The EMS Lighthouse Project

Last episode we described the literature showing no survival benefit to patients with the AutoPulse device. Fear not, I wasn’t ignoring the LUCAS, I just felt it deserved it’s own episode. We’ll cover the LINC and PARAMEDIC randomized controlled trials and the secondary analysis of LINC in shockable rhythms. 

I switched to a new production process using a new mic (Rode NT1) and started using ecamm to record. Yes, I know there is a bit of AV dysynchrony.. I’m working on it. I still have a lot to learn about ecamm but am optimistic about it. 

Citations on LUCAS device:

1. Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R, et al.: Mechanical Chest Compressions and Simultaneous Defibrillation vs Conventional Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest: The LINC Randomized Trial. JAMA. 2014;January 1;311(1):53–61.

2. Perkins GD, Lall R, Quinn T, Deakin CD, Cooke MW, Horton J, Lamb SE, Slowther A-M, Woollard M, Carson A, et al.: Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. The Lancet. 2015;385(9972):947–55.

3. Hardig BM, Lindgren E, Östlund O, Herlitz J, Karlsten R, Rubertsson S: Outcome among VF/VT patients in the LINC (LUCAS IN cardiac arrest) trial—A randomised, controlled trial. Resuscitation. 2017;June;115:155–62.

Citations on Jeff’s Tamiflu Rant

1. Jefferson T, Jones M, Doshi P, Spencer EA, Onakpoya I, Heneghan CJ: Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. BMJ. 2014;348:g2545.

2. Jefferson T, Jones MA, Doshi P, Del Mar CB, Hama R, Thompson MJ, Onakpoya I, Heneghan CJ: Risk of bias in industry-funded oseltamivir trials: comparison of core reports versus full clinical study reports. BMJ Open. 2014;4(9):e005253.

3. Jefferson T: The Tamiflu Story: Why We Need Access To All Data From Clinical Trials. Open Knowledge Foundation Blog.

Our story so far.. episode 92 looked at a study showing lower survival from in-hospital cardiac arrest in patients treated with mechanical compression devices. Episode 93 discussed an implementation study of implementing LUCAS devices in a system with high quality pit crew CPR also showing lower survival, despite spending lots of time in training on how to optimally apply the LUCAS to avoid prolonged compression interruptions and movement. 

Now we’re diving into the literature around AutoPulse, the load-distributing band device. We’ll cover two randomized controlled trials and one well-done observational study comparing AutoPulse to manual CPR. Don’t worry, LUCAS studies will be in the next episode.

Citations
1. Hallstrom A, Rea TD, Sayre MR, Christenson J, Anton AR, Mosesso VN, Van Ottingham L, Olsufka M, Pennington S, White LJ, et al.: Manual Chest Compression vs Use of an Automated Chest Compression Device During Resuscitation Following Out-of-Hospital Cardiac Arrest: A Randomized Trial. JAMA. 2006;June 14;295(22).
2. Ong MEH, Ornato JP, Edwards DP, Dhindsa HS, Best AM, Ines CS, Hickey S, Clark B, Williams DC, Powell RG, et al.: Use of an Automated, Load-Distributing Band Chest Compression Device for Out-of-Hospital Cardiac Arrest Resuscitation. JAMA. 2006;June 14;295(22).
3. Wik L, Olsen J-A, Persse D, Sterz F, Lozano M, Brouwer MA, Westfall M, Souders CM, Malzer R, Van Grunsven PM, et al.: Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial. Resuscitation. 2014;June;85(6):741–8.

Ever wonder what would happen to cardiac arrest survival after a system implements LUCAS devices and trains really hard to deploy them appropriately? Wonder no more. Dr Jarvis reviews a paper from the Austin/Travis County EMS System that will shed some light on the question. This is the second episode in a series on mechanical compression devices.  

Citations:

1.     Gonzales L, Oyler BK, Hayes JL, Escott ME, Cabanas JG, Hinchey PR, Brown LH: Out-of-hospital cardiac arrest outcomes with “pit crew” resuscitation and scripted initiation of mechanical CPR. The American Journal of Emergency Medicine. 2019;May;37(5):913–20.

2.     Crowley C, Salciccioli J, Wang W, Tamura T, Kim EY, Moskowitz A: The association between mechanical CPR and outcomes from in-hospital cardiac arrest: An observational cohort study. Resuscitation. 2024;May 1;198.

