CPR Termination Questions p. 43 STABLE V Tach p. 48 EMS10 Innovators p. 52 AORTIC Catastrophes p.

56

MARCH 2016

SPECIAL SECTION

RESUSCITATION
RECOMMENDATIONS
Key changes for EMS
in the 2015 AHA Guidelines
Update for CPR and ECC, p. 25

Always En Route At

1603jems_C1 1 2/15/16 11:27 AM

 Valuable Technology. Valuable Savings.

Curaplexs brand new line of needle-free administration and

extension sets utilize innovative, new MicroClave neutral
displacement technology. This unique needleless connector is
designed to lessen blood reflux within the catheter lumen upon
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1603jems_C2 2 2/15/16 11:27 AM

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1603jems_1 1 2/15/16 11:25 AM

 Contents
MARCH 2016 VOL. 41 NO. 3

JEMS SPECIAL FOCUS: The 2015 American Heart Association

Guidelines Update for CPR & Emergency Cardiovascular Care

26 EXECUTIVE SUMMARY
By Robert W. Neumar MD, PhD
27 WHATS NEW & WHY
Important changes in the 2015 AHA Guidelines Update
By Erin E. Brennan, MD; Steven C. Brooks, MD, MHSc, FRCPC; Mark S. Link, MD; Robert E.
OConnor, MD, MPH, FACEP; Eric Lavonas, MD; Farida Jeejeebhoy, MD; Diane L. Atkins,
MD; Alan de Caen, MD; Marya L. Strand, MD, MS, FAAP & Henry C. Lee, MD, FAAP
36 OPIOID CRISIS
Prehospital nalaxone administration for opiod-related emergencies
By Ian R. Drennan, ACP BScHK, PhD(c) & Aaron M. Orkin, MD, MSc, MPH
40 KEEPING COOL?
Targeted temperature management in prehospital cardiac arrest patients
COVER PHOTO COURTNEY MCCAIN

By Stefanie L. Wise, MD & Brian J. ONeil, MD, FACEP, FAHA

43 BEYOND THE LIMIT
Why we shouldnt terminate resuscitations after 20 minutes
By Clifton W. Callaway, MD, PhD
46 REVISING PROTOCOLS
A back-to-basics approach to comply with the AHA Guidelines Update
By Michael R. Sayre, MD

DEPARTMENTS & COLUMNS FEATURES

48 ANTIDYSRHYTHMIC AGENTS
8 EMS IN ACTION Scene of the Month
10 FROM THE EDITOR Tech Predictions Managing prehospital stable v tach
By A.J. Heightman, MPA, EMT-P By Eric Cortez, MD; Carla Cash, MD; David P. Keseg, MD, FACEP &
12 PRIORITY TRAFFIC News You Can Use Raymond L. Fowler, MD, FACEP, DABEMS

16 MANAGEMENT FOCUS Leading Others

By Michael Touchstone, BS, EMT-P

17 BACK TO BASICS Thats Hot

52 EMS10: INNOVATORS IN EMS 2015
JEMS selects top 10 innovators of 2015
By Hutton Marshall, BA

56 TICKING TIME BOMB

By Dennis Edgerly, BS, EMT-P

18 CASE OF THE MONTH Full Attention

By Chris Kaiser, NREMT-P How aortic aneurysms become aortic catastrophes
By Robert P. Girardeau, BS, NRP, FP-C
20 RESEARCH REVIEW Effective Sims
By David Page, MS, NRP & Bill Robertson MS, NRP

22 STREET SCIENCE Quality of View

By Keith Wesley, MD, FACEP & Karen Wesley, NREMT-P 48 56
64 HANDS ON Product Reviews from Street Crews
By Fran Hildwine, BS, NREMT-P

66 FIELD PHYSICIANS Down Under

By Mark E.A. Escott, MD, MPH, FACEP

67 AD INDEX & CLASSIFIEDS

68 LAST WORD The Ups & Downs of EMS

2 JEMS | MARCH 2016 www.jeMs.CoM

1603jems_2 2 2/15/16 11:25 AM

 Does he need a trauma center
or the local hospital?

Twenty-year-old male in a motor vehicle accident.

Airbag has deployed. Car has signicant front-end
damage. Is he bleeding internally? Hemorrhage is
the leading cause of death after injury.1

The new trauma parameters on the ZOLL X Series help you accurately and
quickly assess your patients so you can feel condent in your treatment decisions.

Insight for informed decisions.

www.zoll.com/trauma
1
Acosta JA, et al. Journal of the American College of Surgeons. 1998;186(5):528-533. MCN EP 1508 0110
2015 ZOLL Medical Corporation, Chelmsford, MA, USA. X Series and ZOLL are trademarks or registered trademarks of ZOLL Medical Corporation in
the United States and/or other countries.
For more information, visit JEMS.com/rs and enter 3.

1603jems_3 3 2/15/16 11:25 AM



EDITOR-IN-CHIEF A.J. Heightman, MPA, EMT-P aheightman@pennwell.com

MANAGING EDITOR Ryan Kelley rkelley@pennwell.com
EDITOR Allie Daugherty allied@pennwell.com
ONLINE NEWS/BLOG MANAGER Bill Carey billc@pennwell.com
WEB EDITOR Kristina Ackermann kristinaa@pennwell.com
EDITORIAL INTERN Casey Hands caseyh@pennwell.com

MEDICAL EDITOR Edward T. Dickinson, MD, NREMT-P, FACEP

TECHNICAL EDITOR Carolyn Gates, EMT-P, FP-C
MOBILE INTEGRATED HEALTH EDITOR Matt Zavadsky, MS-HSA, EMT

ART DIRECTOR Kermit Mulkins kermitm@pennwell.com

PRODUCTION COORDINATOR Katie Noftsger katien@pennwell.com
CONTRIBUTING ILLUSTRATORS Steve Berry, NREMT-P; Paul Combs, NREMT-B
CONTRIBUTING PHOTOGRAPHERS Vu Banh, Glen Ellman, Craig Jackson, Kevin Link, Courtney
McCain, Tom Page, Rick Roach, Scott Oglesbee, Steve Silverman, Matthew Strauss, Chris Swabb
CONTRIBUTING WRITER Elisse Miller

DIGITAL MEDIA PRODUCTION MANAGER Debra Cotton debrac@pennwell.com

DIGITAL MEDIA CAMPAIGN MANAGER Adrian Zavala adrianz@pennwell.com

PUBLICATION OFFICE
800-266-5367 Fax 858-638-2601

ADVERTISING DEPARTMENT
800-266-5367 Fax 858-638-2601

SENIOR ACCOUNT MANAGER Cindi Richardson 661-297-4027 c.richardson@jems.com

JEMS SALES CONSULTANT Melissa Roberts 918-831-9727 melissar@pennwell.com
REPRINTS, ePRINTS & LICENSING Rae Lynn Cooper 918-831-9143 raec@pennwell.com
SALES/ADMIN COORDINATOR Liz Coyle lizc@pennwell.com

SHOULD YOU NEED ASSISTANCE WITH CREATING YOUR AD, PLEASE CONTACT:
MARKETING SOLUTIONS Paul Andrews 240-595-2352 pandrews@pennwell.com

SUBSCRIPTION DEPARTMENT
847-763-9540

AUDIENCE DEVELOPMENT MANAGER Frankie Keirsey frankiek@pennwell.com

MARKETING MANAGER Eric West ericw@pennwell.com

CHAIRMAN Robert F. Biolchini

VICE CHAIRMAN Frank T. Lauinger
PRESIDENT AND CHIEF EXECUTIVE OFFICER Mark C. Wilmoth
EXECUTIVE VICE PRESIDENT, CORPORATE DEVELOPMENT AND STRATEGY Jayne A. Gilsinger
SENIOR VICE PRESIDENT, FINANCE AND CHIEF FINANCIAL OFFICER Brian Conway
SENIOR VICE PRESIDENT/GROUP PUBLISHER MaryBeth DeWitt marybethd@pennwell.com

www.EMSToday.com
SENIOR VICE PRESIDENT/GROUP PUBLISHER MaryBeth DeWitt
EDUCATION DIRECTOR A.J. Heightman, MPA, EMT-P
MARKETING MANAGER Amanda Brumby amandab@pennwell.com
CONFERENCE MANAGER Debbi Boyne dboyne@pennwell.com
EVENT OPERATIONS MANAGER Amanda Wilson amandaw@pennwell.com
EVENT OPERATIONS MANAGER Jennifer Lindsey jenniferl@pennwell.com
EXHIBIT SALES MANAGER Sue Ellen Rhine 918-831-9786 sueellenr@pennwell.com
EXHIBIT SALES MANAGER Jared Auld 918-831-9440 jareda@pennwell.com

FOUNDING EDITOR Keith Griffiths

FOUNDING PUBLISHER James O. Page (19362004)

For more information, visit JEMS.com/rs and enter 4.

1603jems_4 4 2/15/16 11:25 AM

 NOT ALL COOLING PACKS ARE CREATED EQUAL
Introducing the Cryothermic Cooling Packa safe alternative to chilled saline!

How does it work?

Break the packs inner pouch to activate its patented formula.
Insert it into the Cryothermic Collar to quickly cool the neck and
blood via the carotid triangle. Every 3.5 minutes the entire blood
supply passes through the neck via the carotid arteries and
internal jugular veins. Our studies have shown patient
temperatures cooled by 1 to 3 degrees Celsius in less than 30
minutes, performing equally to chilled saline without side effects!
No skin irritation

C-Collar option shown,

-5.0C in seconds
20-30 minutes below 0C
wrap version also
available

Cryothermic Cooling Pack is 15 Colder

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Simple
Cryothermic Cooling Pack
Fast Cooling
Proven 1 5 10 15 20
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Cost-Effective

About the Cryothermic Cooling Pack

The Cryothermic Cooling Pack has been proven to cool patients quickly. For EMS systems and
emergency departments, the Cryothermic Cooling Pack is a cost-effective substitute for chilled
saline that can consistently cool the patient and provide a bridge to Targeted Temperature
Management systems in the hospital. TTM studies have demonstrated early cooling may improve
neurological status for cardiac arrest, strokes, heart attacks and possibly other conditions.

*Contact info@cryothermicsystems.com to get a complimentary product sample with a completed

review of the product. For more information, visit: www.cryothermicsystems.com
For more information, visit JEMS.com/rs and enter 5.

1603jems_5 5 2/15/16 11:25 AM


WILLIAM K. ATKINSON II, PHD, MPH, MPA,
EMT-P
Health Care Advisor, Raleigh, N.C.
JAMES J. AUGUSTINE, MD, FACEP
Medical Director, Washington Township (Ohio) Fire Dept.
Associate Medical Director, North Naples (Fla.) Fire Dept.
Director of Clinical Operations, EMP Management
Clinical Professor, Dept. of Emergency Medicine, Wright State Univ.
PAUL BANERJEE, DO
Medical Director, Polk County (Fla.) Fire Rescue
Medical Director, Polk & Lake County SWAT Teams
Medical Director, Aviation One Medical Transport Services
BRYAN E. BLEDSOE, DO, FACEP, FAAEM
Professor of Emergency Medicine, Director, EMS Fellowship
Univ. of Nevada School of Medicine
Medical Director, MedicWest Ambulance
CRISS BRAINARD, EMT-P
Deputy Chief of Operations (Ret.), San Diego Fire-Rescue
CHAD BROCATO, JD, DHSC, CFO
Assistant Chief, Pompano Beach (Fla.) Fire Rescue
Adjunct Professor, Kaplan Univ.
CAROL A. CUNNINGHAM, MD, FACEP, FAAEM
State Medical Director, Ohio Dept. of Public Safety, Division of EMS
JAY FITCH, PHD
President & Founding Partner, Fitch & Associates
RAY FOWLER, MD, FACEP
Associate Professor, Univ. of Texas Southwestern School of Medicine
Chief of EMS, Univ. of Texas Southwestern Medical Center
Chief of Medical Operations,
Dallas Metropolitan Area BioTel (EMS) System
ADAM D. FOX, DPM, DO, FACS
Section Chief, Division of Trauma, Rutgers N.J. Medical School
Associate Trauma Medical Director, N.J. Trauma Center Univ. Hospital
RYAN GERECHT, MD, CMTE
EMS and Emergency Medicine Physician, Tacoma, Wash.
JEFFREY M. GOODLOE, MD, FACEP, NREMT-P
Professor & EMS Section Chief, Emergency Medicine,
Univ. of Oklahoma School of Community Medicine
Medical Director, EMS System for Metropolitan Oklahoma City & Tulsa
HUGO GOODSON
Lecturer, Dept. of Paramedicine Auckland (N.Z.) Univ. of Technology
KEITH GRIFFITHS
President, RedFlash Group
ANDREW J. HARRELL, MD
Assistant Professor, Dept. of Emergency Medicine, Univ. of New Mexico
Associate Director, UNM EMS Medical Direction Consortium
Medical Director, Albuquerque Fire Dept.
Medical Director, New Mexico Urban Search & Rescue Task Force 1
Medical Director, Grand Canyon National Park
Tactical EMS Physician, Bernalillo County (N.M.) Sheriffs Dept. SWAT
CHRIS KAISER, NREMT-P
Paramedic, Central Wisconsin
6 JEMS | MARCH 2016
1603jems_6 6
EDITORIAL BOARD
DAVE KESEG, MD, FACEP
Medical Director, Columbus Fire Dept.
Clinical Instructor, Ohio State Univ.
W. ANN MAGGIORE, JD, NREMT-P
Associate Attorney, Butt, Thornton & Baehr PC
Clinical Instructor, Univ. of New Mexico, School of Medicine
SHAUGHN MAXWELL, EMT-P
Captain & Medical Services Officer, Snohomish County Fire District 1
(Everett, Wash.)
MIKE MCEVOY, PHD, REMT-P, RN, CCRN
EMS Coordinator, Saratoga County, N.Y.
EMS Editor, Fire Engineering Magazine
Resuscitation Committee Chair, Albany (N.Y.) Medical College
JASON MCMULLAN, MD
Associate Director, Division of EMS, Dept. of Emergency Medicine, Univ.
of Cincinnati
Director, Fellowship in EMS Medicine, Univ. of Cincinnati
Member of Medical Direction Team, Cincinnati, Blue Ash, Forest Park, &
Green Hills (Ohio) Fire Depts.
MARK MEREDITH, MD
Associate Professor of Pediatrics, Pediatric Emergency Medicine, Le
Bonheur Childrens Hospital (Memphis, Tenn.)
FIONNA MOORE, MBE, FRCS, FRCSED, FRCEM,
FIMC RCSED
Chief Executive & Consultant in Prehospital Care, London Ambulance
Service NHS Trust
BRENT MYERS, MD, MPH, FACEP
Chief Medical Officer & Excutive Vice President, Evolution Health
Associate Chief Medical Officer, American Medical Response
JOSEPH P. ORNATO, MD, FACP, FACC, FACEP
Professor & Chairman, Dept. of Emergency Medicine, Virginia
Commonwealth Univ. Medical Center
Operational Medical Director, Richmond Ambulance Authority
JERRY OVERTON, MPA
Chair, International Academies of Emergency Dispatch
PAUL E. PEPE, MD, MPH, MACP, FACEP, FCCM
Professor of Emergency Medicine, Internal Medicine, Pediatrics, Public
Health, Univ. of Texas Southwestern Medical Center
Director, City of Dallas Medical Emergency Services for Public Safety,
Public Health and Homeland Security
DAVID E. PERSSE, MD, FACEP
Physician Director, City of Houston EMS
Public Health Authority, Houston Dept. of Health & Human Services
Associate Professor, Emergency Medicine,
Univ. of Texas Health Science CenterHouston
EDWARD M. RACHT, MD
Chief Medical Officer, American Medical Response
JEFFREY P. SALOMONE, MD, FACS, NREMT-P
Trauma Medical Director, Maricopa Medical Center
Professor of Surgery, Univ. of Arizona College of MedicinePhoenix
JULLETTE M. SAUSSY, MD, FACEP
Medical Director, District of Columbia Fire & EMS Dept.
KATHLEEN S. SCHRANK, MD
Professor of Medicine and Chief,
Division of Emergency Medicine, Univ. of Miami School of Medicine
Medical Director, City of Miami Fire Rescue
Medical Director, Village of Key Biscayne Fire Rescue
GEOFFREY L. SHAPIRO
Director, EMS & Operational Medicine Training, School of Medicine and
Health Sciences EHS Program, George Washington Univ.
JOHN SINCLAIR, EMT-P
International Director, IAFC EMS Section
Fire Chief & Emergency Manager, Kittitas Valley (Wash.) Fire & Rescue
COREY M. SLOVIS, MD, FACP, FACEP, FAAEM
Professor & Chair, Emergency Medicine, Professor of Medicine,
Vanderbilt Univ. Medical Center
Medical Director, Metro Nashville Fire Dept.
Medical Director, Nashville International Airport
E. REED SMITH, MD, FACEP
Co-Chairman, Committee for Tactical Emergency Casualty Care
Operational Medical Director, Arlington County (Va.) Fire Depat.
Emergency Physician, Virginia Hospital Center
Associate Professor of Emergency Medicine, George Washington Univ.
WALT A. STOY, PHD, EMT-P, CCEMTP
Professor & Director, Emergency Medicine, Univ. of Pittsburgh
Director, Office of Education, Center for Emergency Medicine
MICHAEL TOUCHSTONE, BS, EMT-P
Regional Director, Philadelphia Regional Office of EMS
Director, National EMS Management Association
JONATHAN D. WASHKO,
MBA, NREMT-P, AEMD
Assistant Vice President, North Shore-LIJ Center for EMS
Mobile Integrated Healthcare Committee Member, NAEMT
Measurement Design Group Committee Member, EMS Compass
KEITH WESLEY, MD, FACEP
Medical Director, HealthEast Medical Transportation
KATHERINE H. WEST, BSN, MED, CIC
Infection Control Consultant, Infection Control/Emerging Concepts Inc.
KEITH WIDMEIER, BA, NRP, FP-C
EMS Educator, Univ. of Cincinnati College of Medicine
Paramedic, CareFlight Air & Mobile Services
STEPHEN R. WIRTH, ESQ.
Attorney, Page, Wolfberg & Wirth LLC.
Safety Officer, Hampden Township (Pa.) Volunteer Fire Company
DOUGLAS M. WOLFBERG, ESQ.
Attorney, Page, Wolfberg & Wirth LLC
WAYNE M. ZYGOWICZ, MS, EFO, EMT-P
EMS Division Chief, Littleton (Colo.) Fire Rescue
www.jeMs.CoM
2/15/16 11:25 AM
 ISP tells us the likelihood
of severe injury.
Stewart Wang, M.D., Ph.D., Director,
University of Michigan International Center
for Automotive Medicine

OnStar technology
tells a crashs story.
As you respond to the scene, EMD-certied OnStar Emergency Advisors can relay crash data
that includes an Injury Severity Prediction (ISP). By using Automatic Crash Response* data such
as change in velocity, direction of impact, whether there were multiple impacts and more, the
ISP algorithm calculates and reports if there is a high probability of severe injury. This helps you
prepare for the scene and make decisions about the best treatment center for patients. Its our
way of helping you deliver the right care, right away.

Visit onstarISP.com for more information.

*Visit onstar.com for vehicle availability, details and system limitations. OnStar acts as a link
to existing emergency service providers. Not all vehicles may transmit all crash data.
2016 OnStar. All rights reserved.

For more information, visit JEMS.com/rs and enter 6.

1603jems_7 7 2/15/16 11:25 AM

 EMS IN ACTION
SCENE OF THE MONTH

NYC TERROR DRILL

I n an abandoned subway station in lower Manhattan, emer-

gency responders stage a drill simulating a terrorist attack in
New York. Following the Nov. 13 terror attack in Paris and four
days before New Yorks Macys Thanksgiving Day Parade, mem-
bers of the New York City Police Department, New York City Fire
Department (FDNY) and the Department of Homeland Security
participated in the drill to practice active-threat response,
including trauma care and patient evacuation.

8 JEMS | MARCH 2016 www.jeMs.CoM

1603jems_8 8 2/15/16 11:25 AM

 New York Police Department via AP

www.jems.com mARcH 2016 | JEMS 9

1603jems_9 9 2/15/16 11:26 AM

 FROM THE EDITOR
PUTTING ISSUES INTO PERSPECTIVE
TECH PREDICTIONS
Safety, consistency & control are the EMS buzzwords
for 2016
By A.J. Heightman, MPA, EMT-P
M
ost of what we do in our lives
today has an electronic or
mechanical advantage attached
to it. Our smartphones and computers make
us more effective than everso much so that
today, nearly anyone can be trained to save
a life. Citizen responders are becoming an
invaluable early response benefit to patients
(read Citizen Rescuers: Trained & equipped
volunteers alerted by smartphone to quickly
respond to emergencies in Jersey City, N.J.,
by Robert Luckritz, JD, NREMT-P, in the
January issue) and the White Houses Stop
the Bleed initiative seeks to train bystanders
to stop life-threatening bleeding. (Read more
about this initiative in next months issue.)
EMS TECH REVOLUTION
Were also witnessing technological advances
in EMS equipment, our vehicles and our pro-
cesses almost weekly. Its hard to find a man-
ual-lift stretcher anymore, an indication that
system administrators and manufacturers have
gotten the message that crews backs are highly
susceptible to injury, particularly as the vol-
ume of overweight patients climbs nationwide.
Our data systems are being upgraded and
enhanced to be more relational than ever,
communicating with our medical monitors
and computer-aided dispatch systems.
There will continue to be significant
changes in ambulance and response vehicle
design and safety aspects due to the expiration
of the KKK specifications and the introduc-
tion of the new ambulance standards. Regard-
less of what the new standards present to us,
there are a few things that make so much
common sense that we need to explore them.
The use of smaller, adjustable seats in
the patient compartment is proving to be a
heavily adopted trend that will enhance crew
safety and patient accessibility.
And, as companies increasingly adopt
10 JEMS | MARCH 2016
1603jems_10 10
European-style ambulance interior designs,
were seeing more efficient interiors, with
devices, switches, controls, computers and
access to essential equipment without having
to leave our seats or be unbuckled.
Although some ambulance manufactur-
ers are installing cameras on a 360-degree
basis around the vehicle to give drivers the
opportunity to see blind spots, I feel this will
distract the driver, who has to take their eyes
off the road to monitor four small screens in a
mirror or on a console. We should take a cue
from the auto industry and install back-up
and blind spot obstacle detection sensors and
alerts to help avoid front and rear-end colli-
sion and turning accidents.
RESUSCITATION INNOVATIONS
One area where I envision major emphasis
and innovation is in the area of resuscitation.
The 2015 AHA Guidelines Update, while
not yet comfortable with the research on pre-
hospital comparisons of manual vs. mechanical
CPR, make a strong statement that addresses
the everyday EMS environment and dilem-
mas we face in maintaining consistent and
adequate compression depth on our patients.
Part 6: Alternative Techniques and Ancillary
Devices for CPR states: The use of mechanical
[piston and compression band] devices may be
considered in specific settings where the deliv-
ery of high-quality manual compressions may
be challenging or dangerous for the provider
(e.g., limited rescuers available, prolonged CPR,
during hypothermic cardiac arrest, in a moving
ambulance, in the angiography suite, during
preparation for extracorporeal CPR [ECPR]),
provided that rescuers strictly limit interruptions
in CPR during deployment and removal of
the devices.
The 2015 Guidelines Update also note that
active compression-decompression (ACD)
CPR is now recognized as being effective
when coupled with an impedance thresh-
old device (ITD) to enhance venous return
during chest decompression and improve
blood flow to vital organs. Ive seen the posi-
tive effects of the combined ITD, ACD-CPR
and mechanical compression devices in ani-
mal labs and encourage all EMS agencies to
put these innovations on their radar screens.
MECHANICAL VENTILATION
I also believe well see more and more systems
moving to the use of mechanical ventilators
in all paramedic ambulances. The benefit of
these compact, easy-to-use ventilators has been
proven in medical helicopters and in systems
like the Mesa (Ariz.) Fire and Medical Dept.
and EMSA in Tulsa and Oklahoma City, Okla.,
as well as many other forward-thinking systems.
When we take critical patients into an ED
or specialty center, the staff quickly replaces
the bag-valve mask with a finite-controlled
ventilator that consistently and appropriately
delivers the right tidal volume and rate to the
patient. Its a natural fit for EMS, especially
since we have 25 things to do and limited
staff to do them.
We need our highly trained and clinically
astute personnel to use their brains and not
force them to get tied up using their hands
to resuscitate patients. Thats so 70s!
CONCLUSION
Consistency, continuous monitoring, algorith-
mic patient assessment and alerting, as well
as the complete control of our patients vital
parameters of ventilation and circulation are
the keys to successful resuscitation.
Be forward-thinking and take advantage
of the electronic and mechanical innovations
available to us to implement processes that
will enhance safety and clinical effectiveness
in the fast-paced, challenging and highly-
mobile environment we work in. JEMS
www.jeMs.CoM
2/15/16 11:26 AM
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ESSENTIAL TRAINING FOR SPECIAL POPULATIONS

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1603jems_11 11 2/15/16 11:26 AM

