The Top 5 Papers of 2016: #3

Every year, three EMS experts take to the stage at the National Association of EMS Physicians annual conference to sum up the top five research articles of the previous year. Their goal? Identify research that is relevant, counter-intuitive and practice changing—research that is important to the patients who call 9-1-1 with the expectation that they will be served with the best available care possible. This year, paramedic and emergency room resident Blair Bigham describes the articles he and co-experts Drs. Jon Rittenberger and Michael Millin selected.

The Case of the Bleeding Brain

A 61-year-old economics professor calls 9-1-1 for a sudden onset of severe headache with stroke-like symptoms sustained after she slipped on black ice. She has a history of hypertension.

IV access is established and she is transported to a university hospital with stroke and neurosurgical specialization.

En route, her blood pressure slowly trends down from 160/110 to 80/50. The attending paramedic initiates a fluid bolus. On reassessment, her pupils are equal and reactive, her GCS is 10, and her vital signs are otherwise unremarkable.

A CT scan shows a parenchymal bleed that is amenable to surgery. The professor is admitted to ICU and is discharged neurologically intact after four months of intensive rehabilitation.

The Evidence

• Spaite DW, et al. Mortality and prehospital blood pressure in patients with major traumatic brain injury implications for the hypotension threshold. JAMA Surg, published online, December 2016. 

In this secondary analysis of a large EMS traumatic brain injury database from the Arizona trauma registry, investigators plotted the lowest blood pressure of 3,300 severely head-injured patients. Using statistical modeling, they found the odds of death decreased 18% for every 10 point increase in systolic blood pressure. This survival advantage continued for blood pressures above the traditional cut-off of 90 mmHg up to a systolic of 135 mmHg.

The Bottom Line

The traditional blood pressure of 90 mmHg may not be the right target in patients with head injury. Further research is required to best know if paramedics should drive systolic pressure higher than 90 mmHg is these patients using fluids or vasoactive medications. Care should be taken to avoid iatrogenic hypotension associated with sedation, analgesia, and intubation.

After a decade working as a helicopter paramedic, Blair Bigham, MD, MSC, ACPF, completed medical school in Ontario, Canada, where he is now a resident physician in the emergency department. He has authored over 30 scientific articles, led major national projects to advance prehospital research and participated in multiple collaboratives, including the Resuscitation Outcomes Consortium. He has taught and mentored clinical and academic paramedics and loves his new role teaching medical students. He serves as a volunteer on the board of directors for the MedicAlert Foundation of Canada and is a task force member for the International Liaison Committee on Resuscitation. 

Michael Millin is a board certified EM and EMS physician from Baltimore, MD. He is a member of the faculty of the Johns Hopkins University School of Medicine and medical director of the Johns Hopkins Lifeline critical care transport program. He is also medical director for the BWI Airport Fire and Rescue Department, Maryland Search and Rescue, and associate medical dDirector for the Prince George’s County Fire/EMS Department.

Jon Rittenberger, MD, is an associate professor of emergency medicine and medical command physician for UPMC Prehospital Care. In addition to his emergency medicine practice, he is a founding member of the Post Cardiac Arrest Service at UPMC Presbyterian hospital. His research interest is in brain resuscitation during critical illness states. He brings over 20 years of EMS experience as a provider and researcher.