We know the literature on mechanical CPR devices on mortality in out of hospital cardiac arrest (we DO know this literature, right?), but what about in-hospital arrest? Dr. Jarvis reviews a recent paper that uses the AHA Get With The Guidelines - Resuscitation registry to assess the association between MCDs and mortality. 

Citations
1. Crowley C, Salciccioli J, Wang W, Tamura T, Kim EY, Moskowitz A: The association between mechanical CPR and outcomes from in-hospital cardiac arrest: An observational cohort study. Resuscitation. 2024;May 1;198.
2. Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R, et al.: Mechanical Chest Compressions and Simultaneous Defibrillation vs Conventional Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest: The LINC Randomized Trial. JAMA. 2014;January 1;311(1):53–61
3. Hardig BM, Lindgren E, Östlund O, Herlitz J, Karlsten R, Rubertsson S: Outcome among VF/VT patients in the LINC (LUCAS IN cardiac arrest) trial—A randomised, controlled trial. Resuscitation. 2017;June;115:155–62.
4.  Perkins GD, Lall R, Quinn T, Deakin CD, Cooke MW, Horton J, Lamb SE, Slowther A-M, Woollard M, Carson A, et al.: Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. The Lancet. 2015;385(9972):947–55.
5.  Wik L, Olsen J-A, Persse D, Sterz F, Lozano M, Brouwer MA, Westfall M, Souders CM, Malzer R, Van Grunsven PM, et al.: Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial. Resuscitation. 2014;June;85(6):741–8.
6. Bonnes JL, Brouwer MA, Navarese EP, Verhaert DVM, Verheugt FWA, Smeets JLRM, Boer M-J de: Manual Cardiopulmonary Resuscitation Versus CPR Including a Mechanical Chest Compression Device in Out-of-Hospital Cardiac Arrest: A Comprehensive Meta-analysis From Randomized and Observational Studies. Ann Emerg Med Annals of emergency medicine. 2016;67(3):349-360.e3.
7. Gonzales L, Oyler BK, Hayes JL, Escott ME, Cabanas JG, Hinchey PR, Brown LH: Out-of-hospital cardiac arrest outcomes with “pit crew” resuscitation and scripted initiation of mechanical CPR. The American Journal of Emergency Medicine. 2019;May;37(5):913–20.
8. Koster RW, Beenen LF, Van Der Boom EB, Spijkerboer AM, Tepaske R, Van Der Wal AC, Beesems SG, Tijssen JG: Safety of mechanical chest compression devices AutoPulse and LUCAS in cardiac arrest: a randomized clinical trial for non-inferiority. European Heart Journal. 2017;October 21;38(40):3006–13.
9. Primi R, Bendotti S, Currao A, Sechi GM, Marconi G, Pamploni G, Panni G, Sgotti D, Zorzi E, Cazzaniga M, et al.: Use of Mechanical Chest Compression for Resuscitation in Out-Of-Hospital Cardiac Arrest—Device Matters: A Propensity-Score-Based Match Analysis. JCM. 2023;June 30;12(13):4429.
10. Youngquist ST, Ockerse P, Hartsell S, Stratford C, Taillac P: Mechanical chest compression devices are associated with poor neurological survival in a statewide registry: A propensity score analysis. Resuscitation. 2016;September;106:102–7.
11.  S, Sulzgruber P, Datler P, Keferböck M, Poppe M, Lobmeyr E, Van Tulder R, Zajicek A, Buchinger A, Polz K, et al.: Mechanical chest compression does not seem to improve outcome after out-of hospital cardiac arrest. A single center observational trial. Resuscitation. 2015;November;96:220–5. 
12. Morgan S, Gray JJ, Sams W, Uhl K, Gundrum M, McMullan J: LUCAS Device Use Associated with Prolonged Pauses during Application and Long Chest Compression Intervals. Prehospital Emergency Care. doi: 10.1080/10903127.2023.2183294 (Epub ahead of print).
13.  Levy M, Yost D, Walker RG, Scheunemann E, Mendive SR: A quality improvement initiative to optimize use of a mechanical chest compression device within a high-performance CPR approach to out-of-hospital cardiac arrest resuscitation. Resuscitation. 2015;July;92:32–7.
14.  Li H, Wang D, Yu Y, Zhao X, Jing X: Mechanical versus manual chest compressions for cardiac arrest: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med. 2016;December;24(1):10.
15.  Sheraton M, Columbus J, Surani S, Chopra R, Kashyap R: Effectiveness of Mechanical Chest Compression Devices over Manual Cardiopulmonary Resuscitation: A Systematic Review with Meta-analysis and Trial Sequential Analysis. WestJEM. 2021;July 19;22(4):810–9.
16.  Wang PL, Brooks SC: Mechanical versus manual chest compressions for cardiac arrest. Cochrane Database Syst Rev The Cochrane database of systematic reviews. 2018;20;8:CD007260.
17.  Zhu N, Chen Q, Jiang Z, Liao F, Kou B, Tang H, Zhou M: A meta-analysis of the resuscitative effects of mechanical and manual chest compression in out-of-hospital cardiac arrest patients. Crit Care. 2019;December;23(1):100.