 PRIORITY TRAFFIC
NEWS YOU CAN USE
Legendary LOSS
Leadership lessons from an iconic N.J. medic
T
he prehospital streets of New Jersey
are less protected after one of their
greatest entered eternal rest on Aug.
28, 2015.
Paramedic Walter Drivet was iconic for many
reasons. He delivered exceptional care to N.J.
residents for over 35 years in the highest-risk
areaswhere the patients needed him the most.
I met Walter for the first time as a paramedic
student at a suburban medic unit where hed
come to help teach us incident command in the
early 90s in efforts to formalize our state mass
casualty incident response structure.
That day he assigned me as incident com-
mander. I tried to talk him out of it because I
was only a student who was just there to learn.
I had no experience on the street as a medic.
Walter wouldnt waiver. Young lady, he
said, Im the commander and you just received
an ordernow pony up and make me shine.
I remember his tone of voice like it was yes-
terday despite this being over two decades ago.
In that moment Walter was extending his
hand, bringing me with him as he had with
so many of us in New Jersey. Walter saw our
potential before we realized we had any.
I did end up commanding the drill, and I
dutifully followed orders the rest of the day. I was
better because of this moment, and it ended up
serving as the beginning of an amazing friend-
ship that would be built over the next 25 years.
We later reconnected on the rural streets of
Hunterdon County, where this novice subur-
ban girl had the honor to ride side-by-side with
an inner-city giant. There was no air about it;
Walter delivered amazing lessons in our mobile
classroom where I soaked up every word as if
each were addictive candy.
As anyone taught by Walter knows, despite
being long-winded, the wordsmith in him
allowed him to make his points through an
unbelievable use of twisting the meaning of
words to construct lasting phrases that would
be with his students far longer than we realized.
Walter taught every day of his life. He didnt
need to be in the classroom to impart his wisdom,
and thankfully so, since he had so much to share.
All who have had the honor to teach
12 JEMS | MARCH 2016
1603jems_12 12
New Jersey paramedic Walter Drivet leaves us with
pearls of wisdom. Photo courtesy Jennifer Lindsey
side-by-side with him saw firsthand how his
principles from the street infused the classroom
with knowledge and his studentsheck, even
all of us involvedwere better off for it.
A well-oiled machine, never wavering in the
wake of change, Walter was always looking to
give more for the improvement process and
executing it like he was on a mission.
Affectionately known as the navy walrus,
he used humor to make his points, bluntness
to keep us sharp, large vocabulary to help us
expand, and a personal touch to acknowledge
to us when we had finally made it.
Walters leadership capabilities were infec-
tious. His calmness under pressure was like
watching the Navy SEAL Team 6 going in on
a mission. There could be a metaphoric under-
tow or rip current moving around him and he
showed no sign of worry, for he would always
walk upright out of that ocean, unwavered by
what just occurred.
His medicine was beyond cutting edge. It
was infused with critical care principles, tactical
medicine procedures, evidence-based practice,
systematic approach and a lot of common sense.
Walter was an outstanding paramedic, edu-
cator, and leader, and he will be greatly missed.
It seems fitting to share words of wisdom from
Walter to help remind all of us how we can be
more like him, and maybe even become an icon
in the prehospital realm.
>> Embrace high standards. Always have the
people around you rise to your standard;
never lower yours.
>> Were clinicians, not technicians. It doesnt
matter what words are embroidered on that
patch; our scope of practice far exceeds a
technical level, and its our job to own that
we are in fact clinicians.
>> Respect must be earned. Those who talk a
great game usually dont have one. Now go
earn respect.
>> Pay it forward. Stop looking for the hand-
out and invest in the business. Do a good
deed every day.
>> Prepare for every shift as if it were your
first. Dress the part, check the truck and
be ready for the job.
>> No guts, no glory. Never be intimidated by
the moment, for the moment is what weve
been preparing for.
>> Be resourceful with your time. Time man-
agement is key to success in this field.
>> If youre not putting in 100% effort, its
not worth giving any at all. Interact with
patients the same way every time so youll
never get fooled.
>> You will fail before you succeed. Those fail-
ures will serve you to achieve more than you
realized you could.
>> With knowledge and experience comes
wisdom. Read something every day.
>> Drama is something that should stay in
Hollywood. Were far from Hollywood
guys, so knock it off.
>> Above all else, always do right by the patient.
The patient chooses youyou didnt choose
them, so act like the honor that it is.
>> Pony up. Youre going to go through some
tough stuff. Put on your proverbial big
girl/boy pants and pony up. They are the
moments that define who we are.
In closing, remember to extend your hand to
a newbie with potential. Mentor for the future
and embrace the principles of excellence. For
you just might find yourself in the realm of
Walter Drivet.
Jennifer McCarthy, MAS, NRP, MICP
Jennifer McCarthy, MAS, NRP, MICP, is associate professor
and program director with the Paramedic Science Program
at Bergen (N.J.) Community College.
www.jeMs.CoM
2/15/16 11:26 AM
 RELIGIOUS DISCRIMINATION
& HARASSMENT IN EMS
W e seem to have come so far as a nation in
recent years in the acceptance and toler-
ance of others who may have religious beliefs and
practices different than our own. But the attacks
in Paris and San Bernardino in late 2015 and other
recent world events by ISIS-inspired terrorists seem
to have led to an increase in religious discrimina-
tion in the United States.
This discrimination can be fueled by statements
by public figures such as the recent call to issue a
temporary ban on Muslims entering the U.S. When
people vying to be our leaders are espousing posi-
tions that may be seen as invoking disparate treat-
ment on the basis of religion for national security
reasons, it certainly does get America talking.
This article is intended to promote neither a par-
ticular religious nor a particular political viewpoint,
www.jems.com
1603jems_13 13
but merely to set the stage for where we are today
and what we all need to continue to do to comply
with our current laws.
It sounds easy enough, but the law in this area
is surprisingly unsettled. The Equal Employment
Opportunity Commission (EEOC), the federal agency
that enforces federal antidiscrimination laws, largely
takes an approach of encouraging accommodation
of religious beliefs whenever and wherever possible
unless doing so would create an undue hardship.
But courts have wrestled with religious accommo-
dation issues. With respect to public safety employ-
ers, courts tend to favor employers, noting, When
the employers business involves the protection of
lives and property, courts should go slow in restruc-
turing its employment practices.1
In fact, we as attorneys dont always agree on
what the law actually requires EMS employers to
do in dealing with certain types of religious accom-
modation issues. If an employer or employee face
any religious accommodation issues we encourage
discussion with counsel knowledgeable on this area
of the law, as these issues are very fact-specific and
may also invoke state antidiscrimination law as well.
RELIGIOUS DISCUSSIONS
In our open and increasingly instant news-hyped
society we talk more about religion now than we
have in the pastwith our friends, our family and
our co-workers. In EMS, odds are you frequently
work long hours and spend lots of time with your
co-workers. Theres a lot of time to discuss many
topics, including religion. Although its not against
the law to discuss religion in the workplace, doing
mARcH 2016 | JEMS 13
2/15/16 11:26 AM
 PRIORITY TRAFFIC
so is generally not a good idea as it can lead to
charged emotional reactions, and potential dis-
crimination and harassment claims could result if
those conversations go bad and are perceived as
affecting workplace decisions.
Title VII of the Civil Rights Act of 1964 prohibits
workplace discrimination and harassment based
on (among other things) religion, ethnicity, coun-
try of origin, race or color. Illegal harassment can
extend beyond the typical school-yard bullying that
many of us think of when we think of harassment.
It can extend to making someone uncomfortable
with comments based on religion and either not
stopping when asked or frequently espousing a
differing religious viewpoint from your co-worker,
making that person uncomfortable.
But, its just EMS, some of you may be think-
ing. Were strong personalities who dont hesitate
to share our opinions about just about anything
at work! Its time for these types of attitudes to
change. EMS organizations arent your home away
from home. Theyre workplaces in the eyes of the
law and must follow the same employment laws
and regulations that all businesses follow.
Just like our country is a melting pot of many
races, religions, ethnic backgrounds, colors, and
genders, so is our industry. We need to appreciate
and respect the differences of all our co-workers, not
just the ones who look and think like us. Although
discussion of religion in the workplace may not lead
to inappropriate comments, the safest workplace
practice is to save the religious discussions for out-
side of the workplace.
WORKPLACE RULES & POLICIES
As EMS attorneys, we frequently receive questions
from EMS organizations across the country about
compliance with federal employment laws. With
respect to religion, one of the frequent concerns
we get deals with facial hair and beards. Certain
religions prohibit shaving of beards. Meanwhile,
many EMS organizations have no facial hair poli-
cies, which are typically set forth in personal appear-
ance policies as well as exposure/infection control
plans and infectious disease prevention policies.
Employers must satisfy many requirements to
comply with U.S. Occupational Safety and Health
Administration (OSHA) laws and regulations. Basi-
cally, OSHA requirements ensure that employers
provide their employees with a safe and healthful
workplace. Personal protective equipment (PPE) is
equipment worn to minimize exposure to serious
workplace injuries and illnesses, such as gloves and
protective masks. In EMS, a protective mask should
be worn whenever theres a possibility of contracting
an airborne pathogen as well as whenever there is
14 JEMS | MARCH 2016
1603jems_14 14
a possibility of a patients bodily fluid splashing into
the nose or mouth.2
These masks vary in cost, and a more expen-
sive mask may be the only mask that works effec-
tively for the bearded employee. Lets go back to our
employee whose religious beliefs may prevent him
from shaving. Title VII requires an employer, once
on notice that this employee has a problem with
shaving due to his sincerely held religious beliefs, to
reasonably accommodate the employee, unless pro-
viding the accommodation would create an undue
hardship. However, Title VIIs undue hardship is
defined very differently than the undue hardship
defense for disability accommodation under the
Americans with Disabilities Act (ADA). Under Title
VII, the undue hardship defense to providing reli-
gious accommodation requires a showing that the
proposed accommodation in a particular case poses
a more than de minimis cost or burden, which is
a far lower standard for an employer to meet than
undue hardship under the ADAdefined in that
statute as significant difficulty or expense.3
De Minimis is not defined in statute or regula-
tion, but generally means insignificant. Spending
several hundred dollars to buy a special respirator
for the employees who cant shave because of their
religion could be seen as more than an insignificant
amount of money (de minimis) to many cash-
strapped EMS organizations.
On the other hand, perhaps spending the sev-
eral hundred dollars in the name of promoting reli-
gious tolerance and acceptance to employees may
be money well spent. The organization is certainly
going to need to spend more than that amount if
it needs to go before the EEOC or a court of law to
prove the expense presented an undue hardship
for the organization. Although the law may be on
the employers side, accommodation of religious
beliefs that conflict to a small extent with the work-
place may help avoid charges of discrimination and
can foster a workplace environment of tolerance.
OTHER HARASSMENT/
DISCRIMINATION ISSUES
Other dress code issues that may arise with respect
to religion involve the wearing of hijabs, piercings,
tattoos, long hair (for men), or skirts for religious rea-
sons. There may be requests for time off to attend
religious services or time off in observance of the
Sabbath. There may also be requests for prayer
time at work or to be excused from pre-meeting
prayers or flag ceremonies.
Again, Title VII protects workers from employ-
ment discrimination and harassment based on
religion, and requires employers to provide a rea-
sonable accommodation for employees sincerely
held religious beliefs, observances and practices,
when requested, unless the accommodation would
impose an undue hardship (of more than a de mini-
mis cost or burden) on business operations.
There are three important considerations that
may arise with respect to compliance with Title
VIIs protections against religion discrimination
and harassment:
1. Whether the employee professes a sincerely
held religious belief and asks for an accommo-
dation. The religion might be something really
unusual that youve never heard of (e.g., the
Church of Body Modification) but as long as the
employee sincerely practices that religion, it must
be considered.
2. Whether providing an accommodation would
impose an undue hardship of more than a de
minimis cost or burden upon the business oper-
ations of the employer.
3. Weighing the first two considerations and com-
ing up with a workable solution that respects the
religious views of the employee, while not dis-
rupting business operations or imposing some
other type of undue hardship (such as maintain-
ing adequate staffing), and while not putting the
employees, other co-workers, or patients safety
at risk.
Deciding what constitutes a sufficient disrup-
tion of the employers business operations or what
may be an undue hardship to the employer is eas-
ier said than done, as what EMS employers are
legally permitted to do in this area may largely
depend on where the company is located, as courts
around the country have issued different opinions
on these issues.
The Supreme Court has recently weighed in on
the subject of religious discrimination in employ-
ment, stating in EEOC v. Abercrombie & Fitch Stores,
Inc. that:
Congress defined religion, for Title VIIs pur-
poses, as includ[ing] all aspects of religious obser-
vance and practice, as well as belief, 42 U.S.C.
2000e(j). Thus religious practice is one of the pro-
tected characteristics that cannot be accorded dis-
parate treatment and must be accommodated.
Title VII does not demand mere neutrality
with regard to religious practicesthat they be
treated no worse than other practices. Rather, it gives
them favored treatment, affirmatively obligating
employers not to fail or refuse or hire or discharge
any individual because of such individuals reli-
gious observance or practice. An employer is surely
entitled to have a no-headwear policy as an ordinary
matter. But when an applicant requires an accom-
modation as an aspec[t] of religious practice, it is
no response that the subsequent fail[ure] . . . to hire
www.jeMs.CoM
2/15/16 11:26 AM
 For Emergency
Ocular Irrigation
was due to an otherwise-neutral policy. Title VII requires otherwise-neutral pol-
icies to give way to the need for an accommodation.4
This case involved Abercrombie and Fitch refusing to hire an employee who
wore a hijab to an interview because the hijab would violate its dress code pol-
icy, even though the employee had never actually asked the employer for an
accommodation. The Supreme Court found that the employer didnt have to
have actual knowledge of the need for an accommodation in order to have
potentially discriminated against the applicant.
This Supreme Court case is too new to fully appreciate the effect it may have
on future religious discrimination cases in the lower courts across the coun-
try. What it does show is that this Supreme Court appears to favor employers
making reasonable efforts to accommodate their employees needs for reli-
gious accommodation.

CONCLUSION
The best thing an EMS employer can do to avoid potential claims of religious
discrimination and harassment simply boils down to implementing policies
prohibiting religious discrimination and conducting meaningful training on
those policies while creating a workplace atmosphere that demonstrates
respect for and tolerance and acceptance of people with differing viewpoints,
including their religious beliefs. To achieve this, EMS organizations should be
willing to consider making reasonable workplace accommodations for reli-

ular
gious practices that dont put an undue burden on the employer.

Hands-free oc
Workplace training should make it clear that crude jokes, derogatory com-

go.
ments, and invasive or disrespectful personal questions arent tolerated and
will result in immediate corrective counseling and possible disciplinary action.
ation on th e
The training should also cover how employees can report when they believe
theyre the victim of workplace harassment or discrimination or if theyve wit-
irrig
DONT WAIT! SAVE SIGHT ON SIGHT!
nessed what they believe to be a staff member being harassed or discriminated
against by another staff member.
Its also important to train supervisors to properly handle these allegations
and complaints. Supervisors should be trained on how to properly handle the
The sooner eye irrigation is started,
investigation process, how to properly implement corrective action and disci- the better the prognosis.
pline, and how its prohibited to retaliate in any way against the accuser who
The only hands-free ocular irrigation system offering
makes a good faith report of alleged discrimination or harassment.
Every person at every level within an EMS organization needs to strive to an efficient, effective, and well-tolerated way to flush
create a workforce thats inclusive regardless of individual differences. A zero chemicals or non-embedded foreign bodies from the eye.
tolerance policy for any type of discrimination, offensive words and harassing
In just 20 seconds irrigation can be underway and you can
behavior is essential. And an extra effort by management to respect and use
their best efforts to not force employees to have to choose between their job move to more life-threatening injuries.
and their religion will send a loud and clear message that the religious convic- Patient may be transported without stopping irrigation.
tions of all employees are respected. JEMS

REFERENCES
1. Beadle v. City of Tampa, 42 F.3d 633 (11th Cir. 1995).
2. National Personal Protective Technology Laboratory. (March 1, 2012.) Respirator trusted-source
information. Section 3: Ancillary respirator information. Centers for Disease Control & Infec-
tion. Retrieved Jan. 18, 2016, from www.cdc.gov/niosh/npptl/topics/respirators/disp_part/
respsource3selection.html. Saves Time, Saves Money, Saves Eyes
3. EEOC. (July 22, 2008.) Compliance manual. Section 12: Religious discrimination. Retrieved
Jan. 18, 2016, from www.eeoc.gov/policy/docs/religion.html.
4. E.E.O.C. v. Abercrombie & Fitch Stores, Inc. 35 S. Ct. 2028 (2015).

Pro Bono was written by Christie Mellott, Esq., an attorney at Page, Wolfberg & Wirth,
The National EMS Industry Law Firm. Visit the firms website at www.pwwemslaw.com or find
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1603jems_15 15 2/15/16 11:26 AM

 MANAGEMENT FOCUS
STAY ON TOP OF YOUR GAME
LEADING OTHERS
Competencies for current & aspiring leaders
By Michael Touchstone, BS, EMT-P
T
he frontline supervisor is often the
first position to which organizations
delegate formal authorityauthority
that includes a responsibility to lead. The
third pillar of the National EMS Manage-
ment Associations Seven Pillars of EMS
Officer Competencies is leading others. It
includes skills in communications, interper-
sonal awareness, motivating others, develop-
ing others and influencing.
COMPETENCIES
Communications: Communicating isnt telling,
its a dynamic activity with several foundational
components. In order to achieve authentic
dialog there must be a sender, medium and
receiver, and information must move back and
forth between participants. We must be com-
petent in both written and verbal communi-
cation and do our best to embrace the digital
world where there are media beyond voice
and paper such as PowerPoint presentations,
podcasts, webinars, social media and others.
Using the various available tools and media,
a supervising EMS officer (SEMSO) should
be competent in communicating within and
outside of the organization, and be able to
demonstrate active listening, facilitate discus-
sion and speak in front of groups. A SEMSO
needs to know the who, what, when, where and
how of sending messages within the organi-
zation. This includes being aware of chain of
command, who needs to know the informa-
tion, and whether a phone call, email or memo
(or all three) is warranted. Your boss wont be
happy when his boss asks him a question about
something he doesnt know about because you
left him out of the loop.
Active listening isnt easy; it takes effort and
concentration. One of the most difficult skills
to master is silencing the inner voicethe voice
inside your head thats formulating a response,
beginning the argument or asking questions. If
youre listening to your inner voice, you arent
listening to whoever is speaking.
16 JEMS | MARCH 2016
1603jems_16 16
Interpersonal awareness: This competency
set includes awareness of the impact of psy-
chological traits and behaviors on interactions,
maintaining an environment thats supportive
of appropriate and lawful social interactions,
being perceptive of others motivations, pro-
moting effective communication and nurtur-
ing a positive and effective work environment.
Motivating others: An effective SEMSO
motivates others through a willingness to take
charge and serve as a leader, ensuring staff
members are committed to achieving organi-
zational goals and objectives. Collaboratively
identifying and facilitating achievement of new
individual and organizational goals and objec-
tives, reinforcing success, providing correction
and coaching when goals and objectives are
not met, and building teams are also important
SEMSO motivational competencies.
Developing others: As leaders we have to
prepare those who follow to take on new roles
and responsibilities. SEMSOs have a respon-
sibility to facilitate professional development
and must be able to educate, train, assess, eval-
uate and coach. Not everyone will choose to
pursue promotion, but everyone has room to
improve and grow. Effective SEMSOs are
guides, teachers, mentors and role models.
They must demonstrate basic knowledge
of adult learning theory and instructional
design, perform evaluations and collabora-
tively develop improvement plans. In essence,
SEMSOs create their replacements.
Influencing: Leaders influence people,
through cooperation, persuasion, negotiation
and resolution of conflict, and by empow-
ering, inspiring and demonstrating political
savvy. Effective SEMSOs cooperate with
others inside and outside of the organiza-
tion in order to achieve goals and objectives.
They acknowledge, recognize and inte-
grate different points of view and opinions
to persuade staff, colleagues and peers of the
importance of a particular position, policy,
goal or objective. It may require negotiation
skills and resolving conflicts to achieve the
final outcome.
A SEMSO empowers people by maintain-
ing a supportive environment to foster ideas
that align with the agencys values. SEMSOs
can and should provide inspiration by demon-
strating knowledge of and commitment to
the organizations vision, mission and values
and by providing an environment thats open,
transparent and supportive.
We all work in political environments and
are influenced by politics on many levels. Inter-
nal and external political considerations have
impact; politics affect choices, decisions, and
course of action. Successful leaders are per-
ceptive, shrewd, and comprehend internal and
external political influence.
ACTUALIZING COMPETENCIES
Below are examples demonstrating the com-
petencies of leading others:
>> Developing presentations, writing memos
and using appropriate media to convey
accurate information, optimize information
transfer and influence behavioral change.
>> Acquiring information that provides insight
into issues that affect the personal lives of
staff and maximizes performance by assist-
ing in resolving or remedying those issues.
>> Setting an example and being a role model
by adherence to the organizations mission
and commitment to the values and vision.
>> Determining the appropriate level of dele-
gated authority so individuals can success-
fully complete projects or initiate programs.
>> Soliciting ideas and contributions from
staff that will improve the organization
and crediting the individual when ideas
or contributions are implemented. JEMS
Michael Touchstone, BS, EMT-P, is the regional
director for the Philadelphia Regional Office of
EMS and president of In partnership with
the National EMS Man-
agement Association.
www.jeMs.CoM
2/15/16 11:26 AM

THATS HOT
Recommendations for the safety & transport of burn victims
By Dennis Edgerly, BS, EMT-P
T
here are fire apparatus lining the
street as you arrive. The air is smoky
and thick. Incident command has
requested you stage behind Engine 7. As you
get closer, you see several fire fighters carrying a
man from the smoking house, so you and your
partner grab the stretcher and quickly move
the patient into the ambulance.
Firefighters report the patient was working
in the garage with an unknown accelerant
when the fire ignited. It took them sev-
eral minutes to find the patient but they
were able to remove him from the burn-
ing structure quickly. There are no obvi-
ous signs suggesting the patient had fallen
or been hit by any part of the structure.
PATIENT ASSESSMENT
The patient is an approximately 40-year-
old male responding to noxious stimulus
by moaning. He has a rapid, shallow respi-
ratory pattern with noisy breathing. First- and
second-degree burns cover his face. His shirt is
burned off, with only portions of the material
melted to his burned flesh. His entire anterior
chest and part of his abdomen have sustained
second- and third-degree burns, as well as the
anterior portion of both of his arms. His lower
extremities dont appear injured or burned.
The burn area is extinguished. Your part-
ner uses a bag-valve mask and begins to assist
the patients breathing with high-flow oxy-
gen. You establish an IV in the patients right
antecubital and begin a slow infusion of fluid.
His pulse rate is 130 with strong pulses at the
radial artery. Dry sterile dressings are loosely
placed over the patients chest burns and hes
covered with a blanket. The patient is rapidly
transported to the closest ED with early noti-
fication from you about his status and possible
need for transport to the burn center.
DISCUSSION
EMS providers must always remember to con-
sider their safety before performing any type
www.jems.com
1603jems_17 17
of rescue from a structure thats burning or
has burned. As you are able, remove any cloth-
ing that has been burnt or that is smoldering.
Remove jewelry because, first, metals can hold
heat and continue to burn, and, second, as the
tissue swells, jewelry can create a constricting
band around fingers, wrists or necks.
In the event of an explosion or structural col-
lapse, EMS providers must consider the possi-
His shirt was burned
off, with only portions
of the material melted
to his burnt flesh.
bility of sustained trauma in addition to the burn.
If theres the potential for neck or back injuries,
providers must consider the risk vs. benefit of
immobilizing patients vs. management of other
life-threatening conditions and rapid transport.
Airway management becomes a leading pri-
ority in the care of burn patients. Any patient
whos been exposed to smoke or super-heated
gas should be assumed to have airway burns.
If burned, airways can swell quickly and result
in significant or total airway obstruction. Signs
such as noisy breathing, coughing and the com-
plaint of dyspnea are all signs of impending
airway obstruction. High concentrations of
oxygen and ventilation assistance should be
provided for these patients. In systems where
its allowed, chemical sedation and intubation
may be implemented.
In addition to the airway swelling, a patient
exposed to smoke may also have high levels of
carbon monoxide (CO) and cyanide in their
system. Both of these chemicals alter the bodys
ability to transport and use oxygen. Be aware
that both CO and cyanide can result in a high
BACK TO BASICS
CASES IN BLS CARE
pulse oximetry reading, but the body is unable
to receive or use oxygen.
Burns can cause significant fluid loss as fluid
leaves the damaged tissue. The Parkland or
modified Brooke formula can be used as an
estimated starting point for fluid resuscitation.
The formula suggests administering 4 mL/kg
of fluid per body surface area burned with sec-
ond- or third-degree burns. Half of this fluid
should be administered in the first eight
hours. EMS should, if allowed, administer
pain medication during transport.
Severely burned patients may need to be
transported to a burn center. The Amer-
ican Burn Association recommends the
following criteria for burn center transport:
>> Partial-thickness burns greater than
10% of total body surface area;
>> Burns that involve the face, hands,
feet, genitalia, perineum or major joints;
>> Third-degree burns in any age group;
>> Inhalation injury;
>> Burn injury in patients with pre-existing
medical disorders that could complicate
management, prolong recovery or affect
mortality; and
>> Any patient with burns and concomitant
trauma (such as fractures) in which the
burn injury poses the greatest risk for mor-
bidity or mortality.
CONCLUSION
Theres a lot to consider in the care and man-
agement of patients who have been burned.
Local protocols will guide EMS providers in
how best to transport severely burned patient.
Be aggressive with airway management, watch
for rapid deterioration, transport appropriately
and be safe. JEMS
Dennis Edgerly, BS, EMT-P, began his EMS
career in 1987 and is currently the paramedic
education coordinator for the paramedic
education program at HealthONE EMS. Reach
him at dennis.edgerly@healthONEcares.com.
mARcH 2016 | JEMS 17
2/15/16 11:26 AM
 CASE OF THE MONTH
DILEMMAS IN DAY-TO-DAY CARE
FULL ATTENTION
Dont differentiate from the differential diagnosis
By Chris Kaiser, NREMT-P
M
edic 71, staffed with an EMT and
a paramedic, arrive for an imme-
diate interfacility transfer. Their
patient, a 34-year-old female who had been
thrown from a horse, is being transferred from
the critical access hospitals small ED to a
larger hospital approximately one hour away.
Shes been evaluated and stabilized but requires
urgent orthopedic surgery to correct an open
ankle fracture.
The crew is greeted by the
patients nurse, who gives them
a hand-off report: Its an open Its important for clinicians
fracture of the tibia and fibula
that shes going to have repaired to consider multiple conditions
this afternoon. The doc here
cleaned it as best she could that may cause similar
and we have it splinted for the
trip but were going to have you observable symptoms.
guys finish infusing a gram of
cefazolin as pre-surgical anti-
biotic prophylaxis. Shes doing pretty good
pain-wise with Dilaudid (hydromorphone),
and the doc is also giving you orders to man-
age her pain with more IV Dilaudid in 1 mg
increments as needed.
The patients vital signs have been stable
through her time in the ED, with a blood pres-
sure of 128/74, a pulse of 86, and respirations
of 18 at the time of report. The patient has no
known allergies to medications and takes no
medications. When the EMS crew introduces
themselves, they find her in reasonably good
spirits with a normal level of consciousness. She
rates her pain at a 1 or a 2 but says shes doing
fine and doesnt want more pain medication.
The nurse helps the crew move the patient
to the ambulance cot and the EMT makes sure
the patient is comfortable. Once in the ambu-
lance, the paramedic attaches a 4-lead ECG
that shows a normal sinus rhythm. He also
attaches a noninvasive blood pressure (NIBP)
cuff set to cycle every 15 minutes, connected
a continuous pulse oximeter for monitoring
oxygen saturation (SpO2) during the transport.
18 JEMS | MARCH 2016
1603jems_18 18
He then ensures the patency of the patients
18-gauge IV, which is in her left antecubital
fossa. As they leave the facility traveling with
normal traffic, the patient dozes off to sleep.
Approximately 20 minutes into the hour-
long transport, the cefazolin infusion finishes
and the paramedic replaces it with 1000 mL of
normal saline set at a TKO rate. He rechecks
the patients blood pressure and finds its unex-
pectedly dropped to 90/64. A few minutes
later, the patient awakes and begins complain-
ing of abdominal discomfort and an urgent
need to move her bowels. She quickly fol-
lows her complaint with a discharge of very
foul-smelling, watery, light-brown diarrhea.
She then develops a diminished level of con-
sciousness and a subsequent measurement of
her blood pressure reads 84/40.
The paramedic orders his EMT partner to
turn on the lights and siren and radio ahead to
the receiving facility that the patients condi-
tion has deteriorated to the point where theyll
be stopping in the ED before proceeding to
the operating room. He sops up the diarrhea as
best as he can using towels and a blanket and
then opens the IV solution wide-open to give
a 300 mL fluid bolus. He sets the auto-NIBP
to measure the patients blood pressure every
five minutes, then begins a detailed reassess-
ment of the patient to attempt to determine
the cause of her rapid deterioration.
He finds the patients level of consciousness
has decreased to eye opening and moaning
with verbal stimuli. Her skin is pale, cool and
moist. Her pupils are PEARRL (pupils equal
and round, responsive to light). She has flat
neck veins and mostly clear but diminished
lung sounds. Her abdomen is soft and non-
distended with no obvious tenderness nor
palpable masses found. Her extremities have
weak but present distal pulses with slow cap-
illary refill noted.
The patients BP continues
to diminish despite the 300 mL
saline bolus and the paramedic
elects to continue the IV solu-
tion running wide open. Addi-
tionally, the paramedic decides
to initiate a dopamine infusion
to support the patients blood
pressure since the fluid isnt
helping her hypotension and
the patient doesnt appear to be
traumatically hypovolemic. He
checks the patients paperwork and finds her
weight to be 143 lbs., or 65kg. He starts the
infusion as a piggyback in to the saline drip
at 10 mcg/kg/min using a gravity flowmeter
to regulate the drip to 24 mL/hr.
The paramedic contacts the receiving hos-
pital to give a patient update and to request
a consultation with medical control. As he
waits for the physician, he quickly reassesses
the patient. Her BP has risen to 92/64 and her
pulse is 112 bpm, but her SpO2 has dropped to
88% and a quick evaluation of her lung sounds
reveals a slight wheeze has developed with
further diminishment of overall lung sounds.
When the physician arrives on the phone,
the paramedic requests to administer 0.3 mg
IV epinephrine 1:10,000. The physician agrees
and also gives orders to continue the dopamine
infusion as needed and to administer 50 mg
IV diphenhydramine if the patient responds
to the epinephrine.
The paramedic administers the IV epineph-
rine and re-evaluates the patients BP after a
few minutes. Its climbed to 100/74 and her
www.jeMs.CoM
2/15/16 11:26 AM
 color has returned. As such, the paramedic
elects to reduce the dopamine infusion to
5 mcg/kg/min. She regains near full alertness
a few minutes later, stating that shes feeling
better overall yet still has some abdominal
discomfort. The paramedic discontinues the
dopamine infusion and administers 50 mg IV
diphenhydramine as well as 125 mg IV meth-
ylprednisolone. The patients vital signs remain
stable for the remainder of the transport and
the crew arrives at the receiving hospital with-
out further incident. Shes found to have a pre-
viously unrecognized allergy to the cefazolin.
DISCUSSION
During initial EMS education, providers are
taught that each patient requires different
assessment methodologies that work in concert
to ensure a thorough, systematic examination
of the patient as a whole. These assessments
include, but arent limited to, the initial assess-
ment that generates a general impression and
identifies immediate life-threatening condi-
tions; the secondary assessment that includes
a detailed physical exam and review of the
patients physiological systems; and the ongo-
ing assessment, which identifies and measures
changes in the patients condition.
These assessments may be repeated many
times throughout the providers contact with
a patient. The patient in this case study had
a complex presentation with many potential
causes for her precipitous decline during what
was supposedly a simple interfacility transport.
Through ongoing assessment and monitor-
ing of the patient, the paramedic was able to
identify the patients rapid deterioration and
positively intervene. He recognized the situa-
tion, determined the need to act, carefully and
systematically assessed the patient, considered
the potential causes and differential diagnoses
of the patients deteriorating condition, and
then took a number of appropriate actions
while measuring the results of those actions.
A differential diagnosis is distinguishing a
condition as the potential cause of a patients
and the patients history. Although this pro-
cess may not arrive at a concrete diagnostic
certainty, its infinitely useful in narrowing
the field of potential choices and zeroing in
on needed treatments.
In this case, the patient was suffering from
an atypical anaphylactic reaction. This condition
was very dangerous and was causing the patient
to rapidly decompensate and become hemo-
dynamically unstable. However, the patients
symptoms of hypotension, diarrhea, abdomi-
nal pain and diminished level of consciousness
could have been attributed to other causes, such
as undiscovered traumatic hemorrhage, occult
neurological injury causing shock, or even an
early pulmonary embolism.1 Through assess-
ment and the patients history, the paramedic
was able to determine the patient was suffer-
ing from the atypical anaphylaxis due to the
constellation of the symptoms combined with
the recent medication administration, which
he knew was new to the patient.
Since anaphylaxis doesnt always present with
the classic symptoms of angioedema (swell-
ing), urticaria (hives) and skin itching, and can
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instead be only manifested with hypotension,
gastrointestinal disturbances, and/or hypoxia,
the diagnosis was difficult to determine.2 Rec-
ognizing the cause of the patients condition was
of vital importance because the patient needed
appropriate interventions in a timely fashion.
CONCLUSION
Its important for all EMS professionals to
understand that every patient deserves a thor-
ough and complete assessment, that no patient
is routine, and that every patient is worthy of
our full attention. JEMS
Chris Kaiser, NREMT-P, has been applying band-aids to acci-
dent victims for better than 15 years. Hes the blogger behind
the EMS blog www.lifeunderthelights.com and a member of
the JEMS Editorial Board.
REFERENCES
1. Menaker J, Stein DM, Scalea TM. Incidence of early pulmonary
embolism after injury. J Trauma. 2007;63(3):620624.
2. Bjornsson HM, Graffeo CS. Improving diagnostic accuracy
of anaphylaxis in the acute care setting. West J Emerg Med.
2010;11(5):456461.
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www.jems.com mARcH 2016 | JEMS 19

