The EMS Lighthouse Project

We’ve spoken a lot recently about intubation First Pass Success, including what the definition is. We’ve also discussed different papers about the impact the type of laryngoscope, video or direct, has on first pass success. There’s a new paper out that directly compares video vs direct laryngoscopy. Join us to discuss the DEVICE trial. Citations Prekker ME, Driver BE, Trent SA, et al. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. N Engl J Med. Published online June 16, 2023 Jarvis JL, McClure SF, Johns D. EMS Intubation Improves with King Vision Video Laryngoscopy. Prehosp Emerg Care. 2015 Ducharme S, Kramer B, Gelbart D, Colleran C, Risavi B, Carlson JN. A pilot, prospective, randomized trial of video versus direct laryngoscopy for paramedic endotracheal intubation. Resuscitation. 2017 Pourmand A, Terrebonne E, Gerber S, Shipley J, Tran QK. Efficacy of Video Laryngoscopy versus Direct Laryngoscopy in the Prehospital Setting: A Systematic Review and Meta-Analysis. Prehosp Disaster Med. 2023 Brown CA, Kaji AH, Fantegrossi A, et al. Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study. Acad Emerg Med. 2020 Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation: a Cochrane systematic review and meta-analysis update. British Journal of Anaesthesia. 2022 See omnystudio.com/listener for privacy information.

What even IS FPS? There's been a long running argument about the definition of FPS. And by argument, I mean mostly established in the literature with some people just not liking it. FPS is successful ET passage through the cords within 1 attempt at laryngoscopy or when the blade passes the teeth. That definition worked well when we were using direct laryngoscopy where the hard part of intubation was visualization and the easy part of tube passage. But does it still hold in an age of VL where visualization is easy and tube passage is the hard part. We discuss a paper on this episode that proposes a new definition, perhaps better meeting the needs of the VL era. Citation: Trent SA, Driver BE, Prekker ME, et al. Defining Successful Intubation on the First Attempt Using Both Laryngoscope and Endotracheal Tube Insertions: A Secondary Analysis of Clinical Trial Data. Annals of Emergency Medicine. Published online April 2023:S0196064423002135. doi:10.1016/j.annemergmed.2023.03.021 See omnystudio.com/listener for privacy information.

A new study came out describing the utility of post-mortem CT panscans in patients who died either in the field or in the ED to identify mortal and potentially mortal injuries. This paper has a couple of surprise findings that can help EMS focus our efforts on the care of these patients. Citations: 1. Levin JH, Pecoraro A, Ochs V, Meagher A, Steenburg SD, Hammer PM. Characterization of fatal blunt injuries using post-mortem computed tomography. J Trauma Acute Care Surg. 2023;Publish Ahead of Print. 2. Sakles JC, Ross C, Kovacs G. Preventing unrecognized esophageal intubation in the emergency department. JACEP Open. 2023;4(3):e12951. 3. Chrimes N, Higgs A, Hagberg CA, et al. Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies*. Anaesthesia. 2022;77(12):1395-1415.See omnystudio.com/listener for privacy information.

DSI (delayed sequence intubation) has been proposed as an alternative to RSI (rapid sequence intubation) for patients who can't tolerate interventions needed to properly pre oxygenate patients. But does it work? There have been several observational studies (blantant bias acknowledgement: I wrote one of them!) suggesting it is safe and effective but no randomized trials. Well, now we have one. Join Dr. Jarvis as he describes this RCT of DSI vs RSI in adult trauma patients presenting to an Indian ED. Citation: 1. Bandyopadhyay A, Kumar P, Jafra A, Thakur H, Yaddanapudi LN, Jain K. Peri-Intubation Hypoxia After Delayed Versus Rapid Sequence Intubation in Critically Injured Patients on Arrival to Trauma Triage: A Randomized Controlled Trial. Anesthesia & Analgesia. 2023;136(5):913-919.See omnystudio.com/listener for privacy information.