New Orleans implemented a blood program and assessed the impact of the program on mortality. Dr Jarvis dives into the details of the paper and then Dr Remle Crowe joins in for a discussion on why studying blood in the field is so difficult. 

Citation: 
Broome JM, Nordham KD, Piehl M, Tatum D, Caputo S, Belding C, De Maio VJ, Taghavi S, Jackson-Weaver O, Harris C, et al.: Faster refill in an urban emergency medical services system saves lives: A prospective preliminary evaluation of a prehospital advanced resuscitative care bundle. J Trauma Acute Care Surg. 2024;May;96(5):702–7.

We've reviewed several papers in the past that suggest there might be an advantage to using IV access compared to IO access for medications in cardiac arrest. Is that really a thing? Wouldn't it be great if we had some randomized controlled trials to help answer the questions?  

Funny you should mention RCTs. Dr Jarvis reviews three (THREE!) new RCTs that compare IV to IO access in out of hospital cardiac arrest to try to shed some of that bright light of science on this question!

Citations:

1. Vallentin MF, Granfeldt A, Klitgaard TL, Mikkelsen S, Folke F, Christensen HC, Povlsen AL, Petersen AH, Winther S, Frilund LW, et al.: Intraosseous or Intravenous Vascular Access for Out-of-Hospital Cardiac Arrest. N Engl J Med.

2. Smida T, Crowe R, Jarvis J, Ratcliff T, Goebel M: A retrospective comparison of upper and lower extremity intraosseous access during out-of-hospital cardiac arrest resuscitation. Prehospital Emergency Care. 2024;28(6):1–23.

3. Nielsen N: The Way to a Patient’s Heart — Vascular Access in Cardiac Arrest. N Engl J Med. doi: 10.1056/NEJMe2412901 (Epub ahead of print).

4. Ko Y-C, Lin H-Y, Huang EP-C, Lee A-F, Hsieh M-J, Yang C-W, Lee B-C, Wang Y-C, Yang W-S, Chien Y-C, et al.: Intraosseous versus intravenous vascular access in upper extremity among adults with out-of-hospital cardiac arrest: cluster randomised clinical trial (VICTOR trial). BMJ. doi: 10.1136/bmj-2024-079878 (Epub ahead of print).
5. Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, Leroux B, Vaillancourt C, Wittwer L, Callaway CW, et al.: Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2016;May 5;374(18):1711–22.

6.Daya MR, Leroux BG, Dorian P, Rea TD, Newgard CD, Morrison LJ, Lupton JR, Menegazzi JJ, Ornato JP, Sopko G, et al.: Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Circulation. 2020;January 21;141(3):188–98.

7. Nolan JP, Deakin CD, Ji C, Gates S, Rosser A, Lall R, Perkins GD: Intraosseous versus intravenous administration of adrenaline in patients with out-of-hospital cardiac arrest: a secondary analysis of the PARAMEDIC2 placebo-controlled trial. Intensive Care Medicine. doi: 10.1007/s00134-019-05920-7 (Epub ahead of print).

