January 2, 2021 admin No Comments

Happy New Year! 2020 brought us a lot of challenges, as we all know. Dr. Salim Rezaie of RebelEM comes back on to the show to discuss the most important papers of 2020.

This episode discusses:

Paper #1: CURASMUR

• The Succinylcholine vs Rocuronium for Out-of-Hospital Emergency Intubation (CURASMUR) trial
• Guihard Bertrand et al. Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation: A Randomized Clinical Trial. JAMA 2019. [Epub Ahead of Print]
• Multicenter, single-blind, noninferiority randomized clinical trial comparing Rocuronium 1.2mg/kg IV vs Succinylcholine 1mg/kg IV for RSI
• 17 French out-of-hospital emergency medical units
• Primary: Intubation success rate on first attempt (Noninferiority margin of 7% was chosen)
• 1248 adult patients needing out-of-hospital tracheal intubation

• 1^st Pass Intubation Success Rate:
  • Rocuronium: 455/610 (74.6%)
  • Succinylcholine: 489/616 (79.4%)
  • Between group difference of -4.8%
  • 1-sided 97.5% CI = -9% to infinity
  • Did not meet criteria for noninferiority
• Biggest issue with this study is that the choice of paralytic shouldn’t influence the first pass success rate of intubation unless the dose is incorrect (i.e. to low) or the intubation attempt occurred too early

Clinical Take Home Point:  I am not sure why this is still a debate. If dosed appropriately, and the patient is paralyzed, the agent used should have no effect on the success rate of intubation. There are, however, several untoward effects of succinylcholine (i.e. hyperkalemia, shorter safe apnea time, etc) that push me toward using rocuronium.

Paper #2: VITAMINS

• The VitamIn C HydrocorTisone and ThiAMINe in patients with Septic shock Trial (VITAMINS Trial)
• Fujii T et al. Effect of Vitamin C, Hydrocortisone, and Thiamine vs Hydrocortisone Alone on Time Alive and Free of Vasopressor Support Among Patients With Septic Shock: The VITAMINS Randomized Clinical Trial. JAMA 2020. [Epub Ahead of Print]
• Prospective, Feasibility, Pilot, Multicenter, Randomized, Open-Label, Parallel Group Controlled Trial
• Patients recruited from 10 ICUs in Australia, New Zealand, and Brazil
• Primary: Time alive and free of vasopressors at day 7 (168hrs) after randomization
• 211 patients included in the primary analysis
• Median Time Alive and Vasopressor Free up to Day 7 (Primary Outcome):
  • Treatment: 122.1hrs (Range 76.3 – 145.5hrs)
  • Control: 124.6hrs (Range 82.1 – 147.0hrs)
  • 95% CI -8.3 to 7.2hrs
  • P = 0.83
  • No statistically significant difference
• Also no difference in 28d, 90d, ICU mortality or hospital mortality
• The average time from meeting eligibility criteria to the first dose of medications:
  • Vitamin C: ≈12hrs – Range 5.7 – 19.0hrs
  • Hydrocortisone: ≈8.9hrs – Range 4.0 – 15.0hrs
  • Add to this, time from ICU admission to randomization: ≈12hrs
  • This is >24hrs before medication given. These medications may have been given too late to have a clinical effect
• Clinical Take Home Point: In this trial, treatment of septic shock with intravenous vitamin C, hydrocortisone, and thiamine did not improve duration of time alive and free of vasopressor administration over 7days compared to IV hydrocortisone alone. Believers will say, an average time of >24hrs from ICU admission to first dose of medication set this trial up for failure, but the bigger question is at this point should we use the “metabolic cocktail” in sepsis or not?  I am in the camp that current evidence does not support its use.  We will just have to wait and see how the subsequent trials shake out.

Paper #3: DOSE VF Pilot Study

• Three-arm pilot RCT, with a randomized cluster crossing period, conducted across four paramedic services in Ontario, Canada
• Paper: Cheskes S et al. Double Sequential External Defibrillation for Refractory Ventricular Fibrillation: The DOSE VF Pilot Randomized Controlled Trial. Resuscitation 2020. PMID: 32084567

• One of the three following defibrillation strategies was assigned through computer-generated randomization to one of the four regional paramedic services and performed after three standard defibrillation attempts:
  • Strategy 1: Continued standard defibrillation therapy with pads in the anterior-lateral configuration
  • Strategy 2: Vector change (VC) defibrillation with pads transferred from the standard anterior-lateral to the anterior-posterior position
  • Strategy 3: DSED with pads in the anterior-posterior position and an intentional delay to ensure rapid sequence delivery vs simultaneous defibrillation
• 152 patients recruited
• VF Termination:
  • Standard: 66.6%
  • VC: 82.0%
  • DSED: 76.3%
• ROSC at Any Time: DSED & VC: 40% and Standard 25%
• There were no reported cases of defibrillator malfunction, skin burns, difficulty with pad placement or concerns expressed by paramedics, families or emergency department staff about the trial.
• Clinical Take Home Point: Emergency physicians should continue to consider the use of a second defibrillator when treating refractory ventricular fibrillation. It isn’t clear from this study if increased ROSC will translate into improve neurologically intact survival. In settings where a second defibrillator is not available or not feasible, changing pad placement from anterolateral to anteroposterior when performing defibrillation may help improve VF termination and achievement of ROSC.

Paper #4: IV or IO Epi in OHCA

• Retrospective, observational analysis of adult patients with OHCA of presumed cardiac origin who had EMS CPR, received epinephrine, and enrolled in the Resuscitation Outcomes Consortium (ROC) Cardiac Registry between 2011 and 2015
• Patients were not randomized but divided into IV and IO groups based on administration route of epinephrine
• Paper: Zhang Y et al. Intravenous Versus Intraosseous Adrenaline Administration in Out-of-Hospital Cardiac Arrest: A Retrospective Cohort Study. Resuscitation 2020. PMID: 31982506

• Primary: Survival to hospital discharge
• 35,733 patients included
  • IV Epi: 27,733 patients (77.7%)
  • IO Epi: 7,975 patients (22.3%)
• All outcomes favored IV route over IO route:

• Survival to Hospital DC (Primary Outcome): aOR 1.468 (95% CI 1.264 – 1.705)
• Prehospital ROSC: aOR 1.367 (95% CI 1.276 – 1.464)
• Favorable Neurologic Function: aOR 1.849 (95% CI1.526 – 2.250)
• Location of the IOs was not described. A humeral IO is far different than a tibial IO in a low flow state and also has the potential to confound these results
• There are patient-specific factors that we do not know that could affect these results. For example, if a patient is chronically ill, with poor potential for venous access, and they are less likely to survive, then they are more likely to get IO access which could falsely lower the outcome rates in this group
• Important confounders that would favor IV over IO:
  • Bystander witnessed cardiac arrest (IV 40.0% vs IO 34.6%)
  • Public location (IV 15.4% vs IO 11.4%)
  • Shockable Rhythm (IV 24.0% vs IO 16.1%)
• This appears to demonstrate that the IO group was simply sicker and, this study is not an indictment of IOs as much as an investigation of sicker and less sick cardiac arrest patients (yes, such a thing exists as “less sick cardiac arrest.”)
• Clinical Take Home Point: This study should not change your practice of IV vs IO access in OHCA. Future randomized trials of access are needed to clarify this situation. If you are using IO access in cardiac arrest you want to go as proximal to the central circulation as possible, which is most commonly the humeral IO.

T: OverrunEMS IG/FB: Overrunproductions

#dobetter

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