1603jems_19 19 2/15/16 11:26 AM

 RESEARCH REVIEW
WHAT CURRENT STUDIES MEAN TO EMS
EFFECTIVE SIMS
Applying cognitive load theory to design simulation training
By David Page, MS, NRP & Bill Robertson, MS, NRP
MANAGE THE LOAD
Fraser KL, Ayres P, Sweller J. Cognitive load
theory for the design of medical simulations.
Simul Healthc. 2015;10(5):295307.
EMS providers are often subjected to ineffec-
tive training: death by PowerPoint or verbalizing
skills without actual practice. This can be mit-
igated by simulation training, which can help
both novices and experts improve problem-
solving abilities. How these simulations are built
and delivered greatly determines the learners
20 JEMS | MARCH 2016
1603jems_20 20
ability to gain, retain and recall new knowledge.
Background: To understand cognitive load
theory (CLT), imagine your brain is a computer.
Short-term memory (i.e., working memory)
is your desktop and long-term memory is your
hard drive. Short-term memory is limited when
dealing with new informationwe can remem-
ber about seven new things at one timebut this
working memory desktop has an incredible and
unlimited ability to rapidly access our hard drive
of long-term memories. By focusing on a step-
wise progression of the seven things we want to
Incorporating aspects of cognitive load theory can
help maximize the effectiveness of simulation
training. Photo courtesy Bill Robertson
remember, we convert short-term learning into
schemascomplex algorithms allowing us to
think critically and solve problems.
Method and results: This study cites more
than 100 scientific papers that might guide us
in the design of the most effective simulations,
improving their instructional design, delivery
and results.
The authors discuss some of the threats that
make this kind of learning ineffective: simu-
lations that are unrealistic, too simplistic, too
complex, or where the learning environment
www.jeMs.CoM
2/15/16 11:26 AM
 is unsafe (e.g., when learners are ridiculed or
publically humiliated).
Undesired factors that are unnecessary to
the learning objectives complicate and distract
learners, and become a roadblock to learn-
ing. CLT calls these complications extrane-
ous cognitive load. The authors explain this
as a concept in which ones limited short-term
working memory is redirected to interpret the
format of instruction rather than being used to
effectively process new information.
Examples of this might include a broken or
finicky manikin that requires special manip-
ulation to obtain a blood pressure; auditory
information (e.g., an instructor verbalizing
signs or symptoms) instead of showing the
signs; or having a patient give information as
they would in the field.
The authors also discuss the effects of stress
on cognitive ability. Stress positively affects
learning by narrowing perception and focus-
ing attention to content. It also improves long-
term retention, particularly when combined
with motor (physical action) learning. But
stress negatively affects cognitive workload
by shrinking working memoryif the stress
is too great, learning capacity begins to reduce
and fewer learning objectives are being acquired
and stored into long-term memory.
Or course, in the real world, EMS pro-
viders need to function, at times with severe
stress. The authors suggest that if the stress is
intrinsically linked to the information being


  
learned, rather than being peripheral to the task,
stress can be used effectively. Poorly designed
instructional simulation methods, however, can
contribute to extraneous cognitive load and


be counterproductive.
CLT suggests a simple-to-complex progres-
sion as has been suggested by the sequencing in
the new National Registry for EMTs accred-
itation standards for paramedic programs. Its
also compatible with scaffolding concepts that
help learners progress to autonomous practice.
Segmenting is a theory where new content
is delivered in small chunks, allowing each to be
mastered and stored in long-term memory prior
to using the content in simulation. For example,
a new skill is introduced in a pre-session video
viewed at home, then the student works with a
task trainer, then a simple scenario and finally
in a realistic simulation. In doing so, the stu-
dents working memory is more effectively used
to manage the simulated patient vs. process-
ing new content at the time of the simulation.
Worked example effect, where novice cli-
www.jems.com
1603jems_21 21
GLOSSARY
Scaffolding: Learning process that promotes
a deeper learning by providing, and gradually
removing, supportive elements.
Schemas: Complex memory structures built
on previous experiences that allow us to per-
ceive, think and solve problems.
nicians learn new content by studying worked
examples (e.g., watching video of real cases and
critiquing them prior to working through a simu-
lation) allows students the opportunity to see the
format and logistics of simulation beforehand,
more effectively reserving their working mem-
ory to learn the patient management process.
Discussion: Research into the most effective
ways in which we design and deliver instruction
is paramount. CLT concepts have the potential
to significantly improve how we use simulation
to prepare students for the prehospital envi-
ronment. However, more analysis into how we
measure cognitive load and the most effective
types of simulation (e.g., high vs. low fidelity)
are necessary steps in this determination. JEMS
David Page, MS, NRP, is the director of the
Prehospital Care Research Forum at UCLA. Hes
a senior lecturer and PhD candidate at Monash
University. He has over 30 years of experience
in EMS and continues to be active as a field
paramedic for Allina Health EMS in the Minneapolis/St. Paul
area. Send him feedback at dpage@emsed.net.
Bill Robertson, MS, NRP, is an assistant pro-
fessor of EMS at Weber State University. He
has more than 20 years of experience in EMS,  
critical care transport and clinical education.
He holds both a bachelors and masters degree
in adult education, with an emphasis in health professions. Developed for emergency
evacuation of babies
from the nursery or other
Visit www.pcrfpodcast.org
for audio commentary. locations in hospitals in a
safer manner than anything
BOTTOM LINE available anywhere else. It
What we already know: Simulation is uni-   
    
versally recognized as an important tool in SKEDCO Hazmat/Hospital
preparing clinicians for the dynamic world
Sked Stretcher.
of prehospital medicine.
What this study adds: Poor simulation
practices can prove to overwhelm ones
ability to use their limited working memory
to acquire, process and permanently store
essential new content.
For more information,
visit JEMS.com/rs and enter 11.
2/15/16 11:26 AM
 STREET SCIENCE
CONVERSATIONS ABOUT EMS RESEARCH
QUALITY OF VIEW
Video laryngoscopy improves intubation success rate
By Keith Wesley, MD, FACEP & Karen Wesley, NREMT-P
THE RESEARCH
Jarvis JL, McClure SF, Johns D. EMS intubation
improves with King Vision video laryngoscopy.
Prehosp Emerg Care. 2015;19(4):482489.
THE SCIENCE
This study represents an EMS systems intuba-
tion experience before and after implementing
a video laryngoscope. Prior to the imple-
mentation, while using only direct
laryngoscopy (DL), their first pass
success (FPS) rate was 44% and
their overall intubation success rate
was 64%.
The service recognized their
performance was below their
goal, and with close medical director
oversight, attempted to improve
by switching from DL to video
laryngoscopy (VL).
They chose King Vision because
of the quality of view it provided of the cords
and usability as measured by paramedic pref-
erence during a cadaver lab.
VL proficiency was accomplished with
mandatory training that included hands-on
practice, lecture and online videos. Medics were
required to show competency in VL monthly.
After a phase-in of several months, direct
laryngoscopes were removed from the ambu-
lances and all intubations were required to be
performed using a video laryngoscope.
Over the course of the study, 514 patients
were intubated. There was no difference
between the general patient population before
and after implementation of VL. Results
included the following:
>> Increase in FPS rate from 43.8% to 74.2%;
>> Increase in success per attempt (successful
attempts/total number of attempts) from
44.4% to 71.2%; and
>> Increase in overall success rate (success-
ful intubations/number of patient for
whom intubation was attempted) from
64.9% to 91.5%.
22 JEMS | MARCH 2016
1603jems_22 22
DOC WESLEY COMMENTS
Endotracheal intubation remains one of the
most controversial topics in EMS. One of my
primary concerns in its use is competency.
Jeffrey L. Jarvis, MD, should be commended
for recognizing that his services performance
was less than optimal. Some have proposed
that FPS rate should be close to 80%, second
pass at 85% and third pass at 90%.
This study shows that
practice was a large part
of the improvement to
successful intubations.
The challenge is how to improve our medics
performance. After initial paramedic training,
the opportunity to use the operating room for
continuing intubation education is rare. Its
even less common with decreasing opportu-
nity to intubate patients due to the increasing
use of supraglottic airways as the primary air-
way device and the emphasis on uninterrupted
chest compressions during cardiac arrest. For
the EMS system in the study, the average num-
ber of intubations per medic was 2.9 per year.
Of its 131 paramedics, 12 (9%) had no intu-
bations and 30 (23%) only had one.
Besides improved success rate, these devices
often include the ability to record the intu-
bation for both quality improvement and
educational purposes. Jarvis initially saw a rapid
rise in success rate that declined over a mat-
ter of months, and correcting that required
monthly testing of competency.
Should your service invest in VL? That
depends. How is your success rate? If its
similar to the service in this study, I strongly
encourage you to explore the idea.
Otherwise, perhaps you should consider
removing intubation from your services scope
of practice all together.
MEDIC WESLEY COMMENTS
I love the new science and devices that have
been developed to improve airway manage-
ment. VL has given EMS a new opportunity
to change a less-than-optimal success rate.
With any new manual skill that
requires the use of a different piece of
equipment, training, retraining and
practice is imperative to achieving
success. This study shows that prac-
tice was a large part of the improve-
ment to successful intubations.
Its the responsibility of educators
to require frequent practice and skill
verification. But what about those
services that have education direc-
tors who dont recognize the signifi-
cance of repetition and competency evaluation?
These are the services that will ultimately fail,
even with quality equipment.
Not every service can be as lucky as the one
in this studywith strong medical director
involvement and a staff of highly dedicated
educators.
The cost of this product is very reasonable.
Its money well spent if continued education,
training and educational oversight support it,
and if the providers are tasked to use it. JEMS
Keith Wesley, MD, FACEP, is the medical
director for HealthEast Medical Transportation
in St. Paul, Minn., and United EMS in Wiscon-
sin Rapids, Wis. Hes served as the state med-
ical director for both Minnesota and Wisconsin
and is a frequent speaker at both state and national conferences.
He can be reached at drwesley@charter.net.
Karen Wesley, NREMT-P, is a paramedic and
educator for Mayo Clinic Medical Transport
and is the medic team leader for the Eau Claire
County (Wis.) Regional SWAT team. She can
be reached at admkaren22@hotmail.com.
www.jeMs.CoM
2/15/16 11:26 AM
 For more information, visit JEMS.com/rs and enter 12.

1603jems_23 23 2/15/16 11:26 AM

 For more information, visit JEMS.com/rs and enter 13.

1603jems_24 24 2/15/16 11:26 AM

 JEMS Special Focus: The 2015 American Heart Association
Guidelines Update for CPR & Emergency Cardiovascular Care
Sponsored by:

26 Executive Summary 36 Opioid Crisis: Prehospital naloxone 43 Beyond the Limit: Why we shouldnt
27 Whats New & Why: Important administration for opioid-related terminate resuscitations after 20
changes in the 2015 American Heart emergencies minutes
PHOTO COURTNEY MCCAIN

Assocation Guidelines Update 40 Keeping Cool?: Prehospital targeted 46 Revising Protocols: A back-to-basics
temperature management in cardiac training approach to comply with
arrest patients the AHA Guildelines Update

www.jems.com mARcH 2016 | JEMS 25

1603jems_25 25 2/15/16 11:26 AM

 RESUSCITATION RECOMMENDATIONS
2015 AHA GUIDELINES UPDATE FOR CPR
By Robert W. Neumar, MD, PhD
or this special section of JEMS, commit-
F
tee chairs and key authors of the 2015
American Heart Association (AHA)
Guidelines Update for CPR and Emergency
Cardiovascular Care (ECC) synthesize and sum-
marize the key changes, deliberations, consid-
erations, research and recommendations as they
relate to EMS and the EMS-hospital interface.
The 2015 Guidelines Update focuses on top-
ics with significant new science or ongoing con-
troversy, and so serves as an update to the 2010
guidelines rather than a complete revision. It also
marks the beginning of a new era, because the
guidelines will transition from a five-year cycle
of periodic revisions and updates to a Web-based
format thats continuously updated by using an
evidence evaluation process to facilitate more
rapid translation of new scientific discoveries
into daily patient care. The first release is avail-
able at http://eccguidelines.heart.org and is based
on the comprehensive 2010 Guidelines plus the
2015 update.
What hasnt changed is the emphasis on opti-
mizing the system of care for out-of-hospital car-
diac arrest, emphasizing measurement of process
and outcomes as a foundation for continuous
quality improvement.
BLS & CPR Quality: Theres a new recommen-
dation to consider use of social media to sum-
mon rescuers who are willing and able to perform
CPR and are in close proximity to someone with
a suspected cardiac arrest. Dispatcher-assissted
CPR recommendations were also strengthened.
Notable changes in BLS include new upper
limits for compression rate (100120/min) and
compression depth (56 cm). New data contin-
ues to indicate mechanical CPR isnt superior to
manual CPR and thus isnt recommended for
routine use. Its noted, however, that it might be
beneficial in special circumstances.
The use of the impedance threshold device
alone during CPR isnt recommended based on
the neutral results of a large multicenter trial.
However, the use of the ITD combined with
active compression-decompression CPR may
be considered as an alternative to standard CPR
based on the potential for improved survival with
26 JEMS | MARCH 2016
1603jems_26 26
good neurologic function.
Advanced Cardiovascular Life Support
(ACLS): There are limited changes in ACLS
care during cardiac arrest. Recommendations for
defibrillation are unchanged. Review of existing
data demonstrated no superiority of bag-valve
mask ventilation, supraglottic airways or endo-
tracheal (ET) intubation as strategies for air-
way management and ventilation during CPR.
Although waveform capnography remains
the recommended strategy for confirmation of
ET tube placement during CPR, ultrasound
has been added as an alternative strategy when
capnography isnt available.
The use of vasopressors during CPR was
extensively reviewed, resulting in the removal of
vasopressin from the ACLS algorithm based on
lack of evidence for additional benefit compared
to standard dose epinephrine therapy alone. Its
also now recommended that epinephrine, when
used, should be administered as soon as feasible
in patients with non-shockable rhythms.
Although there were no new recommenda-
tions on the use of physiologic monitoring or
ultrasound to guide resuscitation during cardiac
arrest, the inability to achieve an end-tidal carbon
dioxide value 10 mmHg in intubated patients
after 20 minutes of CPR has been added a poten-
tial component of a multimodal criteria to guide
the decision to terminate of resuscitation efforts.
Finally, the Guidelines restated that the use
of extracorporeal cardiopulmonary resuscitation
as a rescue therapy for refractory cardiac arrest
may be considered when the suspected etiol-
ogy of the cardiac arrest is potentially reversible
during a limited period of mechanical cardiore-
spiratory support. However, implementation of
such a strategy is resource intensive and requires a
highly coordinated system of care to be successful.
Post-Cardiac Arrest Care: The most import-
ant change in post-cardiac arrest care is in tar-
geted temperature management. Based on the
results of major prospective randomized clini-
cal trials, the target temperature range has been
expanded to 3236 degrees C, and the use of
rapidly infused cold saline in the prehospital
setting isnt recommend due to lack of impact
on patient outcomes. The importance of early
coronary angiography in patients with and with-
out STEMI criteria is also further emphasized.
Pediatric BLS & ACLS: Pediatric guidelines
were updated with limited changes and, in most
cases, mirror changes in the adult guidelines.
New algorithms for single-rescuer and multiple-
rescuer pediatric healthcare-provider CPR were
created. The upper limits of chest compression
rate and depth recommended in adult BLS were
also applied to adolescents.
Atropine is no longer recommended for rou-
tine use as an adjunctive therapy during ET
intubation to prevent bradycardia, but could be
considered in patients at high risk for bradycardia.
Finally, amiodarone or lidocaine are considered
equally acceptable for the treatment of shock-
refractory v fib or pulseless v tach in children.
Special Circumstances: The most nota-
ble change here is the recommendation for
non-healthcare BLS providers to administer nal-
oxone in patients with suspected opioid overdose.
Recommendations to consider IV lipid ther-
apy have been expanded from cardiac arrest
caused by local anesthetic overdose to cardiac
arrest caused by drug toxicity. Finally, left uter-
ine displacement is strengthened as the primary
strategy for aortocaval decompression during
cardiac arrest in pregnancy.
Conclusion: Overall, the 2015 AHA Guide-
lines continue to refine our resuscitation strate-
gies based on available new evidence. Successful
resuscitation depends on coordinated systems
of care that start with prompt rescuer actions
and delivery of high-quality CPR, continued
through optimized ACLS and post-cardiac arrest
care. Systems that monitor and report quality of
care metrics and patient-centered outcomes will
have the greatest opportunity through quality
improvement to save the most lives.
Robert W. Neumar, MD, PhD, is the chair
of the AHA ECC Committee, an AHA delegate
to the International Liaison Committee on
Resuscitation, and professor and chair of the
Department of Emergency Medicine at the
University of Michigan Medical School.
www.jeMs.CoM
2/15/16 11:26 AM
 Important changes in the 2015 AHA Guidelines Update

T
he 2015 AHA Guidelines Update isnt a significant revision to the 2010 Guidelines. use of passive ventilation may be consid-
Rather, it uses advances in resuscitation research and the latest scientific evidence to ered (Class IIb).
further define, refine, clarify or otherwise alter the 2010 Guidelines. In a patient with known or suspected opi-
In some areas, the lack of definitive research resulted in not recommending a certain proce- ate overdose who has a pulse but no normal
dure or leaving a guideline unchanged. This doesnt mean that systems currently using a pro- breathing, in addition to standard BLS care,
cess, procedure or resuscitation device must stop using them if their medical leadership feels its reasonable for appropriately trained pro-
their resuscitation results have improved. There was simply insufficient evidence at this time viders to administer intramuscular or intra-
for the committee to make a recommendation for change. nasal naloxone (Class IIa).

BLS, AEDS & CPR QUALITY
By Erin E. Brennan, MD
Although there arent significant changes in the
2015 AHA Guidelines Update relative to BLS
practices and automated external defibrillator
(AED) use, there are a few changes all EMS
providers and educators need to be aware of.
Key Points
>> The guidelines continue to place signifi-
cant emphasis on high-quality CPR given
its association with improved survival.
>> Theres a recommendation for coordinated
team approach (i.e., pit crew approach)
to resuscitation when multiple provid-
ers are available, enabling the coordinated
and efficient provision of chest compres-
sions, airway management, ventilations,
and defibrillation if indicated.
BLS Sequence
>> For trained healthcare providers, pulse and
breathing check can be performed simul-
taneously and should last no longer than
10 seconds.
>> Evidence continues to support the C-A-B
sequence (Class IIb), with a compression-
to-ventilation ratio of 30:2 (Class IIa).
>> For trained healthcare providers, its rea-
sonable to tailor the sequence of rescue
actions to the most likely cause of arrest
BLS Skills
As in previous years, theres an emphasis on
providing high-quality chest compressions as
a key component of effective CPR. Import-
ant characteristics of chest compressions
outlined below are chest compression rate,
depth, adequate recoil, and chest compres-
sion fraction.
>> Depth: Compress to at least 2 in (5cm). Its
been found that injuries are more likely to
occur with compressions > 2.4 in (6 cm),
however, its important to recognize that
the majority of rescuers are more likely
to compress too shallowly and continue
to emphasize pushing hard (Class I).
>> Rate: An upper limit of 120 chest compres-
sions per minute has been added, resulting
in a recommendation of a compression
rate between 100120/minute (Class IIa).
>> Recoil: Avoid leaning to allow full chest
recoil (Class IIa).
>> Fraction: Chest compression fraction is an
indicator of how well the team is mini-
mizing pauses in CPR. Its calculated by
dividing the amount of time compressions
are delivered by the amount of time com-
pressions are indicated. The goal is to have
a fraction as high as possible, with a target
of at least 60% (Class IIb).
Ventilation by either rescue breathing or
bag-valve mask (BVM) continues to be an
important skill for healthcare providers.
>> Avoid excessive ventilation.
>> In patients without an advanced airway,
rescuers should deliver cycles of 30 com-
pressions and 2 breaths (Class IIa).
>> In patients with an advanced airway, res-
cuers should deliver 1 breath every 6 sec-
onds (10 bpm) while continuous chest
compressions are performed (Class IIb).
>> Routine use of passive ventilation during
CPR isnt recommended, however, in EMS
systems that use bundles of care involv-
ing continuous chest compressions, the
AEDs
>> For witnessed adult cardiac arrest when an
AED is immediately available, the defibril-
lator should be used as soon as possible
(Class IIa).
>> For unwitnessed arrest, or in cases where
the AED isnt immediately available, CPR
should be initiated and the AED applied
as soon as it is ready for use (Class IIa).
>> Theres insufficient evidence to recom-
mend the use of artifact-filtering algo-
rithms for analysis of rhythm during CPR.
>> Its recommended to immediately return
to chest compressions after shock delivery
(Class IIb).
CPR Quality, Accountability
& Healthcare Systems
>> Its reasonable to use audiovisual feedback
devices during CPR for real-time optimi-
zation of performance (Class IIb).
>> When resuscitation involves a team of
caregivers, there should be a designated
leader whose task it is to choreograph
the team activities with an effort to min-
imize interruptions in CPR and ensure
high-quality compressions and avoidance
of excessive ventilation.
>> CPR registry data continues to provide
important information about the care and
outcomes of patients and can be used to
improve processes and systems of care.
ALTERNATIVE CPR
TECHNIQUES & ADJUNCTS
By Steven C. Brooks, MD, MHSc, FRCPC
Conventional CPR consisting of manual
chest compressions interspersed with rescue

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 RESUSCITATION RECOMMENDATIONS
2015 AHA GUIDELINES UPDATE FOR CPR
breathing is inherently inefficient with respect
to generating significant cardiac output. A
variety of alternatives and adjuncts to con-
ventional CPR have been developed with the
aim of enhancing perfusion during resuscita-
tion from cardiac arrest, many of which can
be used in the prehospital setting.
A number of clinical trials, many of them
involving patients enrolled by prehospital pro-
viders, have resulted in new data on the effec-
tiveness of these alternatives since the 2010
Guidelines were published.
Impedance Threshold Devices (ITDs)
There was new evidence to guide recommen-
dations for the use of an ITD. One large mul-
ticenter randomized clinical trial from the
Resuscitation Outcomes Consortium called
ROC PRIMED failed to demonstrate any
improvement associated with the use of an
ITD (compared with a sham device) as an
adjunct to conventional CPR. Therefore, the
routine use of the ITD as an adjunct during
conventional CPR is not recommended in the
2015 Guidelines Update (Class III, no benefit).
Combined Use of ACD-CPR & ITD
The use of active compression-decompression
(ACD-CPR) in comparison with conventional
CPR was reviewed for the 2010 Guidelines.
Since then, new evidence is available regarding
the use of ACD-CPR in combination with
the ITD, and an ACD-CPR device has been
FDA approved and is available on the market.
ACD-CPR is performed by using a hand-
held device with a suction cup applied over
the midsternum of the chest. After chest
compression, the device is used to lift up
the anterior chest during decompressions.
This enhances the negative intrathoracic
pressure (vacuum) generated by chest recoil,
thereby increasing venous return (preload) to
the heart and cardiac output during the next
chest compression.
Commercially available ACD-CPR devices
have a gauge providing feedback on com-
pression and decompression forces and a
metronome to guide duty cycle and chest
compression rate.
The new guidelines point out that ACD-
CPR is believed to act synergistically with the
ITD to enhance venous return during chest
decompression and improves blood flow to vital
organs during CPR. Based on best available evi-
dence, the guidelines state that the combination
of ACD-CPR and ITD may be a reasonable
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1603jems_28 28
alternative in settings with available equipment
and properly trained personnel (Class IIb).
Extracorporeal Techniques &
Invasive Perfusion Devices
The term extracorporeal CPR or ECPR is for chest compressions vs. manual chest com-
used to describe the initiation of extracorporeal
circulation and oxygenation during the resus-
citation of a patient in cardiac arrest. This is
similar to heart-lung bypass used during some
cardiac surgical procedures.
The goal of ECPR is to support patients
in cardiac arrest while potentially reversible
conditions are treated. ECPR is a complex
process that requires a highly trained team,
specialized equipment and multidisciplinary
support within the local healthcare system.
The implementation of ECPR in the pre-
hospital setting is currently being done in some
areas of Europe, including Paris, France.
There have been no randomized trials
studying ECPR. Published case series have
restricted ECPR to patients aged 18 to 75
years with limited comorbidities, with arrest
of cardiac origin, after conventional CPR for
more than 10 minutes without return of spon-
taneous circulation (ROSC).
Theres currently insufficient evidence to
recommend the routine use of ECPR for
patients with cardiac arrest. However, in set-
tings where it can be rapidly implemented,
ECPR may be considered for select patients
for whom the suspected etiology of the car-
diac arrest is potentially reversible during a
limited period of mechanical cardiorespira-
tory support (Class IIb). For example, ECPR
could support a cardiac arrest patient while
they undergo PCI to open an occluded cor-
onary artery, could support patients with car-
diotoxic drug overdoses while the poison is
cleared from their system, or could support
victims of cardiac arrest due to myocarditis
while transplant options are explored.
Mechanical Chest Compression Devices
Three large randomized controlled trials
studying patients suffering out-of-hospital
cardiac arrest have been completed since the
2010 Guidelines: The CIRC study (Auto-
Pulse), the LINC Study (LUCAS) and the
PARAMEDIC Study (LUCAS).
None of these three studies demon-
strated improved outcomes for patients with
out-of-hospital cardiac arrest when treated
with mechanical chest compression devices
when compared with conventional manual CPR
performed in a high-quality, consistent manner
with limited compression interruptions.
The evidence doesnt currently demonstrate
a benefit with the use of mechanical devices
(load-distributing band or mechanical piston)
pressions in patients with cardiac arrest. How-
ever, the 2015 Guidelines Update states that
these devices may be a reasonable alternative
to conventional CPR in specific settings where
the delivery of high-quality manual compres-
sions may be challenging or dangerous for
the provider (e.g., limited rescuers available,
prolonged CPR, CPR during hypothermic
cardiac arrest, CPR in a moving ambulance,
CPR in the angiography suite, CPR during
preparation for ECPR) (Class IIb).
ADVANCED CARDIAC
LIFE SUPPORT (ACLS)
By Mark S. Link, MD
Oxygen Dose During CPR
There were no adult human studies identified
that directly compared maximal inspired oxy-
gen with any other inspired oxygen concen-
tration. However, one observational study of
145 OHCA patients evaluated arterial PO2
measured during CPR and cardiac arrest out-
comes. When supplementary oxygen is avail-
able, it may be reasonable to use the maximal
feasible inspired oxygen concentration during
CPR (Class IIb).
Physiologic Monitoring to Guide CPR
Specific physiological monitoring parameters
and values were specified in 2010. However,
in 2015, although the committee did see the
potential value of specific values, the exact tar-
gets were unclear and thus the specific targets
werent specified.
>> Although no clinical study has examined
whether titrating resuscitative efforts
to physiologic parameters during CPR
improves outcome, it may be reasonable
to use physiologic parameters (quantita-
tive waveform capnography, arterial relax-
ation diastolic pressure, arterial pressure
monitoring and central venous oxygen
saturation) when feasible to monitor and
optimize CPR quality, guide vasopressor
therapy and detect ROSC (Class IIb).
Prognostication in Cardiac Arrest
There was evidence to guide the estimates of
ROSC in patients undergoing CPR. If end-tidal
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 carbon dioxide (EtCO2) didnt improve in intu-
bated patients with resuscitation, the odds of
successful outcome was minimal.
>> In intubated patients, failure to achieve
an EtCO2 of greater than 10 mmHg by
waveform capnography after 20 minutes of
CPR may be considered as one component
of a multimodal approach to decide when
to end resuscitative efforts, but it should
not be used in isolation (Class IIb).
>> The above recommendation is made
with respect to EtCO2 in patients who
are endotracheally intubated.
>> In nonintubated patients, a specific EtCO2
cutoff value at any time during CPR
should not be used as an indication to
end resuscitative efforts (Class III: Harm).