Back in episode 80 we discussed a feasibility study out of Salt Lake City that showed IM epi resulted in 3-minute faster administration in cardiac arrest. It was underpowered to show survival, however. Fortunately, the great folks in Salt Lake City is back with a larger bite at the statistical apple. Dr Jarvis discusses the background around what we know about epinephrine in cardiac arrest (briefly, for once), walks us through this new study, and puts it in context of modern clinical practice. 

Citations.

1. Palatinus HN, Johnson MA, Wang HE, Hoareau GL, Youngquist ST: Early intramuscular adrenaline administration is associated with improved survival from out-of-hospital cardiac arrest. Resuscitation. 2024;August;201:110266.

2. Perkins GD, Ji C, Deakin CD, Quinn T, Nolan JP, Scomparin C, Regan S, Long J, Slowther A, Pocock H, et al.: A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2018;August 23;379(8):711–21.

3. Okubo M, Komukai S, Callaway CW, Izawa J: Association of Timing of Epinephrine Administration With Outcomes in Adults With Out-of-Hospital Cardiac Arrest. JAMA Netw Open. 2021;August 10;4(8):e2120176.

4. Hubble MW, Tyson C: Impact of Early Vasopressor Administration on Neurological Outcomes after Prolonged Out-of-Hospital Cardiac Arrest. Prehosp Disaster Med. 2017;June;32(3):297–304.

5.  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.

Do you give naloxone to patients who are in cardiac arrest? Should you? Can it possibly provide any benefit at all once you are already providing effective ventilations? Well, Dr. Jarvis certainly thought not. He might have even thought it out loud. Like, loudly out loud.  

Based on two recent papers looking directly at this question, perhaps he needs to eat some crow and shine the bright light of science on his own damn practice. 

Citations:

1. Strong NH, Daya MR, Neth MR, Noble M, Sahni R, Jui J, Lupton JR: The association of early naloxone use with outcomes in non-shockable out-of-hospital cardiac arrest. Resuscitation. 2024;August;201:110263.

2. Dillon DG, Montoy JCC, Nishijima DK, Niederberger S, Menegazzi JJ, Lacocque J, Rodriguez RM, Wang RC: Naloxone and Patient Outcomes in Out-of-Hospital Cardiac Arrests in California. JAMA Netw Open. 2024;August 1;7(8):e2429154.

3. Niederberger SM, Crowe RP, Salcido DD, Menegazzi JJ: Sodium bicarbonate administration is associated with improved survival in asystolic and PEA Out-of-Hospital cardiac arrest. Resuscitation. doi: 10.1016/j.resuscitation.2022.11.007 (Epub ahead of print).

4. Wampler DA: Naloxone in Out-of-Hospital Cardiac Arrest—More Than 

Remember when we learned interruptions in compressions take a long time to recover blood pressure from? And how, to avoid these, we should do continuous compressions to avoid them. And ventilations aren’t all that important. Right? Right? Well, about that. Maybe the stories of the importance of continuous compressions were greatly exaggerated. Join Dr. Jarvis as he discusses the literature that led us to this point and some evidence that has led him to reconsider how his system approaches cardiac arrest. He’ll eventually get around to discussion a recent paper by Dr. Rose Yin that analyzes arterial pressures during cardiac arrest that was a catalyst for him to make changes in his arrest protocols. 

Citations:

1. Yin RT, Berve PO, Skaalhegg T, et al. Recovery of arterial blood pressure after chest compression pauses in patients with out-of-hospital cardiac arrest. Resuscitation. 2024;201:110311. doi:10.1016/j.resuscitation.2024.110311

2. Azcarate I, Urigüen JA, Leturiondo M, et al. The Role of Chest Compressions on Ventilation during Advanced Cardiopulmonary Resuscitation. JCM. 2023;12(21):6918. doi:10.3390/jcm12216918

3. Berg RA, Sanders AB, Kern KB, et al. Adverse Hemodynamic Effects of Interrupting Chest Compressions for Rescue Breathing During Cardiopulmonary Resuscitation for Ventricular Fibrillation Cardiac Arrest. Circulation. 2001;104(20):2465-2470. doi:10.1161/hc4501.098926

4.Kern KB, Hilwig RonaldW, Berg RA, Ewy GA. Efficacy of chest compression-only BLS CPR in the presence of an occluded airway. Resuscitation. 1998;39(3):179-188. doi:10.1016/S0300-9572(98)00141-5

5. Bobrow BJ, Clark LL, Ewy GA, et al. Minimally Interrupted Cardiac Resuscitation by Emergency Medical Services for Out-of-Hospital Cardiac Arrest. JAMA. 2008;299(10):1158-1165.

