Ten Important Papers

What did the docs and researchers think mattered most last year? Three of them discussed the top 10 EMS-related scientific articles published in 2011 in pro-con debates at NAEMSP.

Medical directors, EMS operators and front-line providers gathered in Tucson, AZ, in January to share the latest and greatest in EMS practices at the National Association of EMS Physicians’ annual conference. To close the five days of innovative meetings, workshops and lectures, emergency physicians Michael Millin and Jon Rittenberger and paramedic Blair Bigham presented the top 10 EMS-related scientific articles published in 2011 in a series of pro-con debates that made the current Republican presidential primary contest look peaceful. From cardiac arrest to trauma and everything in between, the trio took a critical look at literature that promises to change the landscape of EMS care.

Teeing off the talk were two New England Journal of Medicine articles from the Resuscitation Outcomes Consortium (ROC). Long awaited, these two trials randomized out-of-hospital cardiac arrest patients without heartbeats to receive novel therapies. Patients received CPR for either a short (30-second) or long (3-minute) duration prior to first-shock analysis to study the impact of “priming the pump” with “up-front” CPR; also, the use of an impedance threshold device (ITD) was randomly assigned to investigate the hypothesis that increases in intrathoracic pressure improve survival measures. Both trials were expertly run, enrolling more than 10,000 patients and reaching field performance levels considered optimal for the prehospital setting. Ultimately, they found that survival was equal between all groups; neither novel treatment impacted it.

Also in the cardiac arrest category, Greek scientists undertook a systematic review and meta-analysis of studies comparing ALS and BLS care in cardiac arrest and trauma. By collating 18 studies together and running a new statistical analysis, they found cardiac patients treated by ALS providers survive up to twice as often as those treated by BLS providers, but trauma patients do not benefit from the presence of ALS personnel.

Two other articles explored the behavior of rescuers in cardiac arrest situations. The first, conducted at a train station in the Netherlands, asked bystanders about their ability to recognize the need for defibrillation and ability and willingness to use an automated external defibrillator. Sadly, only 9% of those surveyed were able to identify all of the required steps needed to successfully apply an AED to a patient in cardiac arrest. This exposes important gaps in public knowledge. On the responder front, a study from the ROC identified substantial variation in EMS provider practice with regards to pronouncing cardiac arrest patients on scene. In some cities and states, nearly all cardiac arrests are transported without a pulse, compared to hardly any in others. Despite clear guidelines for termination of resuscitation, it appears unnecessary transports are common in many places.

Rounding out the cardiac arrest studies was the world’s first randomized controlled trial of epinephrine vs. placebo for cardiac arrest. Its enrollment was ceased due to political intervention, but not before demonstrating that a randomized controlled trial of epinephrine was not only possible, but important; researchers found that while epinephrine may increase the odds of return of spontaneous circulation, neurologic recovery may be impaired. The guarded interpretation of this study: epinephrine is a necessary evil in resuscitation, but are we giving too much?

Changing topics, the trio reviewed a study that showed septic patients arriving to the emergency department by EMS are likely to be seen and treated quicker, regardless of their acuity. Triggering early sepsis care has a strong potential to improve patient outcomes, as numerous other studies have identified that quicker treatment means higher rates of survival.

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