Beyond Epinephrine: The Future of CPR with Ultrasound and Esmolol

This is the EMS Research Vlog and Podcast where we talk about the research related issues that matter to those who work or study in the area of emergency medical services.

Your host is Bram Duffy who is a paramedic and communications professor.

Welcome to the EMS Research Vlogging Podcast from the studio here in Houston, Texas. I want to start out by drawing your attention to our website where you can check out anything that's show related. When you go to professorbram.com that's professorbram.com at the website you can find the latest show, see my talks in the media, order the latest book, and also look at how to participate in research. This is all stuff that can help you grow in the world of EMS research. Like right now I have a research study open for first responders, so if you don't mind being interviewed by me then go to my website@professorbram.com and click on the Current Research tab to apply.

Drs. Zachary Bovin and Trent Shea are both emergency physicians from Connecticut joining us today from a conference together. I'm happy to have you both on the show today and tell us a little bit about what's going on where you're at over there.

Hi. So my name is Zach Boivin. I am a emergency medicine physician. I am ultrasound fellowship trained but I have an interest in cardiac arrest from some residency research projects that I did.

And my name is Trent Shea. I am also an emergency medicine physician. I'm also ultra fellowship trained. We are teaching together at a conference in Newport, Rhode island and we are in Zach's hotel room. Eager to be here today.

Yeah, it was really fun to connect with you guys and I just think it's awesome that we could all do this together. I found these guys because I read a research article that was recently published by them in the Western Journal of Emergency Medicine. It was like November 2023 article. The title is Epinephrine and Cardiac Arrest Identifying a Potential Limit for Resuscitation. Your study describes how epinephrine is a common drug used in advanced cardiac life support.

Even at acls. It's unclear if it actually helps patients recover with good brain function. Your study aimed to find out if there's any limit how much epinephrine should be used during the resuscitation and to see how it's used in different groups of patients. I saw that you look back at cases from a Single Hospital from 2016 to 2021, 13, 30 patients that you looked at and 184 were discharged with good brain function. That was 13.8%. And most patients with good outcomes received little to no epi. 89 patients with no doses, 75 to only had, like, one to three doses. Really, the more epinephrine doses given, the less likely a patient was to have good brain function. And the findings really seem to put a star around the number seven. Right. Because when we get to that many doses, were going to be concerned about these downward trends. And I want to say, y', all, I appreciate your work on this topic, because as a paramedic, I've lived in the days of overuse of EPI, and like back in 1998, when we were still using high doses of of EPI, it's like, sometimes that went great for the paramedic on the scene, but then you're not so good to the physician who had to take over responsibility. You know, when we got to the ER and it was wild because EMS would.

Always be so confident about getting a CPR safe. And the reality is that not that many of those folks were living out of the hospital. And so that's my experience. But I wanted to ask, what initially motivated you to explore this use of EPI in this kind of way, and how did all this evolve for you all?

Yeah, so I could take that question. So, basically, we saw a lot of epinephrine given by EMS in the field, and then when they came into the emergency department, we just kept giving doses of epinephrine with no, you know, not thinking of the total number. We just kept following acls. And so it actually started as part of a larger research project with point of care ultrasound, which is what we're both specialized in in traumatic cardiac arrests. And then we expanded to medical cardiac arrest, because there's just many more cases of that. And so, you know, the paramedic 2 trial had been out and changed a lot of people's minds about epinephrine because it showed epinephrine got an increase in rosc, meaning return of spontaneous circulation, where, you know, in a cardiac arrest, their heart's stopping, it's not moving there, for all intents and purposes, dead. And so if you get rosc, they are once again, you know, their heart's beating, they have a blood pressure, they have a pulse, but, you know, their brain may not be neurologically intact down the line. So, you know, we saw a patient with more than 20 epinephrine doses in the emergency department, and we figured, you know what, we have to study this. And specifically looking at how many doses are people getting of epinephrine and that had previously not been really researched at a strong level in the literature.

Yeah, we had a patient with 30 epis given, and I remember Zach and I talking about that case, and we're like, my word, 30 epis is like almost two hours worth of resuscitation. Like, what meaningful neurologic activity are we hoping for in this patient, which then led us down this further rabbit hole and led to this publication?

Well, we need some kind of end, obviously, because, you know, we've recognized that this is a problem in some levels. On other levels, though, I'm thinking about how.