6. Idris AH, Aramendi Ecenarro E, Leroux B, et al. Bag-Valve-Mask Ventilation and Survival From Out-of-Hospital Cardiac Arrest: A Multicenter Study. Circulation. 2023;148(23):1847-1856. doi:10.1161/CIRCULATIONAHA.123.065561

7. Nichol G, Leroux B, Wang H, et al. Trial of Continuous or Interrupted Chest Compressions during CPR. N Engl J Med. 2015;373(23):2203-2214. doi:10.1056/NEJMoa1509139

8. Schmicker RH, Nichol G, Kudenchuk P, et al. CPR compression strategy 30:2 is difficult to adhere to, but has better survival than continuous chest compressions when done correctly. Resuscitation. 2021;165:31-37. doi:10.1016/j.resuscitation.2021.05.027

9. Zhan L, Yang LJ, Huang Y, He Q, Liu GJ. Continuous chest compression versus interrupted chest compression for cardiopulmonary resuscitation of non-asphyxial out-of-hospital cardiac arrest. Cochrane Anaesthesia C and ECG, ed. Cochrane Database of Systematic Reviews. Published online 2017. doi:10.1002/14651858.cd010134.pub2

10. Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation. 2004;109(16):1960-1965. doi:10.1161/01.CIR.0000126594.79136.61

What’s the best way to pre-oxygenate our patients prior to intubation? The evidence for this question has been mixed for some time. Dr Jarvis discusses the PREOXI Trial, which directly compares preoxygenation with non-invasive ventilation compared to a face mask to see which provides the best protection against peri-intubation hypoxia. This is an important trial that sheds light on a key component of our bundle of care to make intubation safer.

Citations:

1. Gibbs KW, Semler MW, Driver BE, Seitz KP, Stempek SB, Taylor C, Resnick-Ault D, White HD, Gandotra S, Doerschug KC, et al.: Noninvasive Ventilation for Preoxygenation during Emergency Intubation. N Engl J Med. (2024)
2. Jarvis JL, Gonzales J, Johns D, Sager L: Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia. Annals of Emergency Medicine. 2018;72:272–9.
3. Groombridge C, et al: A prospective, randomised trial of pre-oxygenation strategies available in the pre-hospital environment. Anaesthesia. 2017;72:580–4.
4. Groombridge C, et al: Assessment of Common Preoxygenation Strategies Outside of the Operating Room Environment. Acad Emerg Med. 2016;March;23(3):342–6.
5. Baillard C, et al: Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med. 2006;July 15;174(2):171–7.
6. Ramkumar V, et al: Preoxygenation with 20-degree head-up tilt provides longer duration of non-hypoxic apnea than conventional preoxygenation in non-obese healthy adults. J Anesth. 2011;25:189–94.
7. Pourmand A, et al: Pre-oxygenation: Implications in emergency airway management. American Journal of Emergency Medicine. doi: 10.1016/j.ajem.2017.06.006
8. Solis A, Baillard C: Effectiveness of preoxygenation using the head-up position and noninvasive ventilation to reduce hypoxaemia during intubation. Ann Fr Anesth Reanim. 2008;June;27(6):490–4.
9. April MD, Arana A, Reynolds JC, Carlson JN, Davis WT, Schauer SG, Oliver JJ, Summers SM, Long B, Walls RM, et al.: Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study. Resuscitation. 2021;May;162:403–11.
10. Trent SA, Driver BE, Prekker ME, Barnes CR, Brewer JM, Doerschug KC, Gaillard JP, Gibbs KW, Ghamande S, Hughes CG, et al.: Defining Successful Intubation on the First Attempt
11. Using Both Laryngoscope and Endotracheal Tube Insertions: A Secondary Analysis of Clinical Trial Data. Annals of Emergency Medicine. 2023;82(4):S0196064423002135.
12. Pavlov I, Medrano S, Weingart S: Apneic oxygenation reduces the incidence of hypoxemia during emergency intubation: A systematic review and meta-analysis. AJEM. 2017;35(8):1184–9.