We interviewed Tanner Smida in episode 69 about his very interesting paper using the ESO dataset looking at the association between survival from out of hospital cardiac arrest and type of SGA used (iGel vs KingLT). He found 36% higher odds of survival with iGel. The ink was barely dry on that paper before he published a follow up paper looking at the same association but with a different dataset, this time CARES, and national US registry of OHCA. Citations: 1. Smida T, Menegazzi J, Scheidler J, Martin PS, Salcido D, Bardes J. A retrospective comparison of the King Laryngeal Tube and iGel supraglottic airway devices: a study for the CARES surveillance group. Resuscitation. Published online April 2023:109812. doi:10.1016/j.resuscitation.2023.109812 2. Smida T, Menegazzi J, Crowe R, Scheidler J, Salcido D, Bardes J. A Retrospective Nationwide Comparison of the iGel and King Laryngeal Tube Supraglottic Airways for Out-of-Hospital Cardiac Arrest Resuscitation. Prehospital Emergency Care. Published online January 18, 2023:1-13. doi:10.1080/10903127.2023.2169422See omnystudio.com/listener for privacy information.

Man, did we have fun recording this one. I found myself in a hotel room in Ashland, Oregon with Drs. Ed Racht, Maia Dorsett, and Ritu Sahni talking about Sepsis. We decided this would make for a great crossover episode with The EMS Show, minus our buddy Mikey V. Anytime I get together with this group of friends, I always have fun. We discuss a new sepsis trial but also discuss the OG sepsis paper, Dr. River's Early Goal Direct Therapy and discuss the cautionary tale of performance measures gone awry. We also hit on using EtCO2 as a surrogate for lactate in sepsis and collectively decide Dr. Dorsett is a rockstar. Citation: The National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury Clinical Trials Network. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. N Engl J Med. 2023;388(6):499-510. doi:10.1056/NEJMoa2212663 See omnystudio.com/listener for privacy information.

The cage match you've all been waiting for! iGel vs King LT in cardiac arrest. Which is associated with higher survival? Airways-2 was an RCT of iGel vs ETI in OHCA and found no difference. PART was an RCT of King LT vs ETI in OHCA and found a slight difference favoring King LT. How about in those patients just getting a SGA... how does the iGel compare to King LT? Dr. Jarvis interviews the amazing young researcher and medical student Tanner Smida about his new paper using the ESO dataset to answer just this question. Citation: 1. Smida T, Menegazzi J, Crowe R, Scheidler J, Salcido D, Bardes J. A Retrospective Nationwide Comparison of the iGel and King Laryngeal Tube Supraglottic Airways for Out-of-Hospital Cardiac Arrest Resuscitation. Prehospital Emergency Care. Published online January 18, 2023:1-13.See omnystudio.com/listener for privacy information.

Remember AIRWAYS-2, the British RCT comparing iGel to ETI in adults with cardiac arrest? Have you wondered if those results would hold up in a different prehospital population? Wonder no more. Dr. Jarvis reviews the SAVE Trial, another RCT of adult, non-traumatic cardiac arrest comparing iGel to ETI in Taiwan. Citation: 1. Lee AF, Chien YC, Lee BC, et al. Effect of Placement of a Supraglottic Airway Device vs Endotracheal Intubation on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest in Taipei, Taiwan: A Cluster Randomized Clinical Trial. JAMA Netw Open. 2022;5(2):e2148871. doi:10.1001/jamanetworkopen.2021.48871See omnystudio.com/listener for privacy information.