BVM vs. Advanced Airways

The majority of retrospective observational
studies analyzed demonstrated slightly worse
survival with the use of an advanced airway
when compared with BVM ventilation. How-
ever, interpretation of these results is limited
by significant concerns of selection bias. Two
additional observational studies showed no
difference in survival.
>> Either a BVM device or an advanced air-
way may be used for oxygenation and ven-
tilation during CPR in both the in-hospital
and out-of-hospital setting (Class IIb).
>> For providers trained in their use, either a
supraglottic airway device or an endotra-
cheal (ET) tube may be used as the initial
advanced airway during CPR (Class IIb).

Clinical Assessment of Tube Placement

There was some evidence guiding clinical
assessment of tracheal tube placement.
>> Continuous waveform capnography is
recommended in addition to clinical
assessment as the most reliable method
of confirming and monitoring correct
placement of an ET tube (Class I).
>> If continuous waveform capnometry isnt
available, a non-waveform CO2 detector,
esophageal detector device or ultrasound
used by an experienced operator is a rea-
sonable alternative (Class IIa).
Ultrasound in Cardiac Arrest
The use of ultrasound in cardiac arrest was
evaluated for the 2015 Guidelines Update.
The studies were retrospective observational
and thus limited, but ultrasonography during
cardiac arrest was allowed.
The importance of a coordinated (pit crew) approach to resuscitation and close attention to limiting com-
pression interruptions is heavily emphasized in the 2015 AHA Guidelines. Photo Courtney McCain
>> Ultrasound (cardiac or non-cardiac) may Timing of Epinephrine Administration
be considered during the management of >> It may be reasonable to administer epi-
cardiac arrest, although its usefulness hasnt nephrine as soon as feasible after the
been well established (Class IIb). onset of cardiac arrest due to an initial
>> If a qualified sonographer is present and non-shockable rhythm (Class IIb).
use of ultrasound doesnt interfere with >> Theres insufficient evidence to make a
the standard cardiac arrest treatment pro- treatment recommendation as to the opti-
tocol, then ultrasound may be considered mal timing of epinephrine, particularly
as an adjunct to standard patient evalua- in relation to defibrillation, when cardiac
tion (Class IIb). arrest is due to a shockable rhythm, because
optimal timing may vary based on patient
Vasopressors in Cardiac Arrest factors and resuscitation conditions.
There were a number of questions on vasopres-
sors and its this section in the ACLS chapter Epinephrine Dose
that was most changed. >> Standard dose epinephrine (1 mg every

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 RESUSCITATION RECOMMENDATIONS
2015 AHA GUIDELINES UPDATE FOR CPR
35 minutes) may be reasonable for
patients in cardiac arrest (Class IIb).
>> High dose epinephrine isnt recommended
for routine use in cardiac arrest (Class III:
no benefit).
Vasopressin
>> Vasopressin offers no advantage as a sub-
stitute for epinephrine in cardiac arrest
(Class IIb).
>> Vasopressin in combination with epineph-
rine offers no advantage as a substitute
for standard dose epinepherine in cardiac
arrest (Class IIb).
Steroids in Cardiac Arrest
Steroid use in cardiac arrest was controver-
sial based on two in-hospital arrest studies
by the same institution. Importantly, these
studies bundled steroids with vasopressin
and epinephrine.
>> There are no data to recommend for or
against the routine use of steroids alone
for in-hospital cardiac arrest patients.
>> In in-hospital cardiac arrest, the combi-
nation of intra-arrest vasopressin, epi-
nephrine and methylprednisolone and
post-arrest hydrocortisone may be consid-
ered; however, further studies are needed
before recommending the routine use of
this therapeutic strategy (Class IIb).
>> For patients with out-of-hospital cardiac
arrest, use of steroids during CPR is of
uncertain benefit (Class IIb).
Defibrillation
Defibrillation strategies were evaluated exten-
sively and the guidelines were updated, but
there were no major changes.
>> Based on their greater success in arrhyth-
mia termination, defibrillators using bipha-
sic waveforms are preferred to monophasic
defibrillators for treatment of both atrial
and ventricular arrhythmias (Class IIa).
>> In the absence of conclusive evidence
that one biphasic waveform is superior to
another in termination of v fib, its rea-
sonable to use the manufacturers recom-
mended energy dose for the first shock. If
this isnt known, defibrillation at the max-
imal dose may be considered (Class IIb).
ACUTE CORONARY SYNDROMES
By Robert E. OConnor, MD, MPH, FACEP
The 2015 AHA Guidelines Update continue to
recognize that prompt diagnosis and treatment
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1603jems_30 30
of acute coronary syndromes (ACS) offers the
greatest potential benefit for myocardial sal-
vage. EMS providers must recognize patients
with potential ACS in order to initiate the eval-
uation, appropriate triage, and management as
fast and early as possible because, in the case of
ST elevation myocardial infarction (STEMI),
this recognition allows for prompt notification
of the receiving hospital and preparation for
emergent reperfusion therapy.
Prehospital ECG & STEMI Alerts
Prehospital 12-lead ECGs expedite the
diagnosis, shorten the time to reperfusion
(fibrinolytics or primary percutaneous cor-
onary intervention [PPCI]). The 2015
International Liaison Committee on Resus-
citation (ILCOR) systematic review examined
whether acquisition of a prehospital ECG
with transmission of the ECG to the hospi-
tal, notification of the hospital of the need for
fibrinolysis, or activation of the catheterization
laboratory changes any major outcome. The
2015 Guidelines Update contains the follow-
ing recommendations:
>> Prehospital 12-lead ECG should be
acquired early for patients with possible
ACS (Class I).
>> Prehospital notification of the receiving
hospital (if fibrinolysis is the likely reperfu-
sion strategy) and/or prehospital activation
of the catheterization laboratory should
occur for all patients with a recognized
STEMI on prehospital ECG (Class I).
>> Implementation of 12-lead ECG diagnos-
tic programs with concurrent medically-
directed qualityassurance is recommended
(Class I).
>> Prehospital personnel can accurately
identify ST-segment elevation from the
12-lead ECG.
>> If providers arent trained to interpret the
12-lead ECG, field transmission of the
ECG or a computer report to the receiv-
ing hospital is recommended (Class I).
Non-Physician STEMI Interpretation
When physicians arent present or not avail-
able to interpret an ECG, other methods for
interpretation must be used so that timely
patient care is not adversely affected. The
2015 ILCOR systematic review examined
whether non-physicians such as paramed-
ics and nurses could identify STEMI on an
ECG so that earlier identification of STEMI
could be made with acceptable rates of either
under-diagnosis (false-negative results) or
over-diagnosis (false-positive results).
Although transmission of the prehospital
ECG to the ED physician may improve posi-
tive predictive value and therapeutic decision-
making regarding adult patients with suspected
STEMI, if transmission isnt performed, it may
be reasonable for trained nonphysician ECG
interpretation to be used in making decisions,
including activation of the catheterization labo-
ratory, administration of fibrinolysis, and selec-
tion of destination hospital (Class IIa).
ADP Inhibition in Suspected STEMI
The 2015 ILCOR systematic review addressed
the clinical impact of the timing of admin-
istration of adenosine diphosphate (ADP)
inhibition in the treatment of patients with
suspected STEMI.
The relative merit of early prehospital vs.
hospital administration of ADP inhibition
as a general treatment strategy was assessed.
Differences between individual ADP inhibi-
tors were not examined.
The preferred reperfusion strategy for
STEMI patients is identification and resto-
ration of normal flow in the infarct-related
artery using percutaneous intervention. The
use of potent dual antiplatelet therapy in
STEMI patients undergoing PPCI is asso-
ciated with improved clinical outcomes as
well as lower rates of acute stent thrombosis.
Given the short time from first medical
contact to balloon inflation, treatment with
oral ADP inhibitors in a prehospital setting
has the potential to enhance platelet inhibi-
tion and improve procedural and clinical out-
comes after PPCI.
Three randomized controlled trials (RCTs)
showed no additional benefit to the outcome
of 30-day mortality and no additional benefit
or harm with respect to major bleeding with
prehospital administration compared with
in-hospital administration of an ADP-receptor
antagonist. Therefore, the 2015 AHA Guide-
lines Update recommends that in patients with
suspected STEMI intending to undergo PPCI,
initiation of ADP inhibition may be reason-
able in either the prehospital or in-hospital
setting (Class IIb).
Prehospital Anticoagulants in STEMI
In patients with suspected STEMI, anticoag-
ulation is standard treatment recommended by
the American College of Cardiology Foun-
dation/AHA Guidelines. The 2015 ILCOR
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2/15/16 11:26 AM
 systematic review sought to determine if any
important outcome measure was affected if an
anticoagulant was administered prehospital
compared with whether that same anticoag-
ulant was administered in-hospital.
A single nonrandomized, case-control study
found that while flow rates were higher in
an infarct-related artery when heparin and
aspirin were administered in the prehospital
setting vs. the ED, there was no significant
difference in death, PCI success rate, major
bleeding, or stroke.
While there seems to be neither benefit nor
harm to administering heparin to patients with
suspected STEMI before their arrival at the
hospital, prehospital administration of med-
ication adds complexity to patient care. The
2015 AHA Guidelines Update recommends:
>> That EMS systems that dont currently
administer heparin to suspected STEMI
patients do not add this treatment, whereas
those that do administer it may continue
their current practice (Class IIb).
>> In suspected STEMI patients for whom
there is a planned PCI reperfusion strategy,
administration of unfractionated heparin
(UFH) can occur either in the prehospital
or in-hospital setting (Class IIb).
The 2015 ILCOR systematic review also
examined whether the prehospital administra-
tion of an anticoagulant such as bivalirudin,
dalteparin, enoxaparin or fondaparinux instead
of UFH, in suspected STEMI patients who
are transferred for PPCI, changes any major
outcome. After reviewing the evidence, the
2015 AHA Guidelines Update recommends:
>> It may be reasonable to consider the pre-
hospital administration of UFH in STEMI
patients or the prehospital administration
of bivalirudin in STEMI patients who are
at increased risk of bleeding (Class IIb).
>> In systems in which UFH is currently
administered in the prehospital setting
for patients with suspected STEMI who
are being transferred for PPCI, it is rea-
sonable to consider prehospital adminis-
tration of enoxaparin as an alternative to
UFH (Class IIa).
Prehospital Fibrinolysis &
PCI Center Triage
Prehospital fibrinolysis requires a sophisticated
system of provider expertise, well-established
protocols, comprehensive training programs,
medical oversight, and quality assurance. In
many European systems, a physician provides
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1603jems_31 31
prehospital fibrinolysis, but nonphysicians can
also safely administer fibrinolytics.
The 2015 ILCOR systematic review eval-
uated whether prehospital fibrinolysis is pre-
ferred to reperfusion in-hospital where the
prehospital fibrinolysis expertise, education,
and system support exists. The following rec-
ommendations are included in the 2015 AHA
Guidelines Update:
>> Where prehospital fibrinolysis is avail-
able as part of a STEMI system of care,
and in-hospital fibrinolysis is the alterna-
tive treatment strategy, its reasonable to
administer prehospital fibrinolysis when
transport times are more than 30 minutes
(Class IIa).
>> Its strongly recommended that systems
that administer fibrinolytics in the prehos-
pital setting include the following features:
protocols using fibrinolytic checklists,
12-lead ECG acquisition and interpreta-
tion, experience in advanced life support,
communication with the receiving insti-
tution, medical director with training and
experience in STEMI management, and
continuous quality improvement (Class I).
>> Where prehospital fibrinolysis is avail-
able as part of the STEMI system of care
and direct transport to a PCI center is
available, prehospital triage and transport
directly to a PCI center may be preferred
because of the small relative decrease in
the incidence of intracranial hemorrhage
without evidence of mortality benefit to
either therapy (Class IIb).
>> If PCI is the chosen method of reperfu-
sion for the prehospital STEMI patient, it
is reasonable to transport patients directly
to the nearest PCI facility, bypassing closer
EDs as necessary, in systems where time
intervals between first medical contact and
balloon times are (Class IIa).
Other Interventions
Below is a summary of the 2015 AHA Guide-
lines Update recommendations for other inter-
ventions and treatments for ACS.
ACE Inhibitors: Although angiotensin-
converting enzyme (ACE) inhibitors and
angiotensin II receptor blockers (ARBs) have
been shown to reduce long-term risk of mor-
tality in patients suffering an acute myocardial
infarction (AMI), theres insufficient evidence
to support the routine initiation of ACE inhib-
itors and ARBs in the prehospital or ED set-
ting (Class IIb).
Aspirin: In addition to the prehospital
administration of aspirin, the 2015 Guidelines
Update emphasizes that dispatch centers should
play a key role in early ACS care by instructing
patients with no history of aspirin allergy and
without signs of active or recent gastrointesti-
nal bleeding to chew an aspirin (160325 mg)
while awaiting the arrival of EMS (Class IIa).
Morphine: Although the efficacy of other
analgesics is unknown, the recommendations
for morphine use includes:
>> Morphine is indicated in STEMI when
chest discomfort is unresponsive to nitrates
(Class I).
>> Morphine should be used with caution
in unstable angina/NSTEMI due to an
association with increased mortality in a
large registry (Class IIa).
Nitrates: Recommendations include:
>> EMS providers should administer up to
3 nitroglycerin doses (tablets or spray)
at intervals of 35 minutes until pain is
relieved or low blood pressure limits its
use. (Class I).
>> Nitrates in all forms are contraindicated in
patients with initial systolic blood pressure
< 90 mm Hg or 30 mm Hg below base-
line and in patients with right ventricular
(RV) infarction.
>> Caution is advised in patients with known
inferior wall STEMI, and a right-sided
ECG should be performed to evaluate
RV infarction.
>> Nitrates should be withheld in patients
with inferior STEMI and suspected RV
involvement because of the risk of a sud-
den drop in blood pressure.
>> Because of the risk of hypotension, nitrates
are contraindicated when patients have taken
a phosphodiesterase-5 (PDE-5) inhibitor
within 24 hours (48 hours for tadalafil).
Oxygen: Theres insufficient evidence to
support the routine use of oxygen in uncom-
plicated ACS. However, if a patient is dyspneic,
hypoxemic, or has obvious signs of heart fail-
ure, providers should titrate oxygen therapy,
based on monitoring of oxyhemoglobin sat-
uration, to 94% (Class I).
Ventricular Rhythm Disturbances
Treatment of ventricular arrhythmias during
and after AMI has been a controversial topic
for three decades. Primary v fib accounts for
the majority of early deaths during AMI. The
incidence of primary v fib is highest during
the first 4 hours after onset of symptoms but
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2/15/16 11:26 AM
 RESUSCITATION RECOMMENDATIONS
2015 AHA GUIDELINES UPDATE FOR CPR
remains an important contributor to mortal-
ity during the first 24 hours.
Secondary v fib occurring in the setting of
CHF or cardiogenic shock can also contribute
to death from AMI. V fib is a less common
cause of death in the hospital setting with the
use of fibrinolytics and percutaneous revascu-
larization as early reperfusion strategies. The
2015 AHA Guidelines Update recommen-
dations include:
>> Although prophylaxis with lidocaine
reduces the incidence of v fib, an analysis
of data from ISIS-3 and a metaanalysis
suggest that lidocaine increased all-cause
mortality rates.Thus, the practice of pro-
phylactic administration of lidocaine is
not recommended (Class III).
>> Sotalol has not been adequately studied
(Class IIb).
>> Amiodarone in a single RCT didnt appear
to improve survival in low doses and may
increase mortality in high doses when used
early in patients with suspected myocar-
dial nfarction (Class IIb).
>> Prophylactic antiarrhythmics are not rec-
ommended for patients with suspected
ACS or myocardial infarction in the pre-
hospital or ED (Class III).
>> Routine IV administration of beta-blockers
to patients without hemodynamic or
electric contraindications is associated
with a reduced incidence of primary v fib
(Class IIb).
>> Low serum potassium, but not magne-
sium, has been associated with ventricular
arrhythmias. Its prudent clinical practice
to maintain serum potassium > 4 mEq/L
and magnesium > 2 mEq/L (Class IIB).
>> Routine administration of magnesium to
patients with MI has no significant clinical
mortality benefit, particularly in patients
receiving fibrinolytic therapy.
Figure 1: Manual left uterine displacement with one-handed tech-
nique (A) and two-handed technique used during resuscitation (B)
A B
32 JEMS | MARCH 2016
1603jems_32 32
>> Following an episode of v fib, theres no con- plan accordingly.
clusive data to support the use of lidocaine >> Transport the pregnant woman quickly
or any particular strategy for preventing to a center capable of performing emer-
v fib recurrence. Further management of gency cesarean delivery. If ROSC cant
ventricular rhythm disturbances is discussed be achieved by 4 minutes of resuscitative
in Part 7 of the Guidelines: Adult ACLS. efforts, an emergency cesarean delivery
may allow separate resuscitation of the
SPECIAL CONSIDERATIONS: infant; by decompressing the uterus, this
PREGNANCY may also improve the chances of mater-
By Eric Lavonas, MD nal resuscitation.
& Farida Jeejeebhoy, MD >> Emergency cesarean delivery isnt a field
In 2015, not only did the AHA publish procedure. Even if the cesarean could be
updated guidelines for the management performed successfully, resuscitation of
of cardiac arrest during pregnancy, it also the critically stressed, probably premature
published an extensive scientific statement infant requires equipment and skills that
about preparation for and management of arent available on the ambulance. Instead,
cardiac arrest in pregnancy, available at continue highly effective CPR, transport
http://circ.ahajournals.org/content/ promptly, and give the receiving hospi-
early/2015/10/06/CIR.0000000000000300. tal as much warning as possible so that
they can assemble the specialized teams
Key Points and equipment needed to resuscitate the
>> When a woman in the third trimester mother and deliver and resuscitate the
of pregnancy develops cardiac arrest, two baby. A few minutes extra warning may
patients are involved. Fortunately, best care make the difference.
for the mother and best care for the baby
are almost always the same thing. SPECIAL CONSIDERATIONS:
>> Standard BLS (including hiqh-quality, IV LIPID EMULSIONS
minimally-interrupted CPR) and ACLS By Eric Lavonas, MD
are always the top priority. Do not delay Since the first animal studies were reported
CPR, shock or drug administration just in 1998 and the first human case report in
because the patient is pregnant! The babys 2006, theres been growing enthusiasm for
best chance comes from successful resus- the use of IV lipid emulsion (ILE) (some-
citation of the mother. times known by the brand name, Intralipid)
>> In addition, if the fundus is above the to treat severe poisoning.
umbilicus, perform manual left uterine This treatment was originally developed
displacement. This simply involves push- to treat a rare but feared complication of a
ing the uterus to the left to allow blood nerve block, in which a bolus of the local
from the inferior vena cava to return to anesthetic bupivacaine accidentally got into
the heart. (See Figure 1.) the bloodstream, causing seizures and cardio-
>> Recognize that pregnant women may pres- vascular collapse.
ent a difficult airway. If youre going to The concept has been termed, lipid res-
intubate or place a supraglottic airway, cue. The theory is that by giving a lot of IV fat
very quickly, the fat-soluble drug will dissolve
into fat globules in the bloodstream, taking it
away from the heart cells. In addition, high-
dose fatty acids provide extra energy for heart
cells when they need it most.
FIGURE COURTESY AMERICAN HEART ASSOCIATION
All of this has coined a new term for acci-
dental poisoning by bupivacaine, lidocaine,
and similar drugs: local anesthetic systemic
toxicity (LAST).
Theres little doubt that ILE works for
LAST caused by bupivacaine, although there
have been no human clinical trials, a large
number of animal studies and human case
reports consistently show a benefit.
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2/15/16 11:26 AM
 The information isnt so clear that ILE
works for LAST from other local anesthetics,
and is quite mixed for other drug poisoning.
Certainly there are miraculous case reports of
patients who were in cardiac arrest due to a
drug overdose and who failed all other forms of
resuscitation recovering suddenly after a bolus
of ILE is given. However, animal studies are
mixed, and case reports of failed resuscitation
with ILE are also plentiful.
Theres also a big difference between most
of the animal studies, in which the poison was
given via IV, and most human overdoses, which
involve pills. Some early studies suggest that
ILE administration may increase absorption
of fat-soluble medications from the intestinal
tract, which could make the poisoning worse.
How this balances out for a patient
whos already critically ill isnt known. Oth-
erwise, ILE is quite safe, although it tem-
porarily causes problems with some lab test
results, and may cause pancreatitis and lung
problemsminor concerns when the drug
is used in life-threatening situations.
Lipid emulsion has been used for decades
as part of IV feeding for people whose intes-
tinal tracts dont work, and theyre widely
commercially available. Some animal stud-
ies show that ILE changes the bodys sen-
sitivity to epinephrine and vasopressin, but
as yet there are no data to show that chang-
ing from standard ACLS doses is necessary
or beneficial.
The Bottom Line
ILE therapy can be life-saving for LAST due
to bupivacaine toxicity, and should be consid-
ered part of first-line therapy for these condi-
tions. However, EMS providers should rarely
if ever encounter cases of LAST, and any sur-
gery center that provides regional anesthesia
probably has a protocol to give ILE.
Whether ILE helps with other forms of
critical drug poisoning is much more question-
able. The AHA believes that it may be reason-
able to use ILE in patients with drug-induced
cardiac arrest who are failing standard resusci-
tation measures. This group has little to lose.
Administering ILE
Nobody knows the best dose of ILE. The most
common approach is to use a 20% emulsion
of long-chain triglycerides (e.g., Intralipid),
giving 1.5 mL/kg of lean body mass IV over
1 minute. Repeat boluses may be given once
or twice if needed for persistent cardiovascular
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1603jems_33 33
collapse. If ROSC is achieved, an infusion of
0.25 mL/kg/min for 3060 minutes may pre-
vent recurrent toxicity. The same maximum dose
isnt known10 mL/kg has been suggested.
PEDIATRIC BLS & CPR QUALITY
By Dianne L. Atkins, MD
The new recommendations in the Pediatric
BLS guidelines are intended to improve the
quality of CPR in children. The review was
limited to specific elements of CPR for which
there were new data to guide us.
The pediatric guidelines are intended for
infants less than 1 year of age and pre-pubertal
children. Puberty is defined in females as breast
development and in males as the presence of
axillary hair. Adult BLS guidelines apply after
puberty. There are also new algorithms spe-
cific for 1- and 2-person CPR.
Compressions First?
Asphyxial arrest occurs more commonly in
children compared to primary cardiac arrest,
making ventilations more important in chil-
dren compared to adults. However, simulation
studies demonstrate that the delay in starting
ventilations is only 18 seconds when giving 30
compressions followed by two rescue breaths
for a single rescuer and less for two rescuers.
A common algorithm for all ages decreases
the complexity and provides consistency in
teaching. Outcome data comparing CAB
(i.e., chest compressions, airway, breathing) vs.
ABC (i.e., airway, breathing, chest compres-
sions) for infants and children arent available.
>> Due to the limited amount and quality of
the data, it may be reasonable to maintain
the sequence from the 2010 Guidelines
by initiating CPR with CAB over ABC
(Class IIb, LOE E). Knowledge gaps exist
and specific research will be required to
examine best approach to initiating CPR
in children.
Chest Compression Depth & Rate
Achieving a specific chest compression depth
appears to improve resuscitation outcomes in
children, similar to adult studies. Chest com-
pression depth is often inadequate in chil-
dren and a recent study has demonstrated
that compression depth of > 51 mm (5.1 cm)
in children older than 8 years was associated
with improved 24-hour survival.
Since there was insufficient data to review
compression rate in infants and children, the
2015 Guidelines Update recommends the
adult compression rate.
>> Its reasonable that rescuers provide
chest compressions in pediatric patients
(1 month to the onset of puberty) that
depress the chest at least 1/3 the anterior-
posterior diameter of the chest. This
equates to approximately 1.5 in. (4 cm)
in infants to 2 in. (5 cm) in children. (Class
IIa, LOE C). Once children have reached
puberty, the recommended adult compres-
sion depth of at least 5 cm, but no more
than 6 cm, should be used for the adoles-
cent of average adult size.
>> In order to maximize simplicity in CPR
training, in the absence of sufficient pedi-
atric evidence, the adult chest compression
rate of 100120 compressions per minute
should be used for infants and children.
Compression-Only CPR
In a very large registry study of pediatric
out-of-hospital cardiac arrest, the 30-day sur-
vival with good neurologic function was worse
with compression-only CPR compared to con-
ventional CPR. In a subset of children with
presumed cardiac etiology, compression-only
CPR was as effective as conventional CPR.
In patients with presumed asphyxial
arrest, the outcomes with compression-only
CPR were the same as patients who received
no bystander CPR. In a second study, from
the same registry, compression-only CPR
was associated with worse 30-day outcomes
compared to patients who received conven-
tional CPR.
>> Conventional CPR (i.e., rescue breathing
and chest compressions) should be pro-
vided for pediatric cardiac arrests (Class I
LOE B-NR). The asphyxial nature of
the majority of pediatric cardiac arrests
necessitates ventilation as part of effective
CPR, however, as chest compression-only
CPR is effective in patients with a primary
cardiac event, if rescuers are unwilling or
unable to deliver breaths, we recommend
rescuers perform chest compressions only
CPR for infants and children in cardiac
arrest (Class I LOE B-NR).
PEDIATRIC ALS
By Allan de Caen, MD, FRCP
Effective ALS for children builds upon a
foundation of excellent BLS, and CPR in
particular. If good BLS isnt provided, ALS
interventions will be limited in their ability
to improve patient outcomes. AHA pediatric
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2/15/16 11:26 AM
 RESUSCITATION RECOMMENDATIONS
2015 AHA GUIDELINES UPDATE FOR CPR

ALS guidelines changes for 2015 relevant to prophylactic use of atropine (e.g., with or moderate hypothermia are acceptable
the EMS practitioner can be broken down the use of fentanyl or succinylcholine for therapeutic alternatives for these children.
into pre-arrest, intra-arrest and post-arrest intubation). New literature also suggests Fever after ROSC has been associated
care recommendations. that if atropine is to be administered pre- with worsened outcomes and should be
intubation, theres no lower limit to the dose avoided. No data exists to support initi-
Pre-Arrest Care (i.e., patients should receive 0.02 mg/kg, ating cooling/avoidance of fever in the
>> The use of early and rapid fluid resuscita- not a minimum dose of 0.1 mg). prehospital setting.
tion remains a cornerstone of therapy for >> Post-ROSC hypotension in survivors of
shock states, but the specific role for bolus Intra-Arrest Care pediatric cardiac arrest is common and
fluid therapy for some patients is contro- >> Pediatric observational data now exists associated with poor patient outcome. A
versial. Data suggests that when caring that suggests that either lidocaine or systolic blood pressure above the 5th per-
for febrile infants and children who are amiodarone may be used for shock- centile for the childs age should be main-
in shock in settings where theres limited refractory v fib or pulseless v tach. tained after ROSC by the use of fluid and/
access to ventilatory or inotropic support, >> Despite an extensive review, theres an or inotropes and vasopressors.
the use of bolus fluid therapy may be associ- absence of high-quality evidence sup- >> Extremes (high and low) of patient PaCO2
ated with increased patient mortality. Fluid porting the use of a single factor during and PaO2 post-ROSC are associated with
therapy should still be administered by pediatric resuscitation to guide either worsened patient outcomes. Although the
bolus to infants and children in shock, but termination or continuation of ongo- pediatric evidence is limited and contradic-
with frequent reassessment of the patient ing resuscitative measures. Practitioners tory, its suggested that rescuers target the
during and following boluses to ensure must use multiple clinical factors during patients pre-arrest norm for PaCO2, and
excessive fluid isnt administered. CPR to support these kinds of decisions. oxygen saturations of between 9499%.
>> Atropine has historically been given as
a routine component of pediatric rapid Post-Arrest Care NEONATAL RESUSCITATION
sequence intubation for critically ill infants >> A recent study of infants and children By Marya L. Strand, MD, MS, FAAP
and children. High-quality data supporting remaining comatose after ROSC from & Henry C. Lee, MD, FAAP
this indication is lacking. Recent obser- out-of-hospital cardiac arrest compared For newly born infants or infants during the
vational data shows that its routine use the use of moderate hypothermia (3234 first few weeks after birth, the assessment of
pre-intubation for all critically ill infants degrees C) therapy for 2 days followed by whether resuscitation is required depends on
and children is neither protective for bra- 3 days of normothermia, to maintenance assessment of two vital signs: respirations
dycardia nor associated with reduced mor- of normothermia (3637.5 degrees C) for (apnea or gasping) and heart rate (less than
tality. There may be subgroups of patients 5 days. No significant difference in sur- 100 beats per minute).
with a higher risk of bradycardia during vival or neurologic outcome was found. When either of those characteristics is
intubation that may benefit from the The application of either normothermia abnormal, successful resuscitation depends
on ventilation effective in expanding the lungs.
Table 1: The six ventilation corrective steps (MR. SOPA) Ventilation is most effective when using an
appropriately sized mask, positioning the air-
Corrective Steps Actions
way and making sure the airway is clear of
M Mask adjustment Reapply the mask. Consider the 2-hand technique. obstruction. Key principles of achieving effec-
tive ventilation are shown in Table 1.
R Reposition airway Place head neutral or slightly extended.
Initial ventilation for term infants is provided
Try positive pressure ventilation (PPV) and reassess chest movement. with 21% oxygen. Preterm infants can also be
ventilated using 21% oxygen and should be
S Suction mouth and nose Use a bulb syringe or suction catheter. started at no more than 30%. The oxygen con-
centration should be increased to 100% when
O Open mouth Open the mouth and lift the jaw forward.
chest compressions are needed. Oxygen deliv-
Try PPV and reassess chest movement. ery should be guided by pulse oximetry, and
newborns can take up to 10 minutes to reach
Increase pressure in 510 cmH2O increments, max
P Pressure increase saturations of 85%. (See Table 2, p. 35.) With
40 cmH2O.
the recognition that the most sensitive indicator
Try PPV and reassess chest movement. of a successful response to resuscitation is heart
rate, a new recommendation is the use of 3-lead
A Alternative airway Place an endotracheal tube or laryngeal mask. ECG when possible to monitor heart rate. This
Try PPV and assess chest movement and breath sounds. is due to the relative inaccuracy of auscultation
or palpation of the umbilical pulse. However,
American Academy of Pediatrics and American Heart Association: Textbook of neonatal resuscitation, 6th ed. even when ECG is used, pulse oximetry is also
American Academy of Pediatrics: Elk Grove Village, Ill., p. 95, 2011. Used with permission. required in order to guide oxygen use.

