EMS Research in 2023: A Rapid-Fire Review

At the National Collegiate EMS Foundation’s (NCEMSF) Annual Conference in Baltimore Feb. 24, 2023, Joshua Glick, MD, FACEP, emergency physician at the Hospital of the University of Pennsylvania and medical director for the Penn Medical Emergency Response Team, presented a talk summarizing notable and high-impact EMS research in 2023.

• ECMO in OHCA. A study from the Netherlands published in NEJM compared CPR to ECMO and included patients with persistent VT/VF at 15 minutes. While this study sought to settle the debate of ECMO’s efficacy, study results were less than significant in Glick’s view. Depending on the circumstances, and with better technology, prehospital ECMO may have a meaningful future, but we are not there yet. As technology improves, outcomes and cost-effectiveness may as well, said Glick. “This is not the end-all, be all,” he said of the study.
• Prehospital ketamine. Lipscombe et al. in Prehospital Emergency Care conducted a meta-analysis that looked at first-line treatment of ketamine in casres of agitation. In summarizing 18 papers, Glick’s takeaway from the meta-analysis is that if you plan to administer ketamine, always ask yourself whether you can manage the patient’s airway, or whether it going to pose a problem (for example, in cases of severe facial trauma).
• Hands-only CPR. Bielski et al. in the Journal of Cardiology examined 15 papers and found equivalent outcomes in ROSC, survival to hospital and to discharge, and neurological recovery between conventional and hands-only CPR patient groups. Authors found no significant difference, meaning that hands-only CPR is the preferred method as it’s simpler and safer to administer. “Hands-only CPR works,” said Glick. This is a signal that teaching hands-only CPR education to the public is effective and appropriate, he said.
• TXA for severe prehospital trauma. A paper in NEJM by the PATCH-Trauma Investigators Group outlined a double-blind, randomized, placebo-controlled trial that compared TXA to placebo in severe trauma cases. The study found no benefit for positive neurological outcomes in the study group, but there was a benefit to mortality at 1 and 28 days. No increased risk of major adverse events were experienced. The takeaway: for severe trauma in which a patient is dying in front of you, consider empiric dosing of TXA (1 gram)—while there may not be a huge benefit, there is little harm.
• Epinephrine in out-of-hospital cardiac arrest. Fernando et al. in the journal Chest conducted a meta-analysis of 18 trials examining the efficacy of epinephrine in OHCA. Standard-dose epinephrine improved survival to discharge among patients with nonshockable rhythm, but not those with shockable rhythm. Glick’s takeaway is that epinephrine for prehospital patients in cardiac arrest should be part of the care pathway to potentially get a patient from “not alive” to “alive.”
• Amiodarone/lidocaine in OHCA. The ALPS Trial was a secondary analysis that compared amiodarone and lidocaine to placebo in cases of out-of-hospital cardiac arrest. Benefits were largely inconclusive, said Glick, adding that “we go back and forth on medications in OHCA.” If you have a shockable rhythm, consider early dosing of amiodarone (it probably won’t hurt), advised Glick, but make sure CPR and defibrillation are first.
• Early troponin testing for chest pain. Camaro et al. in European Heart Journal looked at the records of 863 patients experiencing chest pain who underwent either standard transfer or prehospital troponin testing. Patients whose troponin levels were low were not hospitalized. While prehospital troponin testing did result in cost savings related to unnecessary hospitalizations, relying only on a risk score and a blood test to rule out acute coronary syndrome is “not good medicine,” said Glick, adding that while he supports early interventions, “this seems a bit too aggressive and misplaced in my opinion.”
• Social work in EMS. A study in Prehospital and Disaster Medicine determined that in the “during EMS” patient care stage, social workers can augment EMS care and function as emergency workers with roles such as search and rescue, advocacy, networking, and as emergency mental health practitioners with roles in psychosocial assessment, counseling, consultation and referrals. If social workers are available to your system, use them, stressed Glick.
• Intubation in OHCA. Jing Lou in Academic Emergency Medicine examined six strategies of airway management in OHCA and found no significant difference among the six strategies in overall patient survival. The takeaway, according to Glick: in cases of OHCA, if you have nothing else to do in the back of the ambulance during transport, it’s fine to intubate—however, it’s better to focus on proven interventions such as CPR.
• Ultrasound for abdominal pain. Gamberini et al. in the journal Injury looked at the efficacy of the FAST ultrasound exam, which screens for life-threatening abdominal injuries in specific body areas. The study determined that ultrasound is a safe, rapid, non-invasive and highly specific tool that helps trauma patient assessment in the prehospital phase. When done well, ultrasound is an effective tool in the hands of EMS providers, said Glick. “I’ve been in favor of prehospital ultrasound for many years.”