If one is good, two must be better, right? If it applies to cookies and ice cream, why not defibrillators? That’s the question the DOSED-VF trial set out to answer. We’ve covered this topic in episodes 12 and 27, including going over the pilot trial of DOSED-VF. But now the full meal deal is available. And you may have heard it was stopped early because… well, you’d best listen to find out. And, as a special bonus, Dr. Jarvis explains the difference between odds and risk after he fell off into the statistical rabbit hole. Remember, this podcast also has a YouTube version complete with graphs and charts (oh, my!): https://www.youtube.com/@FlightbridgeedHEMS/playlists Citation: 1. Cheskes S, Verbeek PR, Drennan IR, et al. Defibrillation Strategies for Refractory Ventricular Fibrillation. N Engl J Med. 2022;387(21):1947-1956. doi:10.1056/NEJMoa2207304 Other papers discussed in this episode: 2. Mapp JG, Hans AJ, Darrington AM, et al. Prehospital Double Sequential Defibrillation: A Matched Case–Control Study. Braithwaite SA, ed. Academic Emergency Medicine. 2019;26(9):994-1001. doi:10.1111/acem.13672 3. Beck LR, Ostermayer DG, Ponce JN, Srinivasan S, Wang HE. Effectiveness of Prehospital Dual Sequential Defibrillation for Refractory Ventricular Fibrillation and Ventricular Tachycardia Cardiac Arrest. Prehosp Emerg Care. 2019;23(5):597-602. doi:10.1080/10903127.2019.1584256 4.Cabanas JG, Myers JB, Williams JG, De Maio VJ, Bachman MW. Double Sequential External Defibrillation in Out-of-Hospital Refractory Ventricular Fibrillation: A Report of Ten Cases. Prehosp Emerg Care. 2015;19(1):126-130. doi:10.3109/10903127.2014.942476 5. Cheskes S, Dorian P, Feldman M, et al. Double sequential external defibrillation for refractory ventricular fibrillation: The DOSE VF pilot randomized controlled trial. Resuscitation. 2020;150:178-184. doi:10.1016/j.resuscitation.2020.02.010 6. Ranganathan P, Aggarwal R, Pramesh C. Common pitfalls in statistical analysis: Odds versus risk. Perspect Clin Res. 2015;6(4):222. doi:10.4103/2229-3485.167092See omnystudio.com/listener for privacy information.

Dr. Crowe returns to the EMS Lighthouse Project Podcast from our “vacation” in Mexico to discuss the impact of variations between pulse oximetry and blood gas values across races. Citation: Am J Epidemiol10.1093/aje/kwac164JAMA Intern Med10.1001/jamainternmed.2022.1906 See omnystudio.com/listener for privacy information.

National guidelines for the management of seizures recommend midazolam 10 mg IM as first line therapy. The big question is how often EMS follows this guideline or how well that guideline matches up to real world use. Dr. Jarvis makes a road trip to ESO headquarters to discuss this paper using the ESO research dataset with newly minted Texan Mike Verkest and special guest Dr Remle Crowe. We go deep on the very interesting methodology used in this paper as we get our nerd on! Citation: Guterman EL, Sporer KA, Newman TB, et al. Real-World Midazolam Use and Outcomes With Out-of-Hospital Treatment of Status Epilepticus in the United States. Annals of Emergency Medicine. Published online August 2022. doi:10.1016/j.annemergmed.2022.05.024See omnystudio.com/listener for privacy information.

First, there was Episode 31: TXA for Epistaxis (the Zahed RCT from Tehran), then there was Episode 40: TXA for Epistaxis, Part Deux (the NoPAC trial), now there's Episode 64: TXA for Epistaxis, Part Trois, another Iranian RCT. So... we have conflicted evidence, all from RCTs, about whether TXA works for epistaxis. Dr. Jarvis goes through the prior trials and then gives a more detailed look at the new evidence. He closes by talking about how he handles conflicting evidence. Citation: Hosseinialhashemi M, Jahangiri R, Faramarzi A, et al. Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial. Annals of Emergency Medicine. 2022;80(3):182-188. doi:10.1016/j.annemergmed.2022.04.010See omnystudio.com/listener for privacy information.

Description: COVID sucks, no doubt about it. Vaccination has been a game changer for how we live through the pandemic, but we still need therapeutics for those breakthrough cases and the unvaccinated amongst us. Paxlovid is a novel anti-viral agent that showed promise in an initial industry-sponsored trial among unvaccinated patients with the delta strain. But does it hold up in the real world where vaccination is common, and omicron has pushed delta to the wayside? Dr. Jarvis reviews the initial RCT and a recent Israeli observational trial where more than 75% of patients were vaccinated. He also covers the contraindications for its use. Finally, he’ll no doubt massacre the almost impossible-to pronounce generic names for the drugs in Paxlovid. Citations. 1. Najjar-Debbiny R, Gronich N, Weber G, et al. Effectiveness of Paxlovid in Reducing Severe Coronavirus Disease 2019 and Mortality in High-Risk Patients. Clinical Infectious Diseases. Published online June 2, 2022:ciac443. doi:10.1093/cid/ciac443 2.Hammond J, Leister-Tebbe H, Gardner A, et al. Oral Nirmatrelvir for High-Risk, Nonhospitalized Adults with Covid-19. N Engl J Med. 2022;386(15):1397-1408. doi:10.1056/NEJMoa2118542See omnystudio.com/listener for privacy information.