We used to give high doses from the get go, so that I might be given 3 milligrams at once, you know, or something like, you know, or something like that. And so times have changed, and I think that, honestly, I don't care what changes. I'm ready to make a difference in saving people. And I had this sort of strange question, but it's like we're all familiar with giving EPI every three to five minutes during our code. And so.

By the fact that you're Giving that every three to five minutes, these seven doses are going to only take 35 minutes altogether of CPR. Right. So I guess my question is, now, by that time, by the time we're 35 minutes into it, are we really looking at the effects of the EPI because we're, you know, have just. We just happen to be into the code that long, or is it the fact that we've given that actual dose? Because I'm thinking, you know, the only reason that we're thinking about EPI in this. In this way, really, is because this is the standard. That's. That we have to study, because this is the way all codes are run. But is there any factor to figure out if. Where time counts in all this?

Yeah.

So I can. I can take that. It's. God, you, Bram, you hit the nail right on the head. When Zach and I were first putting together this research project, the immutable confounder that we had for epidosis was time. Because as the resuscitation continues on, you give more epinephrine, more time passes. There's literature out there to support that. The longer your resuscitation, the less likely you are to get Ross, the less likely you're going to have good neurologic activity. So it's difficult because time is really a difficult confounder for us to exclude. And I would say it's something that we couldn't exclude in this study, but I think the main reason we chose to pursue this research was after a certain epinephrine dose time frame, I think you have to start considering that your resuscitative efforts might be futile. And it's hard to give a time frame of stuff because there's just such variability. But we thought that the amount of epinephrine that was given was more objective finding of saying, hey, this is something that we know we give every three to five minutes. It has been studied before. Not sure if there are good effects. Are we just wasting all this epinephrine?

So, yeah, in addition, we liked our secondary outcomes, too, because we wanted to see, you know, our patients who are younger getting more epinephrine than patients who are older. And we really found in our study that they got the same amount of epinephrine, whether it was one to three doses or seven plus at the same rate. So that's even suggesting that, you know, that clinicians who are performing these resuscitations are not really necessarily taking into account the amount of epinephrine that they're giving and that length of time in a code. You know, I personally will do more epinephrine, more resources, more utilization of all these resources if the patient's very young, as opposed to someone who comes in with a lot of comorbidities and who you think that even if you got them back at this point, they wouldn't have a great neurologic outcome. So I thought that that was a really interesting secondary outcome that came out of this study.

Yeah. And also, Zach had a great point when we were putting together the paper, that when we were looking at the group that had seven plus epis, the average time of resuscitation is about 50 minutes. And if you. If you factor out the math, 7 epis times 4 minutes is about 28 minutes. So in that patient population, epi was not given at the prescribed ACLS time. So perhaps there is a separate factor for epinephrine and time that we have identified here. But time is a tough confounder for us. Yes.

Yeah. So this is just a sort of a wild question that came into my mind while we were talking about this moment. I'm thinking about, gosh, is it possible now that we could have an attorney who would be interrogating an ER physician in the future and saying. Saying, you know, I don't think that you worked the code on my. On my client to the fullest level. You didn't even give seven epis through the code. You cut it off at Three. So, you know, so I'm just, you know, thinking about what.

Off slanted interpretations that folks who don't study the physiology as well might get out of this. What do you all say about that?

Yeah, so that's a really good point. Ultimately, you know, even we said in the paper, even when you hit that 7 epinephrine dosing, you can still continue the resuscitation, too. And so some people, for me, and you know, because of this research, I stop around 7 epinephrine. That doesn't mean that I call the code at that time. And so someone else, based on their experience, may have a 3 epinephrine dose stoppage point, and then they continue the resuscitative efforts in our opinions. And we're ultrasound trained, so we're biased, but I like to use the ultrasound in combination with the length of time and the number of epinephrines, because if I can look with the ultrasound and the patient's heart's not squeezing at all, that there's asystole, meaning that nothing's moving in cardiac inactivity, then that really has shown in the literature also to be associated with not great outcomes. And so I think you're seeing that in the emergency department being used a lot. And I think that that is becoming pretty important with termination and resuscitation as opposed to, hey, I did three epinephrine doses and I continued CPR and just didn't give additional epinephrine doses.

