EMS World

DEC 2018

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EMSWORLD.com | DECEMBER 2018 59 primar y outcome was sur vival at 30 days. There wa s improved sur vival with epi- nephrine versus placebo (3.2% vs. 2.4%, OR 1.39, 1.06–1.82). Predefined secondar y outcomes included ROSC (36.3% with epi vs. 11.7% with placebo) and, most impor- tant, neurologically intact sur vival at 30 days (2.2% with epi vs. 1.9% with placebo, OR 1.18, 0.86–1.61, not a significant differ- ence). Most telling, they looked at those who were alive at 30 days and determined the propor tion with a devastating neu- rologic disabilit y. This group was much higher if given epinephrine (31.0%) than if given placebo (17.8%). This means that more patients sur vived with epinephrine but did so with worse neurologic function. There are several theoretical reasons why epinephrine should both be helpful and harmful. It stimulates alpha receptors, leading to increased diastolic aortic con- striction, which improves coronar y arter y perfusion. Unfortunately it also stimulates beta receptors, leading to increased myo- cardial irritabilit y and demand that can wor s en is chemia, a s well a s prom ote inflammator y changes that may be asso- ciated with worse neurologic outcomes. My bottom line on this important paper is that it conclusively tells us giving 1 mg of epinephrine ever y 3–5 minutes improves ROSC and sur vival but at the cost of hor- rible neurologic outcom e s , s om ething most people would consider to be a con- traindication to its use. In other words, we now know what doesn't work. We don't, however, know what does work. It is pos- sible epinephrine may still play a positive role for some patients, at some inter val, at some dose. While this may frustrate those who want the answer, it is tremendously exciting because, in true scientific fashion, it gets us one step closer to the truth. Plasma in Severe Trauma The Prehospital Air Medical Plasma trial (PAMPer) is another multicenter prospective randomized pragmatic trial. 4 It randomized adult patients with severe trauma and evi- dence of massive bleeding to get either stan- dard therapy or two units of thawed group AB plasma. The inclusion criteria were injured patients with either profound hypotension (SBP less than 70) or hypotension (SBP www.junkinsafety.com 3121 Millers Lane • Louisville, KY 40216 Tel: 502-775-8303 • Fax: 502-772-0548 Toll Free: 888-458-6546 S A F E T Y A P P L I A N C E C O M P A N Y Stretchers Stretcher Kits & Accessories Evacuation Chairs Backboards First Aid Fire Blankets The name in Safety, Rescue and Survival. Giving 1 mg of epinephrine every 3–5 minutes improves ROSC and survival but at the cost of horrible neurologic outcomes.

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