favorable neurological outcome 3.6 versus 7.6 percent Additionally hypercalcemia was seen in 74% of the calcium cohort versus 2% of the saline Follow-up paper was published in Resuscitation July of 2022 and this looked at the long-term outcomes Same patient group same patient characteristics nothing different about that This confirmed everything from the prior paper and just extended it out even longer again showing no benefit to calcium and a Trend towards harm for both survival and neurological outcome at six month in one year So Meat and potatoes of this is out of hospital cardiac arrest calcium via IV or IO Did not improve ROSC nor mortality and trended towards harm And it is important to note that this trial excluded patients that would that could have potentially had a indication for calcium and administration hyperkalemia hypocalcemia or calcium channel blocker overdose How this has actually changed my clinical practice is as recently as a couple weeks ago with Texas Task Force one I was able to pull this out of our initial bag that we have to carry ALS medications on our person at all times I Because it's just not indicated if we're going to treat a crush injury or suspected hyperkalemia We're able to push that forward from our main cache Additionally, I'm curious to see it wasn't actually studied in this But I don't know what would actually be the magical change of that patient crossing the threshold into the ER Why it would be indicated to still give the calcium on arrival like many people still do Thank You All right. The next one is going to get into blood products. This was published in Lancet hematology in April of 2022 for some background. We've kind of had mixed data on blood products in the pre-hospital realm So observational studies with the military in Iraq and Afghanistan Showed benefit to it The control of major bleeding after trauma or the combat trial in Lancet of 2018 Which was a trial in Denver with pre-hospital plasma did not show benefit or statistical mortality benefit Excuse me Then the pre-hospital air medical plasma pamper trial in the New England Journal Medicine also in 2018 I Showed that giving plasma in the field was safe and they they showed a lower 30-day mortality in patients at risk for hemorrhagic shock So the resuscitation of blood products and patients with trauma-related hemorrhagic shock the refill trial was multi-center Open label randomized control phase 3 trial It was four different United Kingdom British pre-hospital critical care services The patients were randomized one-to-one To either receive saline or PRVC and lyoplas. Lyoplas is lipolyzed plasma Which is a freeze-dried plasma not available in the US at this time the sodium chloride group received up to four boluses of 250 cc's the blood product group received alternating unit of PRVC's mean volume of 282 cc's alternating with lyoplas 213 cc's up to a combined for so it go PRVC lyoplas PRVC lyoplas This was administered until they arrived at the hospital or the systolic blood pressure was greater than 90 If the patient received all four doses of either the control or the Intervention and still require fluids for hypotension. They followed standard UK guidelines and administered sodium chloride At inclusion exclusion criteria pretty Standard though, they defined adults is greater than 16 years old in the UK I guess they're able to get away with that a traumatic injury with a systolic blood pressure of less than 90 or Presumptive with an absent radial pulse So that's not entirely accurate and the hypotension had to be due to suspected hemorrhage They excluded people that had already received blood products If they were known to refuse blood products such as having a religious objection to it pregnancy isolated head head injury without external Evidence of hemorrhage. So for instance a head injury with a massive scalp laceration Bleeding out would be included but not one that you didn't have external bleeding and then prisoners as a standard They got 432 participants they wanted 490. This one was also stopped early because of kovat 209 in the blood product group versus 223 in the saline Very heavily male at 82% a fairly young cohort at 38 years old median age heavy in blood trauma almost 80% With NBC's making up a big portion of that at 62% most were transported by a ground at 62% EMS on scene within 30 minutes of Injury and the average time to administration of either the blood products or the saline was 25 minutes They got to the hospital in 83 minutes average Outcomes so the primary outcome was a composite outcome and that's important to note It was a composite of mortality or impaired lactate clearance or both and there was really no different The blood products was 64% versus saline and 65% for risk ratio 1.01 secondary outcomes of transfusion reactions Which should confirm that it's actually safe to give blood products blood products at 7% Inexplicably saline also had 7% of a transfusion reaction risk ratio 1.05 serious adverse events which were defined as organ failure ARDS Infection or veno-trauma embolism were present in 6% of the blood products versus 2% of the Saline cohort there was no significant difference in mortality lactate clearance or emergency department vital signs Limitations again like I said that mixed composite outcome Lactate clearance is not equal to death and yet. They were weighted the same for this study Both groups received an average of 430 cc's of crystalloids prior to being randomized So it's unclear if that could have confounded the results And then it's important to note this was performed in the United Kingdom that routinely has physicians on the critical care transport team that's not Currently very common in the United States to have a physician transport the patient We have some services that will have EMS physicians respond to the scene, but it's unusual that they'll transport every single patient So the significance of this is that unfortunately for those that were hoping to get more data supporting blood products it did not show a mortality benefit or improved lactate clearance for the PRBC plus lioplasm versus saline and more research is needed Potential benefits or beneficial populations that could be identified these were fairly short transport times You may see more of a benefit and longer transport a rural area you also There was a very heavy towards blunt trauma This is in the United Kingdom the penetrating trauma was knives and I single digits of gunshot wounds So it's possible that those patients would benefit from blood products more than blunt And then a different ratio. So this was a one-to-one ratio A whole blood could also be more beneficial This was a study that was performed and Published in Journal of Trauma of Acute Care Surgery in January of 2022 It Is a little bit contrary to some of the other studies that have been out there Mabry et al in 2021 published in the same journal Comparing the ash California National Guard flight medics that were civilian flight medics in their civilian lives that had significantly better outcomes than the military trained active-duty medics did so showed that ALS and procedures and care improved patient outcomes this was a secondary retrospective Database analysis of adults 18 years and older that had penetrating torso or and or extremity trauma That were transported either by EMS or the police in 25 urban trauma centers there was a total of sixteen hundred and eighteen patients two hundred ninety four of those were transported by a police and 1324 by ALS and For background in some urban areas It's fairly common for police to just grab patients and take off and take them directly to a trauma center The police cohort was slightly sicker They had a lower systolic blood pressure in the emergency department. They had a higher emergency department shock index They had a higher lactate and base deficit What the study showed was that there was no difference in the emergency department mortality in transfusion reactions in or excuse me requirements and For the first 24 hours in hospital length of stay ICU length of stay Ventilator free days. There's no difference So it did not show a benefit to ALS In an urban environment is the key point to this so sometimes this demonstrates that the best treatment for trauma is diesel or getting the patient rapidly to a trauma center a couple of studies that I'll just mention real quick that you can review on your own that have come out that you may have Heard about that came out after I had to submit all these slides to SCCM. You may have heard of the more at all study Published in resuscitation October 2022 head and thorax elevation during CPR using circulatory adjuncts associated with improved outcomes The important takeaway from that is that there was not statistic They did not show p-value that showed that benefit to it It was that to do a number crunching to make that work out and this requires very specific mechanical CPR impedance threshold device and a proprietary automatic patient positioning System to to complete it. It's not as simple as just lifting the head of the bed on your stretcher Another one that actually kind of probably confirms what a lot of y'all are already doing in practice But we now have some data behind it to support our practice published in New England Journal of Medicine in November 2022 defibrillation strategies for refractory ventricular fibrillation showed benefit for double sequential defibrillation and or vector change defibrillation so both showed with double sequential being more efficacious, but both were beneficial for faster termination of ventricular fibrillation ROSC and survival to hospital discharge These are the studies that I went over today, and I'm always available for questions I believe we're gonna have some later on and then you can always email me either at my work or personal email appreciate y'all's time

pre-hospital critical care transport

calcium

sodium bicarbonate

out-of-hospital cardiac arrest

blood products