Yeah, I second, Zach. We're both all sound fellowship trained. I definitely use presence of cardiac activity as a risk stratifier in my cardiac arrest. But, and this is true for all cardiac arrest research and literature, you have to remember that cardiac arrest is a pretty heterogeneous population, and they get tons of different interventions that happen with many people in their resuscitation. And there's so many risk factors that play a positive or a negative role. You have bystander cpr, you have initial downtime. And so I think that the seven epis is a nice cutoff for when you should start to think in your head, like, hey, is. Is. Is this the time that I have to think about terminating resuscitative efforts? What benefit am I having? But I think that just like our ACLS guidelines, our research is suggestive but not necessarily definitive. If you have a patient that has unknown downtime, no bystander CPR presenting an asystole, I'm not then has no signs of life, fixed dilated pupils, I'm not sure I would even go to seven epies in that patient. And I think clinically we'd all be right to do. To do. Do less.

One thing, too was that we also use the combined EMS +ED. So if someone had given seven epinephrines in the field and then they come in, would I be in the wrong to give zero additional doses? Or, you know, what usually happened in the emergency department is that we give maybe one more dose to say, hey, we got an el. We got an iv. We're going to give one more dose, we're going to give it one more go. And so I think that it's, you know, as. As Dr. Shea said, it's a very heterogeneous population. And, you know, things that are important in cardiac arrest aren't necessarily number of epinephrine, but we think it's a good marker for the thought of when you should start to think about, you know, has this gone on too long? And I think that we showed in our research that it goes a lot beyond 7 epinephrine for a lot of patients.

Well, that's still a magic number that's going to stick in my head. And I think that, you know, I'll look back on this podcast and this opportunity I had to meet you all and I'll think, you know, is that it might be the international standard, you know, for a lot of. For a lot of reasons. And, you know, while we're on the topic of CPR together and talking about epinephrine, can I ask you about Esmolol? Because I had mentioned that even as. Even in the field, there are some providers that are starting to use that instead of epinephrine. And so I just wanted to. To get y' all's take on that.

Yeah, no, so we. Esmolol is definitely a medication we consider using in cardiac arrest. And I. In the case of refractory V fib or V tach, if there's been three episodes that do not terminate with defibrillation three times, I'd consider that refractory. I think there is an indication for esmol or sympathetic blockade. Our AHA and ACC guidelines agree with that. They suggest sympathetic blockade as either a class 2A or 2B. I cannot remember off the top of my head, but it is in the guidelines for refractory V fib and V tach. So esmolol is definitely something that I would consider using in those cases. The. The bigger question is, should we stop giving epinephrine a pro arrhythmogenic drug because this patient is in refractory VFIB and V tach. And we know that it's the electrical conducting system rather than the structural system. The lack, the loss of contractility, that's the problem. And I think that's a little bit more of a difficult question to ask, especially since we still have the ACLS guidelines that state that you got to give EPI three to five minutes even in those BFB TAC cases.

So how does it affect your practice then? I mean, because on one end we could have someone that says that, you know, there's a different standard that you're approaching this by or, you know, ACLS is pretty hard to get around when, you know, as a standard, because it's just been so ironclad as far as being our standard for a long time.

Yeah, I mean, I think that ACLS is the standard and I think that I would be hard pressed to recommend anyone outside the hospital go outside of, of acls because I think that there's a huge. Unless there's a policy that says, you know, hey, in our, in our district, in our area, EMS is not going to give epinephrine that has to be written in to protect the EMS providers so that if they go off script, if something bad was to happen, then you say, look, we have a clinical policy that we created through association typically with an emergency department or another EMS agency.

And that's why, that's the reason I'm bringing it up. Because just yesterday, Peter, Dr. PD and Tevi was talking about how he posted online that for their cardiac arrest protocol for V fib at Palm Beach County Fire Rescue, they do not use epinephrine.

Period.

They don't. And when I think about in hospital use, honestly, we have to call the, we're going to, we're going to have to get it down from pharmacy. So by the time you get it down from pharmacy, maybe we should have just gone ahead and done the epi, you know, But I don't know. So there's lots of different things in the moment that happen. Right. That make us make different choices.

No, I got to agree with Dr. Boyvin here. I think Bram, you know, in the pre hospital world, care is much more protocolized than in the in full emergency department setting. At this point, in our medical legal environment, I cannot imagine many protocols going against established ACLS guidelines. And to his credit, if you have a medical director that's willing to back you up on that, that may clinically be the right thing to do. But I think medical Legally, we're still probably giving that EPI every three to five minutes and then giving the Esmolol. When you're thinking about refractory BFIB V tach and just continuing to do it, I just don't see it in this medical legal environment. Perhaps there's more research come up, a future project on esmolol and whether or not that helps with EPI and whether EPI is prorhythmogenic. You know, maybe that will change, but as of now, I don't think we got it. We're going to be issuing EPI from our V for the VTAC algorithm.