Our good friends at Montgomery County Hospital District EMS in suburban Houston brings us a nice feasibility study about the use of esmolol for refractory v-fib. Dr. Jarvis discusses why this is a helpful study. If you like the show, please give us a 5-star rating wherever you get your podcasts. Did you know our podcast is on YouTube, too? Check us out and subscribe on the FlightBridgeED channel. Drop us questions/comments/suggestion for future pods at: Jeff.jarvis@flightbridgeed.com @DrJeffJarvis See omnystudio.com/listener for privacy information.

Dr. Jarvis interviews several EMS industry leaders discussing why we should use Red Lights & Sirens as a clinical intervention and only as indicated. This podcast is part of the first-ever national EMS quality improvement effort led by NEMSQA (https://www.nemsqa.org/lights-and-siren) Join us for interviews with Drs. Doug Kupas, Lawrence Brown, Michael Redlenner, and Mike Taigman to hear about The Case Against Lights & Sirens. Did you know all of our podcasts are also available as in video versions? Check them out on the FlightbridgeED YouTube channel. See omnystudio.com/listener for privacy information.

I got a great question during my FAST22 talk about what to make of two different papers, seemingly on the same topic, that give different results. In this case, it was about the Prague study Mike and I spoke about on the last episode (E59) and the one from Minneapolis (The ARREST trial). It was a great question that’ll I’ll discuss in this episode. I’ll also talk more about the ARREST trial. If you like the show, please give us a 5-star rating wherever you get your podcasts. Did you know our podcast is on YouTube, too? Check us out and subscribe on the Flightbridgeed channel. Drop us questions/comments/suggestion for future pods at: Jeff.jarvis@flightbridgeed.com @DrJeffJarvisSee omnystudio.com/listener for privacy information.

Mikey V and Dr. Jarvis get together again, “live” from Planet Hollywood at Las Vegas for FAST22! We took the opportunity to sit down and discuss two papers on cardiac arrest. Should we stay and play or should we load and go? In other words, should we work our arrests to conclusion where we find them or rapidly transport them? In a paper from Prague, we discuss whether early transport with LUCAS direct to cath lab for ECMO and PCI improves survival. As a foretaste of a pod to come, we’ll discuss the apparent contrasting results between the Prague ECMO study and one from Minneapolis (The ARREST trial) in a future episode. If you like the show, please give us a 5-star rating wherever you get your podcasts. Did you know our podcast is on YouTube, too? Check us out and subscribe on the FlightBridgeED channel. Drop us questions/comments/suggestion for future pods at: Jeff.jarvis@flightbridgeed.com @DrJeffJarvis See omnystudio.com/listener for privacy information.

Y’all have had lots of questions about using sodium bicarbonate in cardiac arrest after we ran an interview with Dr. Menegazzi talking about an abstract he presented showing benefit with bicarb. You wanted more so here it is! Dr. Jarvis reviews a paper from British Columbia from 2017 that looks at just this thing! If you like the show, please give us a 5-star rating wherever you get your podcasts. Did you know our podcast is on YouTube, too? Check us out and subscribe on the Flightbridgeed channel. Drop us questions/comments/suggestion for future pods at: Jeff.jarvis@flightbridgeed.com @DrJeffJarvis Citations: 1. Kawano T, Grunau B, Scheuermeyer FX, et al. Prehospital sodium bicarbonate use could worsen long term survival with favorable neurological recovery among patients with out-ofhospital cardiac arrest. Resuscitation. 2017;119:63-69. doi:10.1016/j.resuscitation.2017.08.008 See omnystudio.com/listener for privacy information.

Join us for a joint release of the first episode of The Pediatric EMS Podcast. We collaborate with the great folks from the PEC podcast, and MedicMindset to introduce this new podcast. We discuss assessment and management of pediatric pain.See omnystudio.com/listener for privacy information.

Do y'all treat a-fib? Have you wondered what the best method of rate control is? Should you use diltiazem or metoprolol? How about the best pad placement for electrical Cardioversion? Should you go anterior posterior or anterior lateral? Great questions! Dr. Jarvis reviews two recent papers to help shed the bright light of science on these two questions.See omnystudio.com/listener for privacy information.