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1603jems_34 34 2/15/16 11:26 AM

 Assuring effective ventilation prior to
beginning chest compressions is vital. If a
newborn is progressing to CPR, intubation
or placement of a supraglottic airway device is
recommended. Supraglottic airways have not
been evaluated during chest compressions, for
administration of medications, or for infants
less than 34 weeks gestational age.
Maintaining normothermia is important
in neonatal resuscitation. Methods to keep
babies warm, particularly preterm infants less
than 32 weeks gestational age, include using
a hat, wrapping in food-grade plastic, warm
blankets, increasing environmental tempera-
ture, using a chemical warming mattress, and
placing the infant skin-to-skin with his or
her mother.
Most neonatal events are due to respiratory
failure, as opposed to older children who likely
have cardiac failure. Because of this difference,
neonatal CPR uses 3 compressions to 1 breath.
This cycle is completed in a 2-second interval,
resulting in 90 compressions and 30 breaths
each minute. Compressions should be deliv-
ered using the 2-thumb technique with both
hands encircling the thorax and the thumbs
on the lower 1/3 of the sternum. The 2-finger
technique is no longer recommended. Unlike
resuscitation for older patients, compressions
and ventilations should be coordinated to avoid
simultaneous delivery.
Drugs are rarely needed for neonatal resus-
citation. However, if a heart rate less than
60 persists despite adequate ventilation with
100% oxygen and CPR, epinephrine (0.1 to
0.3 mL/kg of 1:10,000 epinephrine) or nor-
mal saline (10 mL/kg) may be given by IV.
For a newborn infant, the umbilical vein or
intraosseous route may be the quickest way
to achieve access.
Although previous iterations of guidelines
have recommended intratracheal suctioning of
infants born through meconium-stained amni-
otic fluid, routine suctioning of such patients is
no longer suggested. Instead, appropriate inter-
ventions to support ventilation and oxygen-
ation, such as ventilation with bag and mask,
should be initiated. Intubation and suctioning
with a meconium aspirator can be attempted
if the airway appears to be obstructed.
As neonatal resuscitation requires team-
work and may be an infrequent occurrence for
emergency providers, we encourage teams to
practice both technical skills as well as behav-
ioral and communication skills through sim-
ulation and debriefing. JEMS
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1603jems_35 35
Table 2: Oxygen saturation
target range
Target pre-ductal SpO2 after birth
1 min 60%-65%
2 min 65%-70%
3 min 70%-75%
4 min 75%-80%
5 min 80%-85%
10 min 85%-95%
American Academy of Pediatrics and American Heart
Association: Textbook of neonatal resuscitation, 6th
ed. American Academy of Pediatrics: Elk Grove Vil-
lage, Ill., p. 54, 2011. Used with permission.
Erin E. Brennan, MD, is an assistant pro-
fessor in emergency medicine at Queens
University in Kingston, Ontario. She conducts
research in CPR education and is a member
of the BLS for Healthcare Providers Education
Development committee of the American Heart Association
(AHA). Shes a volunteer member of the AHAs BLS subcom-
mittee and participated in the creation of the 2015 BLS
updated guidelines.
Steven C. Brooks, MD, MHSc, FRCPC, is a
clinician-scientist and associate professor in
emergency medicine at Queens University
in Kingston, Ontario. He conducts research
in the areas of cardiac arrest and resuscita-
tion with a specific focus around innovative technology solu-
tions. He represents the Heart and Stroke Foundation of Canada
as a member of the Advanced Cardiac Life Support Taskforce
of the International Liaison Committee for Resuscitation and
is a member of the Emergency Cardiovascular Care Science
Subcommittee of the American Heart Association.
Mark S. Link, MD, is a professor of medicine
at Tufts University School of Medicine. He
chaired the 2015 ALS Committee for the
American Heart Association Guidelines. Hes
the director of the Center for the Evaluation
of Athletes and the Heart Station, and is co-director of the
Cardiac Electrophysiology Laboratory and the Hypertrophic
Cardiomyopathy Center.
Robert E. OConnor, MD, MPH, FACEP, is
professor and chair of emergency medicine
and professor of public health sciences at the
University of Virginia in Charlottesville, Va.
Hes also an emergency physician at Culpeper
Regional Hospital in Culpeper, Va., and serves as chair of the
board of the American Council of Emergency Physicians. Hes
held a variety of leadership positions within the American
Heart Association (AHA) since 2001, most recently acting as
chair for the committee that updated the 2015 AHA Guidelines
Update on acute coronary syndromes.
Eric Lavonas, MD, is a board-certified emer-
gency physician and medical toxicologist at
Denver Health Medical Center and the Univer-
sity of Colorado. Hes a former member of the
American Heart Assocation ALS subcommittee
and chaired the Special Circumstances of Resuscitation writing
group for the 2015 Guidelines Update. His research involves
antidote development, carbon monoxide poisoning, medication
safety and snake envenomation. Hes a former advanced EMT.
Farida Jeejeebhoy, MD, is an assistant pro-
fessor of medicine at the University of
Toronto. Shes also a cardiologist in the Wil-
liam Osler Health System and served as the
chair for the AHA group that developed the
scientific statement on cardiac arrest in pregnancy.
Dianne L. Atkins, MD, is a professor of pedi-
atrics in the Stead Family of Pediatrics at the
University of Iowa Carver College of Medicine.
Shes conducted research on cardiac arrest
in children and defibrillation in children and
has been actively involved in the American Heart Assocation
Pediatric Subcommittee as well as acted as chair of the Sci-
ence Committee. She recently served on the Institute of Med-
icine Panel which published the report Strategies to Improve
Cardiac Arrest Survival: A time to act in June 2015.
Alan de Caen, MD, is a pediatric intensive
care consultant and clinical professor of pedi-
atrics at the Stollery Childrens Hospital/
University of Alberta in Edmonton, Canada.
His research/clinical interests include resus-
citation medicine and critical care transport medicine. He has
held leadership positions within the International Liaison
Committee on Resuscitation (ILCOR) since 2003, and since
2005 has been co-chair of ILCORs Pediatric Task Force, helping
lead its systematic review process of the pediatric resuscita-
tion literature. He was the writing group chair for the 2015
American Heart Assocation Guidelines on pediatric ALS.
Marya L. Strand, MD, MS, FAAP, is an asso-
ciate professor and director of the Neonatol-
ogy Fellowship Program in the Division of
Neonatal-Perinatal Medicine at Saint Louis
University School of Medicine and a practic-
ing neonatologist at Cardinal Glennon Childrens Medical
Center. Shes also a member of the Neonatal Resuscitation
Program steering committee.
Henry C. Lee, MD, FAAP, is a neonatologist
at Lucile Packard Childrens Hospital and
assistant professor of pediatrics at Stanford
University. He holds board certification in
pediatrics and neonatal-perinatal medicine,
and is the director of research for the California Perinatal
Quality Care Collaborative. Hes also a member of the Neona-
tal Resuscitation Program steering committee.
mARcH 2016 | JEMS 35
2/15/16 11:26 AM
 RESUSCITATION RECOMMENDATIONS
2015 AHA GUIDELINES UPDATE FOR CPR
Prehospital naloxone administration
for opioid-related emergencies
By Ian R. Drennan, ACP, BScHK, PhD(c) & Aaron M. Orkin, MD, MSc, MPH
O
pioid abuse is a major public health
epidemic in the United States and
Canada as the number of deaths
related to opioid toxicity continues to rise. In
2013, there were 16,325 prescription opioid-
related deaths in the U.S., quadruple the num-
ber of deaths that occurred in 1999,1 and an
additional 8,257 deaths from heroin.2,3 A
36 JEMS | MARCH 2016
1603jems_36 36
similar situation exists in Canada.4
There have been multiple efforts to com-
bat this crisis, including calls to improve opi-
oid prescription practices, access to addiction
treatment, and enhanced treatment tools and
protocols for first responders.
With the implementation of public nal-
oxone (Narcan) distribution programs,5 and
PHOTO MATTHEW STRAUSS
administration of naloxone by police depart-
ments and first response programs,6 nalox-
one is becoming widely available to treat
patients with suspected opioid toxicity in the
out-of-hospital setting.
In cities across North America, laypeople
are being equipped with naloxone kits and
overdose resuscitation training, while many
paramedic and EMS agencies still restrict nal-
oxone administration.
This has led to debate regarding the role of
naloxone in the out-of-hospital setting. Who
should be administering it? When and how
should it be administered?
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2/15/16 11:26 AM
 EMS ROLE
EMS providers are often called to respond
to situations involving opioid-related emer-
gencies. These calls may involve a variety of
patient conditions including chronic pain
management for musculoskeletal pain or
cancer-related pain, illicit drug use and inten-
tional overdose.
In general, the term opioid-associated
resuscitative emergency is preferable to opioid
overdose because the patients critical condi-
tion is seldom due to opioids alone. Opioid-
associated resuscitative emergency refers to
any clinical condition thats known or thought
to be associated with opioids where the patient
is obtunded without obvious signs of life.
Isolated opioid toxicity is associated with
central nervous system and respiratory depres-
sion that can quickly progress to respiratory
and cardiac arrest. However, most critical and
life-threatening drug-related emergencies
involve multidrug toxidromes, co-ingestion
or other complicating comorbidities.710
In many situations EMS providers encoun-
ter in the field, the patients clinical presenta-
tion may not be the result of opioid toxicity
alone. EMS providers must be ready to man-
age undifferentiated resuscitative emergencies
involving opioids, and therefore must be pre-
pared to manage opioid toxicity in the pres-
ence of other comorbidities and co-ingestions.
In addition to standard resuscitation pro-
cedures, the goal of naloxone administration
by first responders and EMS providers should
be to improve breathing and restore airway
reflexes in the obtunded patient, not to restore
full level of consciousness.
MECHANICS OF NALOXONE
Naloxone is an opioid antagonist that com-
petitively binds to opioid receptors, reversing
the effects of opioids in the central nervous
system and gastrointestinal tract.
For reversing overdose, naloxone can be
administered using a variety of different meth-
ods: IV,11,12 intramuscularly (IM),12,13 subcuta-
neously (SC),14 intranasally,13,15 by nebulization
(NB),16,17 or via endotracheal tube (ETT).18
The optimal route of administration
depends on a number of factors including
availability, provider skill and level of train-
ing, and the clinical circumstances.
The ideal dosage of naloxone isnt known
and is dependent upon the route of adminis-
tration. An initial dose of 0.4 mg IV or IM is
reasonable to avoid severe opioid withdrawal,
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1603jems_37 37
with repeated doses up to 2 mg to achieve the 2015 AHA GUIDELINES UPDATE
desired effect. Intranasal naloxone should start The 2015 American Heart Association
with a dose of 2 mg.19 (AHA) Guidelines Update examined evi-
Naloxone has a good safety profile with a dence around the use of naloxone by first aid
low incidence of serious side effects, even when providers, BLS providers and ALS providers
administered to patients who are ultimately for severe opioid toxicity and cardiac arrest.19
determined not to have opioidtoxicity.20 Several recommendations were made based
Adverse reactions from naloxone admin- on available evidence pertaining to the admin-
istration are generally a result of reversing istration of naloxone in the prehospital setting.
dependency and precipitating withdrawal The guidelines were designed to provide a safe
states, leading to sympathetic excess.21 Adverse and effective approach to opioid-associated
reactions are rarely life-threatening and can resuscitative emergencies, recognizing that
include: unmasked pain, sweating, nausea and most cases involve multiple pathophysiolog-
vomiting, pulmonary edema, hypertension, ical processes and comorbidities.
tachycardia, agitation and irritability.21 The 2015 AHA Guidelines Update place
Though precipitating severe withdrawal is an emphasis on incorporating lay rescuers
a common concern among prehospital health- in the chain of survival, not only for cardiac
care providers, its a very rare occurrence when arrest patients but for all patients with sus-
small doses of naloxone are given to obtunded pected opioid toxicity. As with patients in
patientspatients with resuscitative emer- cardiac arrest, bystanders have an important
gencies dont immediately go from deeply role in recognizing and responding opioid-
obtunded to severe withdrawal. related emergencies.
Figure 1: Opioid-associated life-threatening emergency (adult) algorithm
for bystanders, first aid providers, and non-healthcare BLS providers19
ASSESS AND ACTIVATE
Check for unresponsiveness and call for nearby help. Send someone to call 9-1-1 and get AED
and naloxone. Observe for breathing vs. no breathing or only gasping.
BEGIN CPR
If victim is unresponsive with no breathing or only gasping, begin CPR. If alone, perform CPR for
about 2 minutes before leaving to call 9-1-1 and get naloxone and AED.
ADMINISTER NALOXONE
Give naloxone as soon as it is available: 2 mg intranasal or 0.4 mg intramuscular. May repeat
after 4 minutes.
DOES THE PERSON RESPOND?
At any time, does the person move purposefully, breathe regularly, moan or otherwise respond?
No Yes
CONTINUE CPR AND USE AED STIMULATE AND REASSESS
AS SOON AS IT IS AVAILABLE Continue to check responsiveness and
Continue until the person responds or until breathing until advanced help arrives. If
advanced help arrives. the person stops responding, begin CPR
and repeat naloxone.
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2/15/16 11:26 AM
 RESUSCITATION RECOMMENDATIONS
2015 AHA GUIDELINES UPDATE FOR CPR

Community-based education programs tar- are in cardiac arrest. administration. The focus of EMS provid-
geting high-risk populations are an important Although naloxone has no clear role in the ers should be on assisting respirations with
component of prehospital response systems. treatment of patients who are in confirmed a bag-valve mask and initiating high-quality
These education programs may include nal- cardiac arrest, rapid naloxone administra- chest compressions and rapid defibrillation
oxone distribution as a component. Most fatal tion can be lifesaving for patients who still where indicated.
opioid-related emergencies are witnessed, and have a pulse but are severely obtunded with Both basic and advanced EMS providers
patients with severe opioid toxicity wont be decreased respiratory effort. Furthermore, nal- should be trained and capable of administer-
able to administer their own treatment. There- oxone administration isnt associated with any ing naloxone. As healthcare providers perform
fore, its reasonable to train bystanders and any- known harms in cardiac arrest patients. pulse checks it may be possible to differentiate
one likely to witness an overdose on what to For first aid and BLS non-healthcare between obtunded patients and those in car-
do in case of an opioid-related emergency.5,22 providers who dont perform pulse checks, diac arrest. Patients with a confirmed opioid-
These programs generally associated cardiac arrest
train participants to rec- should be managed accord-
ognize overdose, activate ing to standard cardiac
EMS, deliver basic first aid The goal of naloxone arrest guidelines.23,24
and to stay with the patient There are no studies
until help arrives. administration by first responders to guide recommenda-
EMS personnel should tions on the administra-
be familiar with these pro- & EMS providers should be to tion of naloxone during
grams, and prepared to cardiac arrest, and no
assume care from trained improve breathing & restore data to show if naloxone
bystanders who may have improves patient outcomes
administered naloxone airway reflexes in the obtunded (i.e., return of spontaneous
prior to EMS arrival. EMS circulation or survival to
personnel also need to be patient, not to restore full discharge) 19 compared
aware of these programs to standard resuscita-
so they can provide reas- level of consciousness. tion care.25 Many opioid-
surance and support to related ardiac arrests arent
bystanders who may have the result of isolated opioid
saved a life by following their first aid training. differentiating between patients who are toxicity but involve co-ingestion of mul-
Studies have shown that community-based severely obtunded with respiratory depres- tiple agents, and medical or mental health
education programs and naloxone distribution sion and those patients who are in cardiac comorbidities that wont respond to nalox-
programs are safe and effective and its rec- arrest is impossible. In this situation, where one administration.
ommended that education in opioid response the provider is unable to differentiate cardiac Out-of-hospital clinicians should be aware
and naloxone administration is available for arrest, providers should follow standard BLS that pulse checks are of limited reliability
at-risk populations.5 care according to the 2015 AHA Guidelines in deeply sedated patients, even when per-
Bystanders trained in these programs often Update, including immediate activation of formed by healthcare providers, so confirm-
administer naloxone successfully and theres EMS, initiation of CPR and application of ing cardiac arrest can be very challenging in
good evidence to show that the availability of an automated external defibrillator (AED).23 this patient population.26
naloxone in the community isnt associated Once standard resuscitation measures are in In patients with an opioid-associated resus-
with increased opioid misuse or higher-risk place, its reasonable for providers to adminis- citative emergency, naloxone should be admin-
drug behaviors. In fact, its often associated ter naloxone to these patients without inter- istered by properly trained providers if theres a
with an increased awareness of these behaviors rupting ongoing resuscitation processes. (See definitive perfusing cardiac rhythm (i.e., pulse
and recognition of opioid-related emergencies Figure 1, p. 37.) determined in less than 10 seconds) or uncer-
among high-risk populations.5 Although theres no clear benefit of nalox- tainty about whether the patient is in cardiac
The appropriate treatment for opioid- one for a patient who is in cardiac arrest, in this arrest. Bag-valve mask ventilations should be
related emergencies in the out-of-hospital situation the potential benefit of administration continued after naloxone administration until
setting is dependent upon the level of train- of naloxone to a patient who isnt in cardiac spontaneous respirations return, and standard
ing of the provider (e.g., first aid, BLS, ALS), arrest outweighs any theoretical risk of nalox- ACLS measures may be required if sponta-
as well as confirmation that the patient is in one administration to a patient in cardiac arrest. neous respirations dont occur.
cardiac arrest. For BLS and ALS healthcare providers Access to more advanced care shouldnt
The chaotic, high-stress and uncontrolled responding for patients of suspected opioid- be delayed for naloxone administration. Fur-
environment of prehospital medicine can make related emergencies in the out-of-hospital thermore, patients who respond to naloxone
it extremely difficult to differentiate patients setting, as with non-healthcare providers, administration should receive follow-up care
who are severely obtunded with decreased its important that standard resuscitation from advanced healthcare providers, unless fur-
respiratory effort, from those patients who measures take precedence over naloxone ther care is competently refused by the patient.