Yeah, I'm mentioning it because Dr. Entebbe is the one to post about it. And really what it comes down to is that the paramedic is going to follow the orders given by the physician medical director. And so there are lots of places around the country that don' have the 100% ACLs, you know, matchups. But this was, you know, certainly new and different. But I want to ask, what is the next big thing to study in cpr, y'?

All?

Because I keep imagining that we're going to have ECMO in the field someday. Right now, I work in an area where we have whole blood on the ambulance, we have Lucas machines. And, you know, I read an article, many of you probably read about how there are drones that are getting set up to bring in AEDs that are, you know, activated by 91 1. So give. Give me some hopes for shooting, shooting far here. I mean, what's next in our lifetimes? What do you think, y'?

All?

So, I mean, we're both point of care, ultrasound trained. So, you know, really, ultimately there's been, as we talked about earlier, there's been a large use of ED, point of care ultrasound and cardiac arrest. We can. We could talk for a whole hour on how we use ultrasound to figure out what's causing the cardiac arrest or how to guide our management. But I think that the next big step is getting ultrasounds, especially the handheld ultrasounds that are becoming very good at visualizing structures, getting them in the hands of ems, getting EMS trained, and ultimately how that can affect the management. Cardiac arrest in the fields. Because ultimately, we know just as much as time is brain and stroke, time is brain and cardiac arrest. And, you know, if you can get a. If you can assess and figure out what is causing the cardiac arrest and it's a reversible cause, you can address that sooner, and that patient has a better chance of a neurologically intact outcome. You know, there's only in our study, I think it was 85% of the patients were out of hospital cardiac arrests. That leaves what, 15% in hospital when we can immediately put the ultrasound on. So that's a huge opportunity for EMS to get more involved in ultrasound and also to potentially bring better care out of the hospital to the patients.

I know that things have developed in my lifetime and when I think about most medicine in this kind of crazy development, I think about sci fi, right, and Star Trek and these kinds of environments. But really what you all are helping us do is on the edge. And so that's why I wanted to you know how to see how fun Yalls predictions might be.

Yeah, no, I, I gotta say Dr. Boyd and I were talking about this beforehand. We have a tremendous amount for our pre hospital colleagues. We have a tremendous amount of respect for our pre hospital colleagues. You guys do intense, real resource limited medicine and you do good, good clinical work. And so I think in terms of the future there's so much stuff that's out there to be excited about. And again, I agree with Dr. Boyd about point of care altsound. I think the biggest thing that ult sound would bring in is not just the patients who you're going to do more for, but knowing when that this patient has pretty much no meaningful prognosis and limiting your resuscitation because that way you guys can go and attend another patient. But I gotta say, the stuff that's out there that's coming for the pre hospital world, it is, it's honestly, we both have a tremendous amount of respect for what you guys do and it's frankly an honor.

I think that our specialties are in point of care ult sound. And I can tell you in terms of research, there is good research out there that says pre hospital providers can do point of care ult sound just as well as we in hospital providers can. I think the problem is less research. I think the problem is more cost and operations because it takes a lot to run a point of care alt sound program. It takes a lot to be a medical director for a paramedic company or any EMS company. So I think the research is out there for a lot of these pre hospital interventions. But it's more a question of cost and operations. So it's always a question for all of us is are the interventions we're doing cost effective? It's unfortunately the way of the world and I, if we had all this, if we had infinite money, I think we should do all the things that you Mentioned Bram, but unfortunately, the training and the cost, it's definitely a hindrance.

Ultimately, you know, we think that this study was great, but it's not a randomized control trial. You know, Trent said, basically, you know, if we had all the money in the world, you know, I would love to be able to do a randomized control trial where you basically just put 0 epinephrine, you know, up against 3 epinephrine, up against 6, up against just all epinephrine. And. But that would require a lot of coordination between ems, the hospital, a lot of money, and, you know, it's hard to make practice changing recommendations on a single center retrospective study. But we're really hoping that this study pushes forward people to think, you know, hey, is this too much time for resuscitation? Is. Is this 19th epinephrine really needed in this case? And so, you know, we're excited to see where the future goes. And, you know, I couldn't help but mention the one single patient who survived greater than. With greater than seven epinephrine doses, and she survived 13 epinephrine doses and 15 shocks. And, you know, ultimately, it's. We just have to think, you know, is this the epinephrine that caused her to survive, or was it the shock?

Yes, I feel the same way. I'm like, oh, is this the. Is this the one? And it's like. And I. I am not gonna be any. I'm not gonna be spiritual based. I'm.

You know what I mean?

I'm not gonna. In those moments, I am gonna be the complete scientist that I can be to do the right thing. But there's something in the back of your mind that always says, you know, do we go? Do we keep going? And that's one of the reasons I appreciate the ACLS change that allows for everyone in the room to give an opinion, and that, I think, helps us catch things that we wouldn't normally have missed before sometimes. That's a lot of great stuff. Thank you, guys for being here. Like many of you, I'm also an EMS instructor, so I know what it's like to have topics that are important to cover but are not actually in your curriculum. So when it comes to EMS research, I want you to know that I've been joining EMS classes lately in a virtual kind of way.

It's fun for me to meet your.

Students and talk about EMS research or even talk about how things are done differently where I am versus where you are. So if you're an EMS instructor like me and you want to give your students a flair of what EMS research is all about, just fill out the inquiry form on my website@professorbram.com this is Professor Bram B R.com and I'll be in touch.

I want to also invite you to check out my latest book. I co authored it with four Arrows who has two doctorates and is an expert on indigenous scholarship and hypnosis.

We've got to look at each individual patient as a human being who is in need. And we've got to know that when we're in need, we do look to others. No matter how self reliant we are. If we are in a situation that we've never encountered before that self reliance begins to seek. Is there anyone that can help me with this situation? I mean you've used a pretty drastic example with the arm cut off. But you know, I don't care how much skill you have, there's very few people who would be able to not say, oh my gosh, I need help. And then all of a sudden someone shows up with a badge. Yeah. And you think, well maybe this is someone that can help. Well, you said that and I said that during the first hour of trauma, people are essentially in a state of what we now know is hypnosis state.

I want to invite you to check it out because we introduce a method for communicating with patients on the scene of the emergency that takes advantage of some of the properties found in hypnosis. The book works to change the way we approach and interact with any emergency patient who's in acute distress. And it can help you be a better practitioner. The book is called Hypnotic Communication in Emergency Medical Settings for Life Saving and Therapeutic Outcomes. Follow a link there below to find it or you know, you could get it almost anywhere books are sold and if you contact me, I would be happy, happy to mail you an autograph sticker designed to be put into the jacket cover.

Hi, I'm Will Chablough from the International Prehospital Medicine Institute. You might know about us because of the literature reviews that we post every month free to review on our website@iphmi.com and also publish through Gems online magazine every month. We've been doing them for five years. So now we've accumulated over 240 literature reviews over the past five years and we've gotten feedback from our audience that said they'd like to have these things as desk references. So they had a rapid reference. Well, we've done it and there are now five volumes of these books, one for each year that we've been publishing them. This is the latest version, Volume five, and as I said, in each of these there's at least 48 literature reviews. They're all cataloged in the beginning of the book so you can see what the topic area is, what pages those reviews are on, and how you can find them quickly. Again, these are a great reference. Whether you're putting a lecture together, working on a paper, studying whatever it is. This gives you the depth field of the science that dictates what we do in the field, or what we should be doing in the field, or why we've changed the way we do things in the field. In any event, as with all of our publications, we've priced these because we want you to be able to have this book. It's only 4.99 in the written in the copy, the hard copy here, and all five of them are available at that price. But you can also get them as ebooks and they're available as ebooks from Amazon, from Apple, from Barnes and Noble, wherever you get your ebooks for the price of 299. So again, we don't do this with an aim towards getting wealthy. We do these because we want you guys to be able to have these materials, relevant information, affordable information, and an access so you can get to it. So you want the hard copies go on Amazon $4.99, go to your ebook store and you get it for $2.99. If you're in the business, this is the kind of material you want to have around to settle those firehouse arguments or to help you put your materials together. Thanks again. See y' all soon.

I'm doing a research project related to first responders who live in the United States and I could use if you don't mind being interviewed over a video call, go to my website and fill out the form. It's@professorbram.com professor bram.com I just want to thank you for listening and I look forward to sharing more insights with you in the next episode. If you enjoy EMS Research, please tell your friends and like share and subscribe to help others get the message.

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