38 JEMS | MARCH 2016 www.jeMs.CoM

1603jems_38 38 2/15/16 11:26 AM

 Patients who initially respond to treatment
may develop recurrent episodes of decreased
respiratory effort, sedation and central nervous
system depression and should be monitored
for an appropriate period of time by advanced
healthcare providers.21
CONCLUSION
As 9-1-1-calls for opioid-associated emergen-
cies continue to increase, EMS providers of all
levels must be properly trained to respond to
these life-threatening emergencies, including
the administration of naloxone.
The goal of prehospital naloxone adminis-
tration should be to restore adequate respira-
tory status and airway reflexes, not to restore
full level of consciousness. EMS providers
must be aware that many critical situations
they encounter may not be the result of isolated
opioid toxicity, and must therefore be prepared
to respond to emergencies involving multiple
comorbidities and co-intoxications. JEMS
Ian R. Drennan, ACP BScHK, PhD(c), is a
paramedic, educator and researcher in
Ontario, Canada. Hes a PhD candidate at
Rescu, St. Michaels Hospital and the Institute
of Medical Science at the University of
Toronto. His research interests are focused on prehospital care
of cardiac arrests and other life-threatening emergencies
including trauma, sepsis and STEMI.
Aaron M. Orkin, MD, MSc, MPH, is an emer-
gency and public health physician and
researcher based in Toronto, Canada. Hes a
clinical public health fellow at the Dalla Lana
School of Public Health and St. Michaels
Hospital. His research concerns programs to train the lay pub-
lic to intervene in opioid overdose and other life-threatening
health emergencies.
REFERENCES
1. Chen LH, Hedegaard H, Warner M. (Sept. 2014.) Drug-poisoning
deaths involving opioid analgesics: United States, 1999-2011.
Centers for Disease Control and Prevention. Retrieved Dec. 5,
2015, from www.cdc.gov/nchs/data/databriefs/db166.pdf.
2. CDC. (Sept. 16, 2015.) Injury prevention and control: Prescrip-
tion drug overdose. Retrieved Dec. 1, 2015, from www.cdc.gov/
drugoverdose/index.html.
3. Hedegaard H, Chen LH, Warner M. (March 2015.) Drug-poison-
ing deaths involving heroin: United States, 2000-2013. Centers
for Disease Control and Prevention. Retrieved Dec. 5, 2015, from
www.cdc.gov/nchs/data/databriefs/db190.htm.
4. Carter CI, Graham B. (July 2014.) Opioid overdose prevention and
response in Canada. Canadian Drug Policy Coalition. Retrieved Dec. 1,
2015, from www.drugpolicy.ca/wp-content/uploads/2014/07/
CDPC_OverdosePreventionPolicy_Final_July2014.pdf.
www.jems.com
1603jems_39 39
New Hampshire residents whose family members or friends are at risk of an opioid overdose can obtain free
naloxone kits provided by state health officials. AP Photo/Jim Cole
5. Clark AK, Wilder CM, Winstanley EL. A systematic review of com-
munity opioid overdose prevention and naloxone distribution
programs. J Addict Med. 2014;8(3):153163.
6. Davis CS, Ruiz S, Glynn P, et al. Expanded access to naloxone
among firefighters, police officers, and emergency medical tech-
nicians in Massachusetts. Am J Public Health. 2014;104(8):e7e9.
7. Jones CM, Paulozzi LJ, Mack KA, et al. Alcohol involvement in
opioid pain reliever and benzodiazepine drug abuse-related
emergency department visits and drug-related deaths: United
States. MMWR Morb Mortal Wkly Rep. 2014;63(40):881885.
8. Madadi P, Hildebrandt D, Lauwers AE, et al. Characteristics
of opioid-users whose death was related to opioid-toxic-
ity: A population-based study in Ontario, Canada. PLoS One.
2013;8(4):e60600.
9. Webster LR, Cochella S, Dasgupta N, et al. An analysis of the
root causes for opioid-related overdose deaths in the United
States. Pain Med. 2011;12(Suppl2):S26S35.
10. Paulozzi LJ, Logan JE, Hall AJ, et al. A comparison of drug over-
dose deaths involving methadone and other opioid analgesics
in West Virginia. Addiction. 2009;104(9):15411548.
11. Robertson TM, Hendey GW, Stroh G, et al. Intranasal naloxone
is a viable alternative to intravenous naloxone for prehospital
narcotic overdose. Prehosp Emerg Care. 2009;13(4):512515.
12. Sporer KA, Firestone J, Isaacs SM. Out-of-hospital treatment
of opioid overdoses in an urban setting. Acad Emerg Med.
1996;3(7):660667.
13. Kelly AM, Kerr D, Dietze P, et al. Randomised trial of intranasal
versus intramuscular naloxone in prehospital treatment for sus-
pected opioid overdose. Med J Aust. 2005;182(1):2427.
14. Wanger K, Brough L, Macmillan I, et al. Intravenous vs. subcuta-
neous naloxone for out-of-hospital management of presumed
opioid overdose. Acad Emerg Med. 1998;5(4):293299.
15. Barton ED, Colwell CB, Wolfe T, et al. Efficacy of intranasal nalox-
one as a needleless alternative for treatment of opioid overdose
in the prehospital setting. J Emerg Med. 2005;29(3):265271.
16. Baumann BM, Patterson RA, Parone DA, et al. Use and efficacy
of nebulized naloxone in patients with suspected opioid intox-
ication. Am J Emerg Med. 2013;31(3):585588.
17. Weber JM, Tataris KL, Hoffman JD, et al. Can nebulized nal-
oxone be used safely and effectively by emergency medical
services for suspected opioid overdose? Prehosp Emerg Care.
2012;16(2):289292.
18. Greenberg MI, Roberts JR, Baskin SI. Endotracheal naloxone
reversal of morphine-induced respiratory depression in rabbits.
Ann Emerg Med. 1980;9(6):289292.
19. Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: Special cir-
cumstances of resuscitation: 2015 American Heart Association
guidelines update for cardiopulmonary resuscitation and emer-
gency cardiovascular care. Circulation. 2015;132(18 Suppl 2):
S501S518.
20. Borras MC, Becerra L, Ploghaus A, et al. fMRI measurement
of CNS responses to naloxone infusion and subsequent mild
noxious thermal stimuli in healthy volunteers. J Neurophysiol.
2004;91(6):27232733.
21. Clarke SF, Dargan PI, Jones AL. Naloxone in opioid poisoning:
Walking the tightrope. Emerg Med J. 2005;22(9):612616.
22. Lagu T, Anderson BJ, Stein M. Overdoses among friends: Drug
users are willing to administer naloxone to others. J Subst Abuse
Treat. 2006;30(2):129133.
23. Kleinman ME, Brennan EE, Goldberger ZD, et al. Part 5: Adult
basic life support and cardiopulmonary resuscitation quality:
2015 American Heart Association guidelines update for car-
diopulmonary resuscitation and emergency cardiovascular care.
Circulation. 2015;132(18 Suppl 2):S414S435.
24. Link MS, Berkow LC, Kudenchuk, PJ, et al. Part 7: Adult advanced
cardiovascular life support: 2015 American Heart Association
guidelines update for cardiopulmonary resuscitation and emer-
gency cardiovascular care. Circulation. 2015;132(18 Suppl 2):
S444-S464.
25. Callaway CW, Soar J, Aibiki M, et al. Part 4: Advanced life support:
2015 International consensus on cardiopulmonary resuscitation
and emergency cardiovascular care science with treatment rec-
ommendations. Circulation. 2015;132(16 Suppl 1):S84S145.
26. Eberle B, Dick WF, Schneider T, et al. Checking the carotid pulse
check: Diagnostic accuracy of first responders in patients with
and without a pulse. Resuscitation. 1996;33(2):107116.
mARcH 2016 | JEMS 39
2/15/16 11:26 AM
 RESUSCITATION RECOMMENDATIONS
2015 AHA GUIDELINES UPDATE FOR CPR
Prehospital targeted temperature
management in cardiac arrest patients
By Stefanie L. Wise, MD & Brian J. ONeil, MD, FACEP, FAHA
Y
ou arrive at the scene of a country
farmhouse 35 miles from the nearest
community hospital.
As the ALS provider, youve been run-
ning through your treatment plan since you
received the dispatch call seven minutes ago:
40 JEMS | MARCH 2016
1603jems_40 40
55-year-old male in cardiac arrest. CPR ini-
tiated by family.
The medical first responder on scene con-
tinues compressions as you apply the monitor
and your partner establishes IV access. The
first dose of epinephrine is given followed
PHOTO COURTESY CRYOTHERMIC SYSTEMS
by two minutes of CPR and a brief pause.
V fib. Clear! Shock! Continue CPR!
Two minutes later youve established a
definitive airway and end-tidal carbon dioxide
spikes to 50 mmHg; your pause for a rhythm
check demonstrates sinus tachycardia and the
carotid pulse is palpable.
You move the patient to the stretcher, lift,
load and go.
Your transport time is at least 30 minutes.
You continue to ventilate. A 12-lead ECG
shows no signs of STEMI, blood pressure has
stabilized, and yet you still have no sign of
www.jeMs.CoM
2/15/16 11:26 AM
 responsiveness. Now what? What more can
you do to potentially improve the eventual
outcome for your patient?
EMERGING CARE STANDARD
Targeted temperature management (TTM),
formally known as therapeutic hypother-
mia, has become the standard of care for
most post-cardiac arrest patients who dont
have a purposeful response to commands after
return of spontaneous circulation (ROSC).
Evidence supports TTMs value in the role
of neurologic protection after cardiac arrest,
increasing the potential for a good neuro-
logic outcome.
Over the past decade, further
effort has gone toward seeking
answers to the ideal specifics of
the cooling process: who should
be cooled, when do you cool,
what temperature is best and for
how long? In the prehospital set-
ting, additional questions arise: Is it
feasible and safe to initiate TTM in
the field? Whats the best method?
Who should be cooled and for
whom is it contraindicated? Does
the timing of its initiation matter?
Is earlier really better?
Not all questions have answers, but the
updated 2015 American Heart Association
(AHA) Guidelines for CPR and Emergency
Cardiovascular Care (ECC) have a few rec-
ommendations on TTM.
Additionally, the Canadian guidelines for
use of TTM after cardiac arrest were pub-
lished in Resuscitation.
Lets review these recent reports and
updates with a focus on the less-understood
aspect of cardiac arrest care: cooling the
victim after ROSC.
2015 AHA GUIDELINES UPDATE
1. All comatose adult patients with
ROSC after cardiac arrest should have
TTM, with a target temperature between
32 degrees C and 36 degrees C selected
and achieved, then maintained constantly
for at least 24 hours.1
2. The routine prehospital cooling of
patients with rapid infusion of cold IV
fluids after ROSC is not recommended.1
3. [T]here are essentially no patients for
whom temperature control somewhere
in the range between 32 degrees C and
36 degrees C is contraindicated.1
www.jems.com
1603jems_41 41
CANADIAN TTM GUIDELINES
1. We recommend that patients who suf-
fer out-of-hospital cardiac arrest are eli-
gible for TTM. (High quality, strong
recommendation.)2
2. We recommend that TTM can be ini-
tiated in any medical environment with
the necessary supports, including prehos-
pital, ED and critical care unit. (Moder-
ate quality, strong recommendation.)2
3. We recommend that clinicians attempt
to achieve target temperature as rapidly
as possible. (Low quality but strong
recommendation.)2
The logic for the use of
cooling collars is centered
on the goal of neurologic
preservation: Cool the
brain to save the brain.
4. We do not recommend a specific cooling
method for TTM.2
5. We recommend that patients under-
going TTM should receive sedation
and analgesia, and, [w]e suggest that
paralytics be used during induction
and rewarming phases of TTM, to facili-
tate tight temperature control and to pre-
vent shivering.2
DISCUSSING THE IMPLICATIONS
In the 2015 AHA update, the temperature
range for TTM has widened, the duration
has potentially extended, and the application
has expanded from primarily v fib arrests to
all arrest etiologies.
The target temperature expansion needs
some explanation. Prior to the 2015 update,
3234 degrees C was accepted as the target
and the treatment was referred to as ther-
apeutic hypothermia. Then a recent study
extended the tight temperature interval: when
33 degrees C was compared to 36 degrees C,
outcomes were similar.3
The authors noted that in previous tri-
als patients became hyperthermic, which
suggested the benefit may come from
temperature control in a manner that
prevents hyperthermia. However, the subjects
enrolled in this study were different than
other trials. The subjects had a very short
time to CPR (one minute), were mostly
v fib arrests, the greater majority had pupil-
lary and corneal reflexes, and a high percent-
age of them were patients with ST elevation
myocardial infarction.
This trial, considered the best conducted
to date, was the evidence needed to be incor-
porated into the Guidelines. Additionally,
previous guidelines limited recommendations
for cooling to v fib arrests.
Both the AHA and Canadian guidelines
clearly remove this limitation:
Cooling is a recommended therapy
for all post-cardiac arrest patients
of essentially any etiology. Although
less clear than other recommenda-
tions, most of the laboratory evi-
dence shows that early initiation of
cooling will likely have more bene-
fit than delayed cooling. No studies
have specifically addressed the tim-
ing factor alone, but it has led to a
surge of interest in the earliest prac-
tical initiation: prehospital TTM.
THE PREHOSPITAL SETTING
Whats behind the AHA recommendation
regarding TTM? Cold IV fluids given in
2 L boluses are potentially bad for prehospital
cooling, but that doesnt mean all prehospital
cooling is bad.
Prehospital cooling methods are based on
the assumption by many medical providers
and researchers that if cooling a post-cardiac
arrest patient is good, then cooling them more
quickly is probably better.
Its also assumed that prehospital initiation
of cooling will encourage the continuation
within the hospital setting, as indicated by
the strong recommendation from the Cana-
dian TTM guidelines.
Protocols have been developed in numer-
ous systems to provide prehospital cooling
by whatever means available to each system.
For many, the most cost-effective and sim-
ple means of initiating cooling procedures is
to keep cold normal saline bags available to
administer after ROSC.
A 2014 study published in the Journal of the
American Medical Association ( JAMA) offered
new perspective. When 4 degrees C IV fluids
were administered (2 L) to ROSC patients
and compared with in-hospital initiation of
mARcH 2016 | JEMS 41
2/15/16 11:26 AM
 RESUSCITATION RECOMMENDATIONS
2015 AHA GUIDELINES UPDATE FOR CPR
cooling, those who received the cold saline flu-
ids had higher incidence of early pulmonary
edema and higher re-arrest ratesalthough
overall survival was unchanged.4
Its the recognition of these complications
that has led to the AHA recommendation
against large cold IV saline boluses as a means
of cooling.
Its unclear whether its the temperature
or amount of cold IV fluids that caused the
complications in the JAMA study. Although
when one considers that cardiac function is
impaired post-arrest, the increase in pulmo-
nary edema is likely due to the volume of fluid.
So, if cold IV saline boluses are considered
to be potentially deleterious, what means do
prehospital providers have for initiation of
targeted temperature management?
SURFACE COOLING
The simplest in concept is any method of
surface cooling. Blood flow to the skin is sig-
nificant, and although it will decrease when
cooling techniques are applied to the periph-
eral vasculature, theres still a significant effect
from the application of ice bags, cold packs,
cold bath or other cooling means directly to
the patients body surface, typically to the
neck, axilla and groin. This is the least inva-
sive approach, and it will avoid the concerns
raised in the JAMA study on the administra-
tion of cold IV saline.
Surface cooling isnt as simple logistically,
however. Standard cold ice or traditional gel
packs need to be kept cold, and accessed when
the appropriate patient is encountered. If kept
on the ambulance at all times, space may be
an issue. If kept at an ambulance base or hos-
pital, access in a timely manner may be dif-
ficult. Set-up and use of cooling machines
on an ambulance may also be cumbersome
or time-consumingtime better spent with
patient care and transport.
Some companies have developed chem-
ical packs that generate very cold tempera-
tures when activated. Some have even been
fashioned into collars with integrated cryo
chemical cooling packs that can be stored at
room temperature and used when necessary
to apply targeted cooling to the neck.
These collars and cryo packs may be
an economical, less cumbersome and less
time-consuming solution. The logic for the
use of cooling collars is centered on the goal
of neurologic preservation: Cool the brain to
save the brain.
42 JEMS | MARCH 2016
1603jems_42 42
One concern with surface cooling is the
amount of time it can take to achieve the tar-
get core temperature; however, this approach
offers an early cooling bridge to TTM
devices and processes in the hospital.
TRANSNASAL COOLING
Transnasal cooling, a newer concept, is a
slightly more invasive approach to direct
cooling of the brain. A 2010 study released
in Circulation detailed the use of a transna-
sal cooling device in the prehospital setting,
finding it to be safe and feasible, as well as
associated with a significant improvement in
the time intervals required to cool patients.5
Use of the device described involves place-
ment of a nasal catheter in the patient and
attaching it to a control unit that then admin-
isters oxygen and a cooling mixture directly
into the nasal cavity that rapidly evaporates
and doesnt introduce a significant amount of
fluid into the airway/trachea.
This device was deemed safe and effective
for the initiation of prehospital cooling, but
some EMS agencies may be limited by cost
of these units.
MOVING FORWARD
Regardless of your systems size, geography,
call volume or structure, your patients will
likely benefit from post-cardiac arrest TTM.
Recent guideline updates in the U.S. and
Canada emphasize the importance of TTM
as a means of improving neurologic outcomes
in cardiac arrest victims.
The safest and most effective method
of prehospital TTM is a question not yet
answered, but evidence does support the safety
and efficacy of prehospital cooling by surface
and transnasal methods.
Although cost, feasibility and availability
of specific cooling methods must be con-
sidered, evidence strongly supports that any
unresponsive adult ROSC patient should be
considered for TTM.
Systems must now consider how to provide
the best care to patients given this evidence
and the current recommendations. Protocol
development should address both the best
management of cardiac arrest as well as the
best care after ROSC, aiming for the highest
goal of good neurologic outcomes. Contin-
uous case review with quality improvement
initiatives and continued research will provide
further insight and guidance for the future
practices of all prehospital providers. JEMS
Stefanie L. Wise, MD, practices clinically as
a board-certified emergency medicine and
EMS physician in Detroit. She educates med-
ical students, resident physicians and EMS
fellows as an assistant clinical professor and
EMS fellowship faculty at the Department of Emergency Med-
icine at Wayne State University School of Medicine.
Brian J. ONeil, MD, FACEP, FAHA, is the
Munuswamy Dayanandan endowed chair,
Edward S. Thomas endowed professor and
specialist-in-chief of emergency medicine in
the Department of Emergency Medicine at
Wayne State University School of Medicine in Detroit. Hes a
member of the International Liaison Committee on Resuscita-
tion and American Heart Assocation (AHA) ACLS committee
and a co-author on the 2015 AHA ACLS guidelines.
REFERENCES
1. Callaway CW, Donnino MW, Fink EL et al. Part 8: Post-cardiac
arrest care: 2015 American Heart Association guidelines update
for cardiopulmonary resuscitation and emergency cardiovas-
cular care. Circulation. 2015;132(18 Suppl 2):S465S482.
2. Howes D, Gray SH, Brooks SC, et al. Canadian guidelines for
the use of targeted temperature management (therapeutic
hypothermia) after cardiac arrest: A joint statement from The
Canadian Association of Emergency Physicians (CAEP), the
Canadian Critical Care Society (CCCS), Canadian Neurocriti-
cal Care Society (CNCCS, and the Canadian Critical Care Trials
Group (CCCTG). Resuscitation. 2016;98:4863.
3. Nielsen N, Wetterslev J, Cronberg T, et al. Targeted tempera-
ture management at 33C versus 36C after cardiac arrest.
N Engl J Med. 2013;369(23):21972206.
4. Kim F, Nichol G, Maynard C, et al. Effect of prehospital induc-
tion of mild hypothermia on survival and neurological status
among adults with cardiac arrest. JAMA. 2014;311(1):4552.
5. Castrn M, Nordberg P, Svensson L, et al. Intra-arrest transnasal
evaporative cooling: A randomized, prehospital, multicenter
study (PRINCE: Pre-ROSC IntraNasal Cooling Effectiveness).
Circulation. 2010;122(7):729736.
RESOURCES
Feuchtl A, Gockel B, Lawrenz T, et al. Endovascular cooling
improves neurological short-term outcome after prehospital
cardiac arrest. Intensivmed. 2007;44:3742.
Link MS, Berkow LC, Kudenchek PJ, et al. Part 7: Adult advanced
cardiovascular life support: 2015 American Heart Association
guidelines update for cardiopulmonary resuscitation and emer-
gency cardiovascular care. Circulation. 2015;132(18 Suppl 2):
S444S464.
Poli S, Purrucker J, Priglinger M, et al. Induction of cooling
with a passive head and neck cooling device: Effects on brain
temperature after stroke. Stroke. 2013;44(3):708713.
Uray T, Mayr FB, Stratil P, et al. Prehospital surface cooling is
safe and can reduce time to target temperature after cardiac
arrest. Resuscitation. 2015;87:5156.
www.jeMs.CoM
2/15/16 11:26 AM

Why we shouldnt terminate resuscitations after 20 minutes
By Clifton W. Callaway, MD, PhD
O
ver the years, there have been many
proposals about how long EMS
should continue CPR and when to
decide that further resuscitation is futile.
A National Association of EMS Physicians
(NAEMSP) position statement in 2000 pro-
posed that an adequate effort of CPR was 20
minutes, based on limited data, and this num-
ber has persisted in many protocols through-
out the country,1 although the number isnt
repeated in more recent NAEMSP positions.2,3
The American Heart Association (AHA)
2015 Guidelines discuss the limited data on
how long to continue resuscitation, and ulti-
mately choose not to make any recommen-
dation because of such insufficient data.4 This
leaves open the question, How long should
we continue CPR when pulses dont return?
Although the maximum tolerated duration
of CPR may not be known precisely, there
www.jems.com
1603jems_43 43
are evidence-based guidelines for identify-
ing patients for whom extended resuscita-
tion is futile. The most carefully researched
BLS and ALS termination of resuscitation
algorithms were based on analysis of a large
number of resuscitations in multiple Canadian
EMS systems.5,6
For BLS-only resuscitation, termination of
resuscitation is recommended for patients who:
1. Arent witnessed to arrest by EMS;
2. Never received a rescue shock; and
3. Never have return of pulses prior to com-
mencing transport.5
In multiple EMS systems with 3.1% overall
survival to hospital discharge, 3/776 patients
(0.4%) who met all three criteria survived to
hospital discharge with good functional status.5
For ALS resuscitations, termination of
resuscitation is recommended for patients who:
1. Arent witnessed to arrest by EMS;
PHOTO COURTESY ZOLL
2.
Arent witnessed to collapse by bystanders;
3. Have no bystander CPR;
4. Never receive a rescue shock; and
5. Never have return of pulses prior to com-
mencing transport.7
There were no survivors among patients
who met all five criteria in a cohort of patients
with 5.1% overall survival to discharge.7
When ALS and BLS termination of resus-
citation rules arent met, expected survival may
be higher than for the overall cohort.6 For
example, in a series of patients with 5.4% over-
all survival, patients where the BLS rule was
negative (at least one of the three criteria wasnt
met) survived at a rate of 11.9%.
Among patients where the ALS rule was
negative (at least one of the five criteria wasnt
met), survival was 7.9%. Therefore, its reason-
able to continue CPR efforts in patients who
dont meet these rules.
mARcH 2016 | JEMS 43
2/15/16 11:26 AM
 RESUSCITATION RECOMMENDATIONS
2015 AHA GUIDELINES UPDATE FOR CPR
Recent studies examined how total dura-
tion of resuscitation was related to the odds
of favorable functional recovery. In a series of
1,014 patients in Pittsburgh who had an over-
all 11% survival to hospital discharge, 90% of
the patients with good functional status (mod-
ified Rankin score 03) at hospital discharge
had return of pulses within 16 minutes of the
paramedics initiating CPR.8
Similarly, 90% of the patients with poor
functional status at hospital discharge had
return of pulses within 24 minutes of starting
CPR. These data suggest that 90% of patients
with good functional recovery have return of
pulses with professional CPR < 20 minutes,
but also imply that there are survivors with
longer CPR durations.8
Supporting this implication, a Korean data-
base found that EDs that have an institutional
policy to continue CPR for only 20 minutes
had lower survival (2.1%) than hospitals who
continued CPR for 2030 minutes (5.2%) or
> 30 minutes (5.6%).9
How can we recognize the 10% of patients
where efforts > 20 minutes are worthwhile?
In many of these cases, the patient is com-
ing and going. For example, a patient has
Figure 1: Clinical approach for continuing or stopping CPR
START CPR
FOR BLS ONLY, ARE ALL
3 CRITERIA PRESENT?
- Arrest not witnessed by EMS
- Never received rescue shock
- Never had pulses
CONTINUE CPR
ARE ANY SIGNS OF
LIFE PRESENT?
- EtCO2 > 10 mmHg
- Persistent cardiac electrical activity
- Transient return of pulses
- Other clinical signs
44 JEMS | MARCH 2016
1603jems_44 44
brief responses to rescue shocks, but rapid
re-fibrillation, resulting in many brief peri-
ods of circulation with lots of brief periods of
CPR in between.
When the total number of shocks gets into
double digits, that patient is trying hard not
to die. Other patients have occasional pulses
after vasopressors but then rapidly deteriorate
to pulseless electrical activity. These patients
have severe cardiogenic shock or other shock
that may require mechanical support while
the cause is treated.
In both of these situations, theres some
minimal or interrupted spontaneous circu-
lation during the cardiac arrest, potentially
prolonging the tolerance to CPR.
WAVEFORM CAPNOGRAPHY
Waveform capnography is one tool to rec-
ognize the patient with preserved circulation
during CPR. Excretion of CO2 requires good
blood flow to the lungs and continued metab-
olism by the patient.
High end-tidal carbon dioxide (EtCO2)
( > 20 mmHg) during CPR is a sign of life
just like continued electrical activity in the
ECG. Its reasonable to continue resuscitative
FOR ALS-CAPABLE, ARE
ALL 5 CRITERIA PRESENT?
- Arrest not witnessed by EMS
- Arrest not witnessed by bystanders
- No bystander CPR
- Never received rescue shock
- Never had pulses
CONSIDER STOPPING CPR
efforts longer in a patient whos excreting CO2
during CPR.
Conversely, the 2015 AHA Guidelines sug-
gest that failure to achieve EtCO2 > 10 mmHg
after 20 minutes of CPR may be used to sup-
port termination of CPR.10
Because measurement of CO2 may have
technical glitches, the Guidelines caution that
this number should be used in conjunction
with other clinical considerations and ideally
measured via endotracheal tube.
Taken together with the termination of
resuscitation algorithms, these data suggest
a clinical approach for deciding how long to
continue CPR thats based on clinical features
and clinical response specific to the patient,
not a set time interval. (See Figure 1.)
The probability that CPR and drugs alone
will restore pulses declines over 2025 minutes
of resuscitation, and it would be desirable to
have an alternative plan for patients who still
show signs of life.
ECLS & ANGIOGRAPHY
There are at least two other potential desti-
nations for the patient whos tolerating long
CPR: extracorporeal cardiopulmonary life
support (ECLS) and emergency angiography
with ongoing CPR.
Both of these destinations require an inte-
grated system dedicated to providing advanced
care and with premeditated plans and criteria
for invoking these pathways.
However, systems that implemented these
approaches have demonstrated that select
patients can have reliable rates of good out-
comes after very prolonged CPR.
ECLS consists of cannulating large arteries
and veins in order to start cardiopulmonary
bypass. This procedure requires surgical exper-
tise, perfusionists and an intensive care unit
experienced with the care of these patients.
Once ECLS is instituteda 3045 min-
ute procedurethe cardiopulmonary bypass
machine has completely replaced cardiac activ-
ity. The patient can have other procedures
to reverse the cause of cardiac arrest: coro-
nary angiography, pulmonary embolectomy
or other treatments.
Although ECLS is performed in many
parts of Asia, availability remains limited in
the United States. However, the number of
programs capable of performing ECLS will
probably increase over the next decade.
Nevertheless, ECLS will only be appropriate
for highly selected patients who are both strong
www.jeMs.CoM
2/15/16 11:26 AM
 (i.e., young) enough to tolerate the procedure
and who have potentially reversible causes of
cardiac arrest. When ECLS is used, good func-
tional recovery has been reported for patients
with total CPR durations of 6075 minutes
or even durations of 80 minutes.11,12
For patients suspected to have cardiac
arrest from acute coronary occlusion, another
approach is to perform coronary angiogra-
phy with ongoing CPR. Cardiac arrest
can be refractory because theres ongoing car-
diac ischemia.
MECHANICAL CPR
Mechanical CPR devices are now available
to perform chest compressions in the tight
spaces under the fluoroscopy arm of the car-
diac catheterization suite.
Several centers have reported successful
opening of a blocked coronary artery during
CPR, allowing the patient to recover cardiac
activity and do well.13
Total durations of CPR in these series of
patients ranged from 45240 minutes. Like
ECLS, this resource-intensive approach needs
to be premeditated by an institution as a heroic
pathway for selected patients who are most
likely to benefit. Transport of selected patients
requiring prolonged CPR for ECLS or for
angiography during CPR is physically diffi-
cult. Although the Guidelines dont recom-
mend mechanical CPR as routine replacement
for high-quality manual CPR, the Guidelines
acknowledge that mechanical CPR can play
an important role in settings where its hard
to perform high-quality CPR, which would
include the back of a moving ambulance or
during performance of advanced procedures.14
CONCLUSION
There are some patients for whom prolonged
CPR is futile. The termination of resusci-
tation algorithms usually can identify these
patients with less than 20 minutes of CPR.
When these rules arent met, 90% of patients
who will respond to conventional CPR do so
within 1624 minutes.
When preserved excretion of CO2 on wave-
form capnography, persistent cardiac elec-
trical activity, or other clinical signs suggest
that CPR is generating good blood flow in
an individual patient, prolonged resuscitation
still may result in good outcomes.
Developing programs and systems to
deliver mechanical cardiac support for med-
ically eligible patients when conventional CPR
www.jems.com
1603jems_45 45
Mechanical CPR devices are proving to be valuable during prolonged resuscitations and where transport in a
moving ambulance is involved. Photo Roger Cotton
fails can result in good outcomes even after
6080 minutes of CPR. JEMS
Clifton W. Callaway, MD, PhD, is profes-
sor, vice-chair, and holder of the Ronald D.
Stewart Endowed Chair in Emergency Med-
icine Research at the University of Pitts-
burgh. Hes the current chair of the
American Heart Association ECC Committee. Hes the Pitts-
burgh site investigator for the Resuscitations Outcome Con-
sortium and the Neurological Emergencies Treatment Trial
network. Clinical activities include a post-resuscitation care
team to improve the systematic care of patients who have
been resuscitated with CPR.
REFERENCES
1. Bailey ED, Wydro GC, Cone DC. Termination of resuscitation in
the prehospital setting for adult patients suffering nontrau-
matic cardiac arrest. National Association of EMS Physicians
Standards and Clinical Practice Committee. Prehosp Emerg
Care. 2000;4(2):190195.
2. Millin MG, Khandker SR, Malki A. Termination of resuscitation
of nontraumatic cardiopulmonary arrest: Resource document
for the National Association of EMS Physicians position state-
ment. Prehosp Emerg Care. 2011;15(4):547554.
3. National Association of EMS Physicians. Termination of resusci-
tation in nontraumatic cardiopulmonary arrest. Prehosp Emerg
Care. 2011;15(4):542.
4. Kleinman ME, Brennan EE, Goldberger ZD, et al. Part 5: Adult
basic life support and cardiopulmonary resuscitation quality:
2015 American Heart Association guidelines update for cardio-
pulmonary resuscitation and emergency cardiovascular care.
Circulation. 2015;132(18 Suppl 2):S414S435.
5. Morrison LJ, Visentin LM, Kiss A, et al. Validation of a rule for
termination of resuscitation in out-of-hospital cardiac arrest.
N Engl J Med. 2006;355(5):478487.
6. Morrison LJ, Verbeek PR, Zhan C, et al. Validation of a universal
prehospital termination of resuscitation clinical prediction rule
for advanced and basic life support providers. Resuscitation.
2009;80(3):324328.
7. Morrison LJ, Verbeek PR, Vermeulen MJ, et al. Derivation and
evaluation of a termination of resuscitation clinical predic-
tion rule for advanced life support providers. Resuscitation.
2007;74(2):266275.
8. Reynolds JC, Frisch A, Rittenberger JC, et al. Duration of resus-
citation efforts and functional outcome after out-of-hospital
cardiac arrest: When should we change to novel therapies?
Circulation. 2013;128(23):24882494.
9. Cha WC, Lee EJ, Hwang SS. The duration of cardiopulmo-
nary resuscitation in emergency departments after out-of-
hospitalcardiac arrest is associated with the outcome: A nation-
wide observational study. Resuscitation. 2015;96:323327.
10. Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: Adult advanced
cardiovascular life support: 2015 American Heart Associa-
tion guidelines update for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation. 2015;132(18 Suppl
2):S444S464.
11. Nagao K, Kikushima K, Watanabe K, et al. Early induction of
hypothermia during cardiac arrest improves neurological out-
comes in patients with out-of-hospital cardiac arrest who
undergo emergency cardiopulmonary bypass and percuta-
neous coronary intervention. Circ J. 2010;74(1):7785.
12. Kim SJ, Jung JS, Park JH, et al. An optimal transition time
to extracorporeal cardiopulmonary resuscitation for pre-
dicting good neurological outcome in patients with out-of-
hospital cardiac arrest: a propensity-matched study. Crit Care.
2014;18(5):535.
13. Larsen AI, Hjrnevik AS, Ellingsen CL, et al. Cardiac arrest with
continuous mechanical chest compression during percutane-
ous coronary intervention. A report on the use of the LUCAS
device. Resuscitation. 2007;75(3):454-459.
14. Brooks SC, Anderson ML, Bruder E, et al. Part 6: Alternative
techniques and ancillary devices for cardiopulmonary resus-
citation: 2015 American Heart Association guidelines update
for cardiopulmonary resuscitation and emergency cardiovas-
cular care. Circulation. 2015;132(18 Suppl 2):S436S443.
mARcH 2016 | JEMS 45
2/15/16 11:26 AM
 RESUSCITATION RECOMMENDATIONS
2015 AHA GUIDELINES UPDATE FOR CPR
A back-to-basics training approach to
comply with the AHA Guidelines Update
By Michael R. Sayre, MD
T
he 2015 American Heart Association
(AHA) Guidelines Update for CPR
and Emergency Cardiovascular Care
(ECC) provide an implementation challenge
for EMS agencies, big or small. For this revi-
sion, the AHA devoted significant effort to
thinking about the impact of these guidelines
on EMS agencies and the overall system of
care outside of the hospital.1
Because of the need to reach a victim of
cardiac arrest quickly, almost all EMS agen-
cies partner with other organizations including
police, fire, public health, schools and hospitals
with the goal of a seamless system optimized
46 JEMS | MARCH 2016
1603jems_46 46
to give the victim the best possible shot at sur-
vival. The large number of potential rescuers
makes the math daunting.
In the Seattle EMS system, we care for
about 450 cardiac arrest patients a year out of
a total population of 675,000 people. To put
that another way, we attempt to resuscitate
about 65 victims for every 100,000 people.
That number is pretty typical. Most North
American EMS systems will fall in the range of
attempting to resuscitate 5080 cardiac arrest
victims per 100,000 population, depending on
the age distribution in the area.
Our agency has about 1,000 uniformed
Successful implementation of a resuscitation inter-
vention requires more than one round of training for
each person. Photo courtesy Michael Sayre
personnel, yet a cardiac arrest occurs only once
or twice a day. This means each four-person fire
company crew will, on average, care for only
one or two cardiac arrest patients annually.2
Most available research suggests that suc-
cessful implementation of CPR guidelines in
an EMS agency takes 12 years. This imple-
mentation delay is difficult to overcome given
the relative infrequency of resuscitation events.
Training has to fill the gap. Experience
has taught us that successful implementation
of a resuscitation intervention requires more
than one round of training for each person
working in an EMS system. Typically, three
training events are needed to expect reason-
able rescuer performance at stressful cardiac
arrest resuscitations.
www.jeMs.CoM
2/15/16 11:26 AM
 PERFORMANCE, NOT PROTOCOL
Recently, the Resuscitation Outcomes Con-
sortium (ROC) published the results of the
continuous chest compressions trial.3 The
difference in survival to hospital discharge
between the two arms of the trial was 0.7%.
Many readers were intrigued by these results.
Ignored by most readers is the difference in
survival to hospital discharge among the study
sites. In one site, survival to hospital discharge
was about 3.5%. In another
site, hospital discharge sur-
vival was almost 19%. This
difference isnt explained by
variations in age, bystander
CPR or other easily mea-
sured variables.4
A key lesson learned
is that performance, not
protocol, drives survival.
Changing your EMS agen-
cys protocol to comply with
the new guidelines could be
helpful; however, the large
variation in survival among
the study sites noted in the
ROC trial argues that larger gains can happen
by focusing on excellent performance.
HIGH-PERFORMANCE CPR
Over more than a decade, our systems cardiac
arrest neurologically favorable survival to hos-
pital discharge has slowly improved. This has
occurred despite lack of any new medications
or a change in response configuration.
Whats made the difference?
The system implemented an organized
approach to team training and CPR and car-
diac arrest management.
Several of the senior paramedics helped to
crystallize the training process as high-per-
formance CPR. This approach is freely avail-
able online at www.resuscitationacademy.com/
index.php/resources. Videos show a way to
implement effective CPR team work for 2-,
3- and 4-person crews.
Other EMS systems have implemented
high-performance CPR with dramatic results.
Salt Lake City Fire Department implemented
a variation on high-performance CPR in Sep-
tember 2011.5 Neurologically favorable sur-
vival to hospital discharge for all resuscitation
attempts more than doubled from 7.5% to 16%.
Changing your EMS agencys
protocol to comply with the new
guidelines could be helpful,
however, larger gains
can happen by focusing on
excellent performance.
By focusing on feedback to crews fol-
lowing resuscitation attempts to increase
use of high-performance CPR, EMS lead-
ers in Mesa, Ariz., increased survival to
hospital discharge from 9% in 2009 to 14%
in 2011.6
The EMS system in the entire state of
North Carolina has notched impressive gains
in survival following implementation of
high-performance CPR training.7 The Tulsa
and Oklahoma City EMS systems have also
improved survival significantly.8
BACK TO BASICS
When revising your protocols to incorporate
the new science in the 2015 AHA Guide-
lines, make sure your training emphasizes the
basics. High-performance CPR incorporates
the following principles: chest compression
rate between 100 and 120, repetitive train-
ing with individual feedback during training
to drive home the chest compressions depth
of 22.4 inches while avoiding leaning, and
controlling ventilation with small breaths just
sufficient to make the chest rise.
In our system, we use a simple metro-
nome set at 110 beats per minute to ensure
our crews keep their com-
pressions in the right range.
We teach a three-finger
technique to gently squeeze
the bag for ventilation to
avoid excessive tidal volume.
Rescuers learn to hover
their hands over the chest
rather than, Im clear, youre
clear, everybodys clear, to
lessen post-shock pauses in
chest compressions.
Our instructors empha-
size that BLS owns CPR.
The BLS crews learn that
paramedics must not be per-
mitted to interfere with quality chest com-
pressions while doing paramedic stuff like
endotracheal intubation.
By focusing on these principles of high-per-
formance CPR in your training and perform-
ing at least three training sessions in the next
year, youll see dramatic improvement in sur-
vival from cardiac arrest in your community as
a direct result of implementing the 2015 AHA
Guidelines Update on CPR and ECC. JEMS
Michael R. Sayre, MD, is the medical direc-
tor for the Seattle Fire Department. Hes the
former chairman of the American Heart Asso-
ciations (AHA) Emergency Cardiovascular
Care Committee. He was part of the Ethical
Issues writing group for the 2015 AHA Guidelines update.

REFERENCES
1. Kronick SL, Kurz MC, Lin S, et al. Part 4: Systems of care and con-
tinuous quality improvement: 2015 American Heart Association
guidelines update for cardiopulmonary resuscitation and emer-
gency cardiovascular care. Circulation. 2015;132(18 Suppl 2):
S397S413.
2. Dyson K, Bray J, Smith K, et al. Paramedic exposure to
out-of-hospital cardiac arrest is rare and declining in Victoria,
Australia. Resuscitation. 2015;89:9398.
3. Nichol G, Leroux B, Wang H, et al. Trial of continuous or
interrupted Chest compressions during CPR. N Engl J Med.
2015;373(23):22032214.
4. Rea TD, Cook AJ, Stiell IG, et al. Predicting survival after
out-of-hospital cardiac arrest: Role of the Utstein data ele-
ments. Ann Emerg Med. 2010;55(3):249-57.
5. Hopkins C, Burk C, Moser S, et al. Implementation of pit crew
approach and cardiopulmonary resuscitation metrics for
out-of-hospital cardiac arrest improves patient survival and
neurological outcome. J Am Heart Assoc. 2016;5(1).
6. Bobrow B, Vadeboncoeur T, Stolz U, et al. The influence of
scenario-based training and real-time audiovisual feedback
on out-of-hospital cardiopulmonary resuscitation quality and
survival from out-of-hospital cardiac arrest. Ann Emerg Med.
2013;62(1):4756.e1.
7. Malta Hansen C, Kragholm K, Pearson DA, et al. Association of
bystander and first-responder intervention with survival after
out-of-hospital cardiac arrest in North Carolina, 20102013.
JAMA. 2015;314(3):255264.
8. Goodloe JM. Stay on time: A conversation about the impor-
tance of count & cadence of chest compressions. JEMS.
2014;39(11):S36S40.

www.jems.com mARcH 2016 | JEMS 47

1603jems_47 47 2/15/16 11:26 AM

 Patients with stable v tach may experience a con-
stellation of symptoms but generally dont require
cardioversion unless instability develops. Photo Mat-
thew Strauss

48 JEMS | MARCH 2016 www.jeMs.CoM

1603jems_48 48 2/15/16 11:26 AM

 Managing prehospital stable v tach
By Eric Cortez, MD; Carla Cash, MD; David P. Keseg, MD, FACEP,
& Raymond L. Fowler, MD, FACEP, DABEMS
Y
oure dispatched for an ill 55-year-
old male. Upon arrival you find him
sitting on the sofa in no apparent dis-
tress. He states hes been feeling ill for the past
three days. Hes otherwise asymptomatic.
Initial assessment reveals an intact airway,
normal breathing and clear lungs, no neurologic
deficits, and no gross abnormalities on exposure.
During the circulation exam, you note a
regular rhythm with a fast heart rate. Capillary
refill is normal, peripheral pulses are strong,
and skin color and temperature are normal.
Initial vital signs are: heart rate (HR) 145
bpm, blood pressure (BP) 130/90 mmHg,
respiratory rate (RR) 14 and pulse oximetry
97% on room air.
The patient has a past medical history of
hypertension controlled with lisinopril, no aller-
gies, no previous surgeries, and denies the use
of alcohol, tobacco or other drugs. The remain-
ing physical examination is unremarkable.
Your partner initiates an IV while you place
the patient on the cardiac monitor and obtain
a 12-lead ECG. You and your partner review
it and determine the patient is experiencing
ventricular tachycardia (v tach). Despite the
patient endorsing mild symptoms, you con-
clude the patient is hemodynamically stable.
What are the pharmacologic treatment strat-
egies for prehospital stable v tach?
BACKGROUND
The clinical manifestations of v tach occur
along a spectrum. Patients are typically clas-
sified as pulseless, unstable or stable.
Pulseless v tach is typically treated with
advanced cardiac life support (ACLS) inter-
ventions, including CPR, defibrillation and
antidysrhythmics.1 Unstable v tach is most
often treated with electrical cardioversion.
Patients with stable v tach may experience
www.jems.com
1603jems_49 49
a constellation of symptoms, like the patient ment of stable v tach presenting in the field.
in the case scenario, but generally dont require
cardioversion unless instability develops.
Antidysrhythmics recommended for the
treatment of various subtypes of stable v tach
include amiodarone, lidocaine and procain-
amide.1 However, review of the field care of the
patient in stable v tach reveals a tendency among
some agencies to administer supportive care only.
We report here the results of a survey of
the U.S. Metropolitan Municipalities EMS
Medical Directors (Eagles) Consortium
regarding the treatment of stable v tach in
the prehospital arena.
SURVEY RESULTS
The members of the U.S. Metropolitan
Municipalities EMS Medical Directors Con-
sortium were surveyed in August 2015 regard-
ing which pharmacologic interventions are
used by their EMS agencies for the treatment
of stable v tach. A total of 36 medical direc-
tors participated in the survey. The results are
summarized in Table 1.
Table 1: Treatment methods
of stable v tach in major
U.S. metropolitan areas
Number of
Treatment
EMS systems
Amiodarone 24
Lidocaine 8 riority of procainamide and sotalol over lido-
Amiodarone
1 Amiodarone is recommended in ACLS
and lidocaine
Procainamide
1 effectiveness of amiodarone has also been ques-
and lidocaine
No treatment 2 concluded amiodarone is safe but ineffective
Total 36
The most commonly utilized antidysrhyth-
mic was amiodarone (67%), followed by lido-
caine (22%). Two agencies used more than
one pharmacologic agent (e.g., lidocaine and
procainamide, or lidocaine and amiodarone).
Two agencies reported only supportive treat-
DISCUSSION
Stable v tach presents as a regular wide-
complex rhythm, and the appropriate rhythm
diagnosis can be a challenge to EMS provid-
ers. The spectrum of the treatment options for
stable v tach include waitful watching during
the prehospital phase, antidysrhythmic therapy
at any phase, and elective cardioversion at the
appropriate juncture.1
The 2010 American Heart Association
(AHA) Guidelines Update recommended
procainamide, amiodarone, sotalol or lidocaine
for the treatment of stable v tach.1 Table 2 on
p. 50 provides information on recommended
antidysrhythmic dosing and potential side
effects of administration.
The new 2015 AHA guidelines recommend
procainamide, amiodarone or sotalol for the
treatment of stable v tach. However, a higher
class of recommendation is given to procain-
amide compared to amiodarone and sotalol.
Procainamide and sotalol should be avoided
in patients with a prolonged QT interval. In
stable polymorphic v tach, magnesium and
amiodarone may be helpful.2
Deciding which antidysrhythmic agent to
use for stable v tach treatment can be a com-
plex decision with several considerations. The
first consideration is determining which agent
is most effective. Research has suggested supe-
caine for termination of stable v tach.2,3
guidelines for the treatment of v tach, but the
tioned. In a retrospective case series, authors
for termination of v tach.4 Another study con-
cluded from a retrospective case series that
mARcH 2016 | JEMS 49
2/15/16 11:26 AM
 ANTIDYSRHYTHMIC AGENTS
Table 2: Antidysrhythmic therapies1 who can provide limited past medical history.
Dosing Side effects The third consideration is whether anti-
dysrhythmic therapy is actually necessary to
2050 mg/min IV until dysrhythmia cessa-
Bradycardia, safely manage clinically stable v tach in the
tion, hypotension, or prolongation of QRS
Procainamide hypotension, prehospital setting.
interval, or a total of 17 mg/kg is given;
torsades de pointes Given the conflicting evidence for clinical
maintenance rate 14 mg/min
efficacy, the presence of multiple side effects,
150 mg IV over 10 minutes; repeated as Bradycardia,
Amiodarone and difficulties in recognizing potential con-
needed to a maximum of 2.2 grams/24 hours hypotension, phlebitis
traindications, the medical directors of some
Bradycardia,
EMS agencies have chosen not to include
Sotalol 1.5 mg/kg IV over 5 minutes or less hypotension,
torsades de pointes antidysrhythmic agents as a part of standard
operating protocol for this condition. Indeed,
Slurred speech, altered
1.5 mg/kg IV bolus; non-treatment (i.e., waitful watching) of
Lidocaine consciousness,
maintenance rate 14 mg/min stable v tach is an option in some EMS sys-
seizures, bradycardia
tems, with more aggressive care being initi-
amiodarone is also ineffective for treatment Amiodarone administration can be com- ated should the patients condition declines.
of stable monomorphic v tach.5 plicated by patient characteristics (e.g., preg- If supportive care is insufficient and insta-
The second consideration is the risk- nancy), wrong rhythm classification (e.g., bility develops, further measures including
benefit ratio of antidysrhythmic agents, which irregular, wide-complex tachycardia suggest- synchronized cardioversion may be employed.
are associated with serious side effects that ing atrial fibrillation with aberrant conduction; The fourth consideration is whether the
can worsen patient outcome. (See Table 2.) polymorphic v tach), and clinical side effects antidysrhythmic agent used for stable v tach
For example, patients with pre-existing QT (e.g., hypotension). should be the same one used for either unsta-
interval prolongation may experience poly- Often, predisposing risk factors can be diffi- ble v tach or v tach without a pulse.
morphic v tach (torsades de pointes) if cult to identify in the emergent scenario involv- An important consideration for EMS
administered procainamide or sotalol. ing the undifferentiated critically ill patient systems is that utilizing the same agent for

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 various conditions eases stocking, training and
other logistical concerns. However, although
amiodarone is the antidysrhythmic agent rec-
ommended by the AHA for pulseless v tach,
this recommendation is not based on high levels
of evidence but rather only on expert opinion.1
It may be useful to repeat this survey following
the publication of the 2015 AHA Guidelines to
determine if any significant change occurs from
the current field management of stable v tach.
Moreover, the authors of the present study
believe that the clinical outcomes from EMS
management of these patients should be mea-
sured according to rigorous criteria.
A research study highlighting drug interven-
tion vs. supportive care would help validate the
guidelines via clinical data, likely giving rise to
recommendations that provide a unified approach
to the clinical management of these patients.
CONCLUSION
Providing a review of various approaches used by
larger EMS systems, this discussion highlights
variations in the management of the treatment
of prehospital patients with stable v tach.
For more information, visit JEMS.com/rs and enter 15.
www.jems.com
1603jems_51 51
EMS systems must consider clinical efficacy,
safety of use, need for prehospital administra-
tion, potential contraindications, and operational
issues when selecting the method of managing
these cases. JEMS
Eric Cortez, MD, is a fellowship-trained EMS physician and
board-certified emergency medicine physician. Hes the
associate medical director for the Columbus (Ohio) Division of
Fire. He also serves as a clinical assistant professor of emer-
gency medicine at Ohio Health Doctors Hospital in Columbus.
Carla Cash, MD, is affiliated with the University of Ten-
nessee Health Science Center and is currently a third year
resident in emergency medicine at the University of Texas
Southwestern Dallas.
David P. Keseg, MD, FACEP, has served as medical director
of the Columbus Division of Fire for 29 years. Hes an associate
professor of emergency medicine at the Ohio State University
and a member of the U.S. Metropolitan Municipalities EMS
Medical Directors (Eagles) Consortium. Hes a member of
the JEMS Editorial Board.
Raymond L. Fowler, MD, FACEP, DABEMS, is professor and
chief of the Division of EMS, Department of Emergency Medicine,
at the University of Texas Southwestern Medical Center. Hes
attending emergency medicine faculty at Parkland Memorial
Hospital in Dallas. Hes in his 37th year of emergency medicine
practice and is a member of the JEMS Editorial Board.
REFERENCES
1. Neumar RW, Otto CW, Link MS, et al. Part 8: Adult advanced cardio-
vascular life support. 2010 American Heart Association guidelines
for cardiopulmonary resuscitation and emergency cardiovascular
care science. Circulation. 2010;122(18 Suppl 3):S729S767.
2. Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: Adult advanced
cardiovascular life support. 2015 American Heart Association guide-
lines update for cardiopulmonary resuscitation and emergency
cardiovascular care. Circulation. 2015;132(18 Suppl 2):S444S464.
3. Gorgels AP, van den Dool A, Hots A, et al. Comparison of pro-
cainamide and lidocaine in terminating sustained monomorphic
ventricular tachycardia. Am J Cardiol. 1996;78(1):4346.
4. Ho DS, Zecchin RP, Richards DA, et al. Double-blind trial of lido-
caine versus sotalol for acute termination of spontaneous sustained
ventricular tachycardia. Lancet. 1994;344(8914):1823.
5. Marill KA, deSouza IS, Nishijima DK, et al. Amiodarone is poorly
effective for the acute termination of ventricular tachycardia. Ann
Emerg Med. 2006;47(3):217224.
6. Tomlinson DR, Cherian P, Betts TR, et al. Intravenous amiodarone
for the pharmacological termination of hemodynamically toler-
ated sustained ventricular tachycardia: Is bolus amiodarone an
appropriate first line treatment? Emerg Med J. 2008;25(1):1518.
mARcH 2016 | JEMS 51
2/15/16 11:26 AM
 2015

EMS10: Innovators in EMS is sponsored by Physio-Control, Inc.

1603jems_52 52 2/15/16 11:26 AM

 JEMS selects top 10 innovators of 2015
By Hutton Marshall, BA
ts with great pleasure that JEMS welcomes you to the
I
eighth annual EMS10: Innovators in EMS awards pro-
gram, spotlighting 10 individuals or teams behind the
boldest, most consequential innovations happening around
the world in EMS today.
Sponsored by Physio-Control and JEMS, the EMS10
Innovators were chosen by a panel of colleagues and peers for
their unique, creative solutions within the industry. This panel
weighed dozens of nominations from individuals and organiza-
tions, ultimately choosing those not only with laudable inno-
vations and accomplishments, but with unique backgrounds
and motivations that inspired their passion.
More than 60 leaders in EMS were nominated to be one of
our EMS10 Innovators this year, and the winners come from
four different countries and span three continents. To read the
full supplement, visit jems.com/ems10.
From dense urban landscapes to developing countries, our
EMS10 Innovators have found ways to adapt to whatever envi-
ronment they find themselves in. Proper EMS care is quick,
responsive and intelligent, and this years winners have found
exciting new ways to ensure EMS around the world embod-
ies these qualities.
As youll read in the following profiles, these men and women
have approached age-old problems in EMS with dynamic new
solutions, many of them embracing the newfound technologi-
cal resources at the disposal of the EMS industry.
As the digital world continues to embed itself in every aspect
of our lives, these industry leaders have found a way to harness
the ever-improving technology for the benefit of the patients
and communities they serve.
Revolutionary innovation is no small feat in any industry,
especially for one steeped in tradition like emergency medi-
cine. Many of this years Inno-
vators put great faithand thus
great riskin betting on their
dreams and ideas. Their suc-
cess stems directly from their
courage to step out on a limb
to make emergency medicine
faster, safer and smarter. Their
work not only moves the EMS
industry forward, it makes the
communities we all reside in
safer. For that, we all owe them
a debt of gratitude.
The EMS10: Innovators in
EMS awards not only allow
Christoph Redelsteiner
us to stay abreast on the latest
www.jems.com
1603jems_53 53
developments in the industry, but the profiles afford us an
up-close and personal look at this years winners. Their moti-
vations and personal histories are as diverse as their accom-
plishments. In the face of mounting challenges in the EMS
industry, these Innovators chose action over complacency with
the status quo. Through creativity, research and hard work, these
men and women solved problems in EMS in a manner never
before seen by their peers. Reading about their personal path
to EMS should inspire all as to whats possible through effort,
hard work and the quest for improving emergency medicine.
Among this years Innovators, youll read about Christoph
Redelsteiner, PhD, MSW, MS, EMT-P, an American-trained
Austrian professor, social worker and paramedic spearhead-
ing the daunting task of revitalizing and restructuring EMS
throughout a national paramedicine system sorely in need of
modernization. The system is overburdened with non-emer-
gency calls, and underpopulated with newly trained paramedics.
Luckily, Redelsteiner seems uniquely poised to address the
issue, using his broad background to design an entirely new
pedagogical approach to EMS in Austria.
Bringing paramedicine and nursing together to form an
interdisciplinary EMS program, Redelsteiner hopes to improve
patient outcomes through responsive on-scene care, increase
operational efficiency and provide young paramedics with a
more enticing, long-term career path.
Youll also read about Joshua Bobko, MD, FACEP, who works
year-round to expand the number of people ready to help others
when disaster strikes. Whether it be an earthquake, a tornado
or an active shooter situation, such emergencies can reach us
at the most unexpected of times, and an EMS first responder
might not always be nearby. In these situations, medical response
delayed by just minutes can mean the difference between life
and death. Bobkos First Care
Provider program builds off
curriculum developed in his
law enforcement and military
training and empowers indi-
viduals to act in times of crisis.
EMS is, by necessity, an
industry oriented for action,
but its research, education and
discovery that drive it forward.
Sara Houston, BS, NREMT-P
and Ginny Renkiewicz, MHS,
NREMT-P, have done this not
only in their own research, but
by fostering a new generation
Joshua Bobko
of paramedics that appreciates
mARcH 2016 | JEMS 53
2/15/16 11:26 AM
 first ambulatory system didnt
reach the country until 1985.
The first CPR training wasnt
until 1992. Behind both was
Nnamdi Nwauwa, EMT, CCEMTP,
MBBS, MPH, MMSCEM, a Nige-
rian emergency physician whos
seen enough tragedy and tur-
moil to turn anyone away from
emergency care. Instead, its only
fueled his passion to inspire
change.
Nigeria has a population of
Ginny Renkiewicz Sara Houston over 180 million people, but Nnamdi Nwauwa
Nwauwa estimates that there
are less than 100 professionally
the role research plays in EMS. certified EMTs working in the country. The impact of such a
Their Foundation for Prehospital Medicine Research, disparity is too great to know, but Nwauwa is doing all he can to
through its annual research summit, allows future physicians inspire change by bettering public policy and increasing advocacy.
and paramedics the opportunity to work In the skyscraping urban landscape of
side by side with biostatisticians and pub- Jersey City, N.J., getting anywhere in under
lish their research articles in an academic six minutes is a huge feat. Getting anywhere
publication. Their work engages the future in three minutes seems like a pipe dream.
leaders of EMS in data-driven research and Under the leadership of Robert Luckritz,
expands the wealth of knowledge EMS JD, NREMT-P, however, Jersey City EMS
agencies draw from. appears poised to do just that.
Bryan Burry, EMT-P, saw countless chal- Using an Israel-based emergency
lenges during his decades-long career as a response system as its model, Jersey City
paramedic. One of the most prominent EMS has created United Rescue Jersey City, a
problems he encountered, however, hap- volunteer-based program whereby volun-
pened between calls, when it came time to teers are integrated into the EMS system.
sterilize the ambulance and equipment. He Now, when emergency calls go out, the
found the chemical-laden approach to wip- nearest volunteers will be notified, allow-
ing down stretchers, EMS bags and other ing the patient to receive care as soon
Robert Luckritz
ambulance equipment ineffective, harmful as possible, which is critical in hard-to-
to the EMTs and paramedics and too vul- access locations like high-rise buildings and
nerable to human error. college campuses. The newly implemented system may help
His year-old venture, Nano Defence Solutions, has an lower Jersey City EMSs already notable emergency response
approach that seems to leap time from less than six min-
directly from the pages of a sci- utes, to a near-unprecedented
ence fiction novel. By creating three minutes.
a light-activated, antimicrobial, Widespread environmen-
nanoscopic layer that can bind tal concerns have inspired
magnetically to every nook and many to look to the benefits
cranny of an ambulance in sec- of renewable energy sources,
onds, Burrys approach prom- and the EMS industry is no
ises to keep ambulances near exception. Dan Fellows, BS,
perfectly sterile for over 30 days head of the Richmond Ambu-
after application. lance Authority in Virginia, is
Improving an existing EMS one of the nations foremost
system is a steep uphill battle; and most innovative leaders
creating an EMS system from in this regard, spearheading
scratch is a different mountain an effort to incorporate solar
Bryan Burry Dan Fellows
to climb altogether. Nigerias panels into the design of his

54 JEMS | MARCH 2016 www.jeMs.CoM

1603jems_54 54 2/15/16 11:26 AM

 ambulance fleet. Fellows has a
natural appetite for innovation
in his urban fleet, and his recent
solar upgrade now allows Rich-
mond ambulances to idle with-
out expending any energy to
power their internal electronics.
In an environment where
an increasing number of calls
are for non-emergency situa-
tions, David Persse, MD, sees
the blanket response of rushing
patients to an ED physician via
David Persse ambulance as inefficient and
ineffective in many such cases.
In response, Persse has devel-
oped an entirely novel approach to the problem: Connect ED doc-
tors directly to patients on-site using mobile technologynamely,
a tablet-run video app similar to Skypewhereby the patient can
convey their situation directly to a physician and receive treat-
ment better tailored to their situation, whether it be a cab ride
to a mental health clinic or a next-day appointment at a non-
emergency medical facility. He calls it the ETHAN program:
Emergency Telehealth and Navigation. Persse has developed a
way to connect patients to the care they need with EMS-level
speed without wasting precious emergency resources.
Shaughn Maxwell, EMT-P and Richard Campbell, MD,
adopted a saying earlier last year: If the law is wrong or out-
dated, change the law.
The two did just that while developing their community
paramedicine program in Washington state, successfully advo-
cating for the revision of a law that banned paramedics from
treating patients for non-emergency purposes. The legislative
victory now allows counties throughout the state to adopt
similar programs.
Their work didnt stop there, either. Now, Maxwell and
Campbell have continued to develop their community para-
medicine program in their own Snohomish County, training
select paramedics to adopt
a more community-based
rolea unique hybrid of a
first responder and a social
workerthat plays a much-
needed role in the community.
Every EMS department has
regular callers: chronic patients
dialing 9-1-1 multiple times
a month for the same issue.
Not every department, how-
ever, finds a way to treat them
beyond a ride to the ED.
Doug Hooten, MBA, on the Doug Hooten
other hand, has found a way to
address the patients underly-
ing problem, whether theyre in need of stable housing, mental
health treatment or simply reliable transportation to a medical
clinic. His solution is mobile integrated healthcare, which is
essentially a broad network of resourcescommunity para-
medics, non-emergency transportation, social servicesthat
Hootens MedStar Mobile Healthcare can connect patients to.
The system isnt just bettering patient outcomes, its bringing
the entire community together in order to do so.
CONCLUSION
From these profiles, we hope you get a sense of optimism of
the future of EMS, as well as inspiration for your own dreams
and ideas for EMS. As this years EMS10: Innovators in EMS
show, big ideas can result in big changes for the better.
Moreover, we hope these men and women show that inno-
vations come in all shapes and sizes. These efforts came in the
form of exciting new medical products, revolutionized opera-
tional systems and new educational programs altogether. The
underlying theme running through all of them, however, was
their creators passion in the good they can do for patients and
the first responders serving them.
If you happen to encounter one of our EMS10 Innovators,
please convey your appreciation for their contributions to EMS,
as their accomplishments surely didnt come without personal
and professional risk. Finally, we hope this years EMS10 Inno-
vators show that such achievement is indeed possible, and that
the long-established EMS environment can still change for
the better as the result of EMS professionals who dare to try.
So for our readers with an idea or a dream of how to improve
our care for patients, we hope our EMS10 Innovators demon-
strate that such dreams are decidedly within your grasp. JEMS

Hutton Marshall, BA, is a Texas native and an award-winning journalist and pho-
tographer currently based in San Jose, Costa Rica. He primarily covers technology,
environmental science and politics.

Read the full profiles in the complete digital

Shaughn Maxwell Richard Campbell
supplement available at jems.com/ems10

www.jems.com mARcH 2016 | JEMS 55

1603jems_55 55 2/15/16 11:26 AM

 PHOTO KEVIN LINK
How aortic aneurysms based on the direction that blood is traveling
within certain portions:
become aortic catastrophes >> Ascending aorta: The portion where blood
ascends from the root to the point where
By Robert P. Girardeau, BS, NRP, FP-C it begins to obliquely flow across the top
of the heart. The most proximal portion

I
n prehospital emergency medicine, there
are few diseases that carry the same high
priority and respect as aortic catastrophes.
From very early in our training, providers at
all levels are taught to search for, suspect and
ultimately fear derangements of the aorta.
And in all reality, the respect and attention
this illness demands isnt in vain.
The aorta is the largest blood vessel within
the body and originates directly from the
heart. It carries all of the bodys circulating
blood volume at the point it leaves the left
ventricle. When the integrity of the aortas
wall is compromised, a person can exsangui-
nate in just a few short contractions of the
heart. At the risk of sounding clich, aortic
catastrophes can kill a patient in a heartbeat.
Patients with an acute illness to their aorta
are unbelievably fragile, requiring tight control
of their condition by educated and dedicated
providers. This frailty coupled with the risk of
instantaneous and irreversible cardiovascular
collapse are what give aortic catastrophes such
a reputation and need for such surveillance.
>> Aortic arch: The portion of the TA
ANATOMY & PHYSIOLOGY
The aorta is the primary arterial vessel within
the thorax and abdomen. Due to its prom-
inence within these two compartments, the
aorta is most basically classified into two
regions: the thoracic aorta (TA) and the
abdominal aorta (AA).
Starting in the mid-chest on the anterior
surface of the left ventricle, the TA begins
its dance through the chest, twisting its way
through the other great vessels. Ultimately,
the aorta is a candy cane-shaped vessel with
the hook wrapping along the top of the heart
and the staff running parallel to the spine.
(See Figure 1, p. 58.)
Because of the unique anatomy that the
proximal TA has, its further categorized
of the ascending aorta is known as the
aortic root, and is where the right and
left coronaries originate.
where blood travels obliquely between
the ascending and descending portions.
The vessels that supply the arms and head
with their circulation originate on the
LEARNING Objectives
>> Define the three tunics, the three
sections of the thoracic aorta, aortic
aneurysm, and aortic dissection.
>> Explain the process by which an aor-
tic aneurysm becomes a dissection.
>> Formulate a series of care plans that
appropriately account for the patients
presentations and aortic dissections
most common complications.

56 JEMS | MARCH 2016 www.jeMs.CoM

1603jems_56 56 2/15/16 11:27 AM

 arch, and are important for diagnostics
and prognosis as well see later on.
>> Descending aorta: The final portion of
the TA where blood descends from the
arch until it reaches the diaphragm.
As the TA travels inferiorly along the left
border of the spine, it dives through an open-
ing within the diaphragm. Once the aorta
passes through the diaphragm, its referred
to as the AA.
The AA continues to travel inferiorly as
it provides all of the abdominal organs with
their perfusion. Once it gets to the level of
L4, it bifurcates into the iliac arteries, which
supply the lower extremities with oxygen-
ated blood.
This gross anatomy of the aorta plays a
significant role in the symptoms, exam find-
ings, and prognosis of the patients with an
acute aortic emergency.
In terms of microscopic anatomy, all blood
vessels within the human body are made up of
three distinct, concentric cell layers known as
tunics. The composition of these cell layers
greatly vary from one to the next.
HELP DRIVE
THE FUTURE OF EMS
REGISTER FOR EMS ON THE HILL DAY
April 20, 2016 (briefing April 19), Washington, D.C. | naemt.org
www.jems.com
1603jems_57 57
>> Tunica intimna: This is the inner-most lin-
ing of a blood vessel. This layer is mainly
comprised of endothelial cells that con-
trol the migration of certain molecules
and blood cells between the intravascular
and extravascular spaces.
>> Tunica media: This middle layer is the
thickest of the three. Its thickness is pro-
portional to the caliber of the vessel. Its
comprised of elastic tissue (elastin) and
smooth muscle. Elastin is an extremely
elastic protein that is the aortas main
load-bearing compound.
>> Tunica adventitia: Lastly, the outer layer
is a thin coating of connective tissue. The
tunica adventitia is fairly confluent with
the connective tissue of the vessels sur-
rounding environment.
DEFINITIONS &
PATHOPHYSIOLOGY
When talking about an aortic catastrophe, in
most cases were referring to an aortic aneu-
rysm that has dissected. In the most dramatic
of scenarios, the aorta blows open and spills a
For more information, visit JEMS.com/rs and enter 16.
patients entire circulating blood volume in a
matter just seconds. This worst-case scenario
results in sudden death. However, in most
other instances an aneurysm tears and begins
KEY Terms
Abdominal aorta: The portion of the
aorta thats housed within the abdo-
men between the diaphragm and iliac
bifurcation.
Aortic aneurysm: The chronic process
by which inflammation usually causes
destruction and weakening on the aor-
tas wall, allowing it to expand by at least
50% its expected size.
Aortic dissection: The disease process by
which the inner layer of the aorta (tunica
intimna) tears and allows blood to flow
between the layers of the aorta, causing
these layers to dissect from one another.
Thoracic aorta: The portion of the aorta
thats housed between the heart and the
diaphragm within the chest cavity.
It has never been more
important for EMS
professionals to speak
out on behalf of our
patients needs and on
issues that impact our
ability to provide
quality medical care.
HOSTED BY
mARcH 2016 | JEMS 57
2/15/16 11:27 AM
 TICKING TIME BOMB
to leak. This more common scenario results in
patients who are symptomatic in some regard.
The distinction between aortic aneurysm
and aortic dissection is an important one.
Aneurysms of the aorta and any other artery
for that matter, are characterized by a demar-
cated segment of the vessel that has increased
in diameter by 1.5 times when compared to the
expected caliber of the vessel.1 The process by
which an aneurysm forms is highly dependent
upon the patient it affects and its location on
the aorta. Many people with aortic aneurysms
live years without knowing of the condition or
suffering any complications from it.
The actual causative agents that lead to the
development of an aneurysm are believed to
be multifactorial, but arent completely under-
stood. There are molecular and mechanical
components that cause most aneurysms. As
the aorta is subjected to noxious insults such
as chronic hypertension and smoking, inflam-
mation occurs within the wall that leads to
degradation of elastin and necrosis of smooth
muscle cells.2,3
In the portion of the aorta distal to the left
subclavian artery, these inflammatory changes
Figure 1: Aorta anatomy
Aortic arch
Ascending
thoracic aorta
Aortic root
Abdominal
aorta
58 JEMS | MARCH 2016
1603jems_58 58
lead to development of atherosclerotic plaques,
not unlike coronary artery disease (CAD).
However, its believed the presence of this
atherosclerosis within an aneurysm is more
associative than causative, as both result from
inflammation within the vessel wall. In the
ascending aorta, atherosclerosis is rarely seen
most likely due to differences in the cellular
makeup in this portion of the TA.4
These inflammatory changes slowly begin
to degrade the wall of the vessel, causing it
to bulge over time. As the bulge continues to
grow, it gives way to the aneurysm. Once this
degradation of the aneurysms wall reaches crit-
ical mass, the constant pounding from ventric-
ular contraction ultimately leads to the tearing
that causes dissection.
For a thoracic aortic aneurysm (TAA), the
etiology varies based on the location of the
aneurysms inception. For aneurysms proximal
to the descending aorta, the causes are heav-
ily associated with alterations or congenital/
genetic abnormalities in the tissue of that por-
tion of the aorta (bicuspid aortic valve, aortic
coarctation, surgical aortic valve intervention).
Due to the larger proportion of elastin that the
Left
subclavian
artery
Descending
thoracic
aorta
Diaphragm
TA has, TAAs are typically very silent in their
development. Rarely do patients present with
complaints associated with TAA development.
Most TAAs grow quite slowly (< 0.5 cm/year),
with aneurysms proximal to the left subcla-
vian artery growing as slow as 0.1 cm/year.5
In contrast, abdominal aortic aneurisms
(AAAs) tend to progress at a faster rate: 0.2
to < 1 cm per year. Similar to TAAs, as AAAs
grow larger, their rate of growth also increases.6
AAAs are also generally asymptomatic; how-
ever, theyre more commonly associated with
symptoms not caused by a dissection (abdom-
inal pain).7
Aortic dissection is the acute tearing of
the tunica intima leading to hemorrhage
within the medial tunic. The current school
of thought regarding the cause of the tear
focuses on the presence of hypertension in
consort with a chronic aneurysm. Theres an
especially high risk of dissection in patients
with aneurysm if they develop an acute hyper-
tensive crisis.
There are other non-aneurysm causes of
aortic dissection such as acute hypertensive
crisis following cocaine abuse and trauma.
Both of these conditions lead to a shearing
of the aorta and likely will be fatal within
moments of their occurrence.
Whatever the cause of the tear, with every
beat of the heart, additional blood is forced
between the tunics. As blood is forced into
this space, the layers of the vessel begin to
separate from each otherhence the term
dissection. The area created by blood filling
the space between layers is called the false
lumen. The false lumen can propagate in
either direction away from the tear, and can
extend into any other artery in consort with
the aorta (coronaries, carotids/cerebrals, ver-
tebrals, renals and peripherals to the limbs).
The growth of the false lumen is the actual
cause of symptoms for patients. Any progres-
sion along these other vessels often leads to
ischemic conditions of the associated struc-
tures such as myocardial ischemia and stroke.
If the dissection propagates proximally
and reaches the aortic root, it can obliter-
ate the aortic valve and/or cause pericardial
effusion/tamponade.
The most accepted means of classifying
an aortic dissection looks at which parts of
the aorta are effected, regardless of the site
of the tear or aneurysm. Type A aneurysms
must involve the aorta proximal to the left
subclavian artery, while Type B aneurysms
www.jeMs.CoM
2/15/16 11:27 AM
 can involve any part of the aorta except the TA proximal to the left
subclavian artery. Type As are associated with an increased morbid-
ity and mortality.

INCIDENCE & RISKS

The incidence of aortic aneurysm significantly favors Caucasian males
over the age of 64.6,7 While women tend not to develop aortic aneu-
rysms as readily as males, they are more likely to suffer from dissection.8
There are a host of genetic conditions that predispose patients to
aortic aneurysms, especially those that effect collagen formation such
as Marfan syndrome and Ehlers-Danlos syndrome. An important dis-
tinction among the genetic causes is that they almost never involve an
elderly patient. Many times, genetic disorders are the cause of aneu-
rysm dissections in patients less than 40 years of age.9
Additionally, theres a very strong familial component to the condi-
tion. Nearly 20% of aneurysm repair patients also have a first-degree
relative suffering from the condition.10
Aside from a known genetic disorder, the two largest risks for the
development of an aortic aneurism are a history of hypertension and
atherosclerosis. Some of the other risk factors include inflammatory
disorders, coronary artery bypass grafting, percutaneous coronary inter-
vention, aortic valve replacement/repair, aneurysm of other moderate
caliber vessel(s), bicuspid aortic valve, abnormalities in aortic develop-
ment (i.e., aortic coarctation), high-intensity weightlifting, and most
notably smoking.
For providers trying to discern aortic disease from another condi-
tion, there are a host of other risk factors that may play a role in the
development of an aneurysm and its subsequent dissection. Unfortu-
nately, these additional risks are shared with numerous other cardiovas-
cular conditions such as coronary artery disease, myocardial infarction
(MI), heart failure, etc.
Regardless of the processes leading to the development of an aneu-
rysm, rarely will a prehospital provider encounter patients with an
unknown and asymptomatic aneurysm, and be able to diagnose the
condition with any high degree of certainty. This being said, the abil-
ity to rapidly assess for and rule-in dissection is a whole other matter
entirely. Recognition of aortic dissection is of great importance to these
patients and quite plausible in the prehospital setting.

PATIENT PRESENTATION
The most common symptom of aortic dissection is pain. The onset
is almost always very abrupt and severe. The pains quality is usually
described as sharp or tearing, with sharp being more common. The
location of the pain can vary wildly depending on the location and
involved structures. For isolated dissections of the AAA, abdominal
and back pain are very likely. For patients with a TAA dissection, pos-
terior chest pain is usually present with anterior chest pain accom-
panying Type A dissections. Should there be propagation along any
confluent vessels, the pain can radiate to almost anywhere. Should a
coronary be involved, symptoms of an MI may be present; if a renal
artery dissects, flank pain on the affected side is possible; and if an
iliac artery is destroyed, the affected ischemic limb could be painful.
Providers should especially be concerned for dissection if a patient
presents with a known history of an aortic aneurysm and the sudden
onset of the pain described above. Should these same patients with
a known aneurysm and sudden chest/back pain also present with a For more information, visit JEMS.com/rs and enter 17.

www.jems.com mARcH 2016 | JEMS 59

1603jems_59 59 2/15/16 11:27 AM

 TICKING TIME BOMB
Aortic dissections develop via a small tear in the aor-
tas innermost layer. WikimediaCommons/ J. Heuser
hypertensive state, theyre quite likely to be
suffering from an acute dissection. Providers
cant miss this sequela of symptoms!
Because of the variation in the location of
an aneurysm and the mobility of the dissection,
symptoms can vary greatly from one patient to
the next. For instance, if a dissection involves
the left subclavian artery, patients will pres-
ent with a disparity in blood pressure between
arms. If the vertebral arteries are involved,
there patient may present with paresthesias due
to spinal cord ischemia. Its difficult to diag-
nose a dissection on the basis of one of these
attributing symptoms alone, however these, in
addition to the classic symptoms above, should
only help solidify your diagnosis.
TRANSPORT
If left untreated, aortic dissection should be
considered a death sentence, especially in cases
of large or Type A dissections. Should the
tunica adventia rupture as a result of a grow-
ing dissection, the patient will spill blood into
the affected cavity and exsanguinate in a mat-
ter of moments.
The greatest asset these patients can be
offered by EMS providers is early recognition,
followed by appropriate transport to the cor-
rect destination. In many areas, these patient
require the expert surgical services only avail-
able at academic, tertiary care centers. Should
transport to such a facility not be possible,
providers should make every effort to trans-
port to a facility with cardiothoracic and vas-
cular surgical services on staff. Patients with
known aortic aneurysms will typically be able
to tell you which hospital theyre followed at
and where they should be transported. Aero-
medical utilization may also be plausible in
consult with a physician colleague via medical
command. Aeromedical should be limited to
patients with a high degree of suspicion for
dissection and are in an area where transport
to the appropriate facility isnt possible within
a reasonable amount of time.
MANAGEMENT
Management of these patients focuses on sev-
eral hallmark therapies. Ultimately, the goal
is to keep the patient alive long enough to
get into surgery with as few complications
as possible.
Initial management is no different than any
other medical or surgical emergency, pay atten-
tion to your ABCs (airway, breathing and cir-
culation). If a patients mental status warrants
intubation, intubate and ventilate. If a patient
is hypotensive, judiciously resuscitate them.
Next move on to the acute medical man-
agement. First, providers must respect the
critical role that analgesia has in this illness.

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 TICKING TIME BOMB
Dissections in the presence of tachycardia and
hypertension are extremely dangerous and
prone to sudden death. Pain can lead to both
of these factors. Aggressive pain management
is key in preventing the exacerbation caused
by hypertension and tachycardia.
After pain control is accounted for, provid-
ers should move on to very tight hemodynamic
control. Blood pressure and heart rate control
are of great importance to these patients. The
initial goal is to ensure a patients systolic blood
pressure remains between 100120 mmHg.
In patients who are hypertensive with a heart
rate > 60 bpm, the initial therapy should be
IV beta-blockers.1 My preference for the pre-
hospital and critical care transport setting is
esmolol. Although others such as labetalol are
more commonly seen in the inpatient setting,
esmolol is probably the strongest choice in our
environment because its highly titratable and
has a very short half-life. Should a patient have
an unfavorable reaction to esmolol, the infu-
sion can be turned off and its effects will wear
off within minutes. Esmolol is very effective
Because of the aortas size and involvement in
nearly every organ system, dissections can have cat-
astrophic consequences in nearly every part of the
body. WikimediaCommons/ Edoarado
62 JEMS | MARCH 2016
1603jems_62 62
at reducing hypertension thats secondary to
increased heart rate, and thus should only be
given for patients with heart rates 80 bpm and
above. Patients who will only stand for a min-
imal reduction in heart rate (7090 bpm) may
only have minimal reductions in blood pres-
sure. Do keep in mind, however, that esmolol
is a very strong vesicant and should be given
through a well-flowing, moderate-bore IV.
If beta-blockers arent indicated (i.e., heart
rate is < 60 bpm), contraindicated (e.g., allergy,
asthma, etc.), or simply ineffective, a nitro-
prusside infusion should be the next agent of
choice. As a direct peripheral vasodilator, nitro-
prusside is quite effective at quickly decreas-
ing the blood pressure while maintaining the
tone and integrity of the aorta. Other direct
vasodilators such as hydralazine shouldnt be
administered to these patients as they can
decrease the tone of the vessel to the point
that its more susceptible to increased stress
and further tearing.
Any of these treatments in the acute phase
of dissection should be via IV infusion to
closely monitor their efficacy and titrate
as needed.
CONCLUSION
Patients suffering from aortic dissection are
indeed at risk of catastrophic outcomes. As
dissections progress, patients can have devas-
tating long-term consequences such as renal
failure, paralysis, cerebrovascular accident or
MI. Additionally, dissections have a high like-
lihood of precipitously deteriorating, killing
patients in a matter of seconds.
Early recognition of this condition is par-
amount to survival. These patients are often
surgical emergencies and require specialized
services available at only certain facilities.
Rapid transport to the correct facility will
greatly ensure the best chance and survival.
Lastly, very targeted treatments and tight reg-
ulation of hemodynamics by prehospital and
critical care providers will greatly increase the
chance that these patients make it to the oper-
ating room for definitive surgical recovery. JEMS
Robert P. Girardeau, BS, NRP, FP-C, is a critical care and flight
paramedic with Thomas Jefferson University Hospitals Criti-
cal Care Transport and Flight Program, JeffSTAT. Hes also an
educator and field provider in the greater Philadelphia area.
He can be reached at rgirardeau@gmail.com.
REFERENCES
1. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/
ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagno-
sis and management of patients with thoracic aortic disease:
A report of the American College of Cardiology Foundation/
American Heart Association Task Force on Practice Guidelines,
American Association for Thoracic Surgery, American College of
Radiology, American Stroke Association, Society of Cardiovas-
cular Anesthesiologists, Society for Cardiovascular Angiography
and Interventions, Society of Interventional Radiology, Society
of Thoracic Surgeons, and Society for Vascular Medicine. Circu-
lation. 2010;121(13):e266e369.
2. Campa J, Greenhalgh R, Powell J. Elastin degradation in abdom-
inal aortic aneurysms. Atherosclerosis. 1987;65(12):1321.
3. Eagleton M. Inflammation in abdominal aortic aneurysms: Cellu-
lar infiltrate and cytokine profiles. Vascular. 2012;20(5):278283.
4. Cheung C, Bernardo AS, Trotter MW, et al. Generation of human
vascular smooth muscle subtypes provides insight into embry-
ological origin-dependent disease susceptibility. Nat Biotechnol.
2012;30(2):165173.
5. Woo YJ, Mohler ER III. (Oct. 27, 2015.) Epidemiology, risk fac-
tors, pathogenesis and natural history of thoracic aortic aneu-
rysm. UpToDate. Retrieved Jan. 19, 2016, from www.uptodate.
com/contents/epidemiology-risk-factors-pathogenesis-and-
natural-history-of-thoracic-aortic-aneurysm.
6. Mohler ER III. (Oct. 4, 2014.) Epidemiology, risk factors, patho-
genesis and natural history of abdominal aortic aneurysm.
UpToDate. Retrieved Jan. 19, 2016, from www.uptodate.
com/contents/epidemiology-risk-factors-pathogenesis-and-
natural-history-of-abdominal-aortic-aneurysm.
7. Rahimi S. (Sept. 28, 2015.) Abdominal aortic aneurysm. Med-
scape. Retrieved Jan. 19, 2016, from http://emedicine.medscape.
com/article/1979501-overview.
8. Dillavou E, Muluk S, Makaroun M. A decade of change in
abdominal aortic aneurysm repair in the United States: Have
we improved outcomes equally between men and women?
J Vasc Surg. 2006;43(2):230238.
9. Januzzi JL, Isselbacher EM, Fattori R, et al. Characterizing the
young patient with aortic dissection: Results from the Inter-
national Registry of Aortic Dissection (IRAD). J Am Coll Cardiol.
2004;43(4):665669.
10. van Vlijmen-van Keulen CJ, Pals G, Rauwerda JA. Familial abdom-
inal aortic aneurysm: A systematic review of a genetic back-
ground. Eur J Vasc Endovasc Surg. 2002;24(2):105116.
RESOURCES
Jim J, Thompson R. (Sept. 25, 2015.) Clinical features
and diagnosis of abdominal aortic aneurysm. UpToDate.
Retrieved Jan. 19, 2016, from www.uptodate.com/contents/
clinical-features-and-diagnosis-of-abdominal-aortic-aneurysm.
Manning WJ, Black JH III. (Dec. 30, 2015.) Clinical man-
ifestations and diagnosis of aortic dissection. UpToDate.
Retrieved Jan. 19, 2016, from www.uptodate.com/contents/
clinical-manifestations-and-diagnosis-of-aortic-dissection.
Woo YJ, Mohler ER III. (Sept. 24, 2013.) Clinical manifestations
and diagnosis of thoracic aortic aneurysm. UpToDate. Retrieved
Jan. 19, 2016, from www.uptodate.com/contents/clinical-
manifestations-and-diagnosis-of-thoracic-aortic-aneurysm.
www.jeMs.CoM
2/15/16 11:27 AM
 FEBRUARY 23 25, 2017
CALVIN L. RAMPTON SALT PALACE CONVENTION CENTER
SALT LAKE CITY, UTAH

LEARN EXCEL NETWORK

For more information, visit JEMS.com/rs and enter 21.

SAVE THE DATE OWNED &

PRODUCED BY
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OF EMS TODAY www.EMSToday.com

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 HANDS ON
PRODUCT REVIEWS FROM STREET CREWS

Dont Lose That Tube!

When you see a 10 lb. weight hanging from an endotracheal tube placed in an
inverted airway manikin, you cant help but be impressed. That was at EMS Today in
the mid-1990s, and the original Thomas Tube Holder (TTH) quickly became a standard
piece of equipment in airway kits. The new TTH Select from Laerdal improves upon an
industry standard. The TTH Select is now faster to place thanks to a friction lock, which
means you just have to push the yellow thumbscrew to
place the device. The traditional thumbscrew continues VITALS
to assure secure, easily adjustable placement. Another Dimensions: 4.5" x 2.75" x 2"
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strap with push stick to help place the strap behind the www.laerdal.com
patients neck also remains. 877-LAERDAL (523-7325)

Scalable Incident Situational Awareness

During a mass casualty incident or a natural or man-made disaster, its important for commanders to have a
broad view of the incident and maintain situational awareness. Are area hospitals being overwhelmed during
an ice storm? Has a hurricane knocked out power to a large portion of your county? What hospitals are open to
receive casualties following an earthquake? Or, did an area hospital just lose all landline communications due to
a freak car accident? The Healthcare Incident Management System software package from Knowledge Center
provides a common platform for hospitals, governmental agencies
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412-206-2993 Sandy in 2012 and by all accounts it met that test extremely well.

VITALS
A Street-Tough Lunchbox Sizes: Shuttle (7.75" x 5.2" x 2");
Healthy eating can be a struggle in EMS. Long hours, Rover (10" x 7" x 1.5");
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take-out and long transports all make it difficult to Price: $34.95 (Shuttle);
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heavy-duty, stainless steel Lunchboxes from Planet Box www.planetbox.com
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Box lunchboxes are dishwasher safe. Accessories include dippers for keeping sauces
separate, magnets for decoration or identification, icepacks and carry bags.

Fran Hildwine, BS, NREMT-P, is a simulation learning technician at the Pennsylvania College of Health Sciences in Lancaster, Pa., a paramedic with Chester
County Hospital and EMS instructor at Good Fellowship Ambulance Club in West Chester, Pa. Contact him at fran100b@zoominternet.net.

64 JEMS | MARCH 2016 www.jeMs.CoM

1603jems_64 64 2/15/16 11:27 AM

 For more product reviews: www.jems.com/Hands-On

Affordable AED Trainer

Push hard, push fast, at a rate of 100120 compressions per minute
and use an automated external defibrillator (AED) as soon as
possible. Those are two of the most basic points
of CPR educationan important public
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way for providers who become instructors
to earn some extra cash. One of the major
hurdles to establishing your own CPR
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trainers. For established instructors and training
centers, the ability to have an AED trainer for every
two or three students will make for faster classes,
increasing your return on investment. The AED
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VITALS
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Dimensions: 7.5" x 6" x 1.75"
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Price: $149.95
practice in a quiet environment.
www.wnlproducts.com
800-884-9629

Comfortable EMS Pants

EMS uniform pants have developed into a specialty item
that addresses many of the unique needs of our industry.
EMS pants need to look professional; carry specific supplies
such as trauma shears, multiple pairs of gloves, a small
flashlight and a multi-tool; and stand up to a high amount
of sitting, squatting and kneeling. The new Tactix EMS
Pants from First Tactical address all of these requirements
with a design that has some unique features. The concealed,
flex-action waistband moves with you and helps keep your shirt
tucked in. The thigh pocket has a zippered top opening, a hook-
and-loop-secured large compartment and a durable nylon-
lined scissor/flashlight/dual pen pocket. Pockets on the calf
can hold multiple pairs of gloves and there are even external
access pockets for knee pads. Now you can perform CPR and
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VITALS
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IN THE NEXT ISSUE: >> Laerdal SimMan ALS >> Leatherman Trax >> First-Light USA TORQ
>> Jones & Bartlett Learning EMS Textbook Updates >> PPSS Slash-Resistant Combat Shirt

www.jems.com mARcH 2016 | JEMS 65

1603jems_65 65 2/15/16 11:27 AM

 FIELD PHYSICIANS
EMS DOCS PERSPECTIVES ON STREET MEDICINE
DOWN UNDER
Street doc sheds light on EMS culture in Australia
By Mark E.A. Escott, MD, MPH, FACEP
I
n January of 2000, I had the opportunity
of starting medical school at Flinders Uni-
versity in Adelaide, Australia. As a Texas
paramedic, I was naturally curious about get-
ting involved with the ambulance service in
South Australia. I was also certain that coming
from an advanced EMS system in America, I
could offer my advice in order to improve their
system. What I found instead was a system
so far advanced from most in the
United States that it completely
changed my notion of what EMS
could be. Youre only a professional
One of the lead visionaries of
this evolutionary leap in EMS when respected professionals
was one of my mentors, Hugh
Grantham, MD, who currently acknowledge you as such.
serves as professor of paramedics
and assistant dean in a premier
ambulance studies program at Flinders Uni-
versity. Fifteen years later, I spoke with him
about the current state of EMS education and
practice in Australia.
How did paramedics in Australia
go about making the transition from
technicians to degreed clinicians? change, the union has clearly pinned its col-
The process of evolution was a staged change
in both education and culture. In order to
change the culture within the profession, edu-
cational understanding had to occur. To change
the culture around the profession, respectnot
just for the skill and nature of the dangerous
job, but for knowledge and understanding
had to be generated. Each educational step
forward allowed a corresponding change in
internal and external culture to occur.
The paramedic whose handover was once
disregarded and clinical records disposed of
has now become the valued health professional
and first link in an integrated system. As he
stepped up through different levels of educa-
tion, the cultural changes kept pace. Although
a degree-level education is readily identifi-
able as a milestone, it would mean nothing if
66 JEMS | MARCH 2016
1603jems_66 66
it wasnt accompanied by the respect of other
health professionals. The cultural changes that
drive the respect are almost more important
than the education that enabled them.
Paramedics in the U.S. struggle from
relatively low wages, which results
in excessive overtime work. How
do you address this in Australia?
The issue of wages is really related to respect. It
has been handled both well and poorly in Aus-
tralia through negotiations between employers
and unions. For example, I would pay tribute to
the professionalism demonstrated by the ambu-
lance union in South Australia. Rather than
making noisy demonstrations and demanding
autonomous and unsupported for a few min-
ors to the mast of patient care since the early
1990s. When they came to make an appeal for
professional wages, it was made quietly with
professional dignity behind closed doors. The
arguments were supported by good evidence
of education and considered reasoning that
admitted there was room for improvement.
Youre only a professional when respected pro-
fessionals acknowledge you as such.
Whats the most pressing issue in EMS
practice in Australia at the moment?
Its the same as it is for EMS education in
Australia: The changing nature of the para-
medic workload and how EMS systems must
adjust to accommodate it. Well always have
a small percentage of traditional emergencies
that need a full paramedic crew, vehicle and
equipment. The question is: Does that equip-
ment and configuration cope well with the
complex, time-consuming and challenging
cases that are becoming the expected bread
and butter? In the past, it was enough to have
saved the life and moved the problem to an
ED. Now, as a true health professional, a para-
medic has to be equipped and supported to go
beyond just transferring the problem. Weve
got to educate our paramedics to
be good at this and gain satis-
faction from it. We also have to
provide an environment with the
equipment, dispatch criteria and
structure to support this activity.
How do you think EMS
medicine will change in
the next 510 years?
EMS medicine is going to change steadily as its
role and expectations do. The most important
change is that paramedics provide definitive
care and an integrated, seamless interaction
with the rest of the medical system. At the start
of a patient contact story, a paramedic operat-
ing in an isolated silo of time, where they are
utes, will be a thing of the past. The modern
paramedic will be part of an integrated medical
system that shares care and responsibility from
the start and continues their care to the end.
This change is both a function of an increased
need, and recognition of an increased ability
in todays EMS world. JEMS
Mark E.A. Escott, MD, MPH, FACEP, is the
medical director and founder of Rice Univer-
sity EMS in Houston, Texas. Hes the founder/
director of the Baylor College of Medicine
EMS Collaborative Research Group, where he
also serves as the director of the Division of EMS and Disaster
Medicine and an assistant professor in the Section of Emer-
gency Medicine. He also serves as the public health authority
in Montgomery County, Texas, and is board certified in emer-
gency medicine and subspecialty board certified in EMS.
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1603jems_67 67 2/15/16 11:27 AM

 LAST WORD
THE UPS & DOWNS OF EMS

OFF-THE-CLOCK SAVES arrived, and after two shocks, the boys heartbeat the right instinct to help.
Its a parents worst nightmare: Your child returned. Its not just that Bergstrom was in the right This save follows on the heels of three other
is hurt, but you dont know how to help. place at the right time; he was at the right place, recent saves off-duty ATCEMS personnel were
Its in situations like these when EMS crews are with the right training, at the right time, and had involved in: Just as he was about to go home after
truly invaluable, which is why Austin- a shift, Mark Hawkins helped saved
Travis County EMS (ATCEMS) para- the life of a 50-year-old runner who
medic Chance Bergstrom was recently collapsed in cardiac arrest outside the
honored with a Lifesaving Award for EMS station; Danielle Henson helped
resuscitating a 14-year-old boy. save a 15-year-old boy in cardiac arrest
Bergstrom was driving in the parking at a local swimming pool; and Craig
lot of a local shopping center when he Smith helped save a young boy who
saw a young boy collapse while walk- was being repeatedly submerged in a
ing with his parents. His mother was local river after falling off his inner tube.
screaming for help, and Bergstrom We give a thumbs up to Bergstrom
knew he had to spring into action, even and his ATCEMS colleagues for acting
though he was off duty. quickly, even while off the clock. Their
Bergstrom couldnt find a pulse on Austin-Travis County EMS paramedic Chance Bergstrom (right) receives the heroism shows that helping others is
the boy, so he began CPR. A police Lifesaving Award from Sunset Valley Police Department along with police much more than a job description
officer equipped with an AED soon officer J.C. Hall, who also responded to the incident. Photo courtesy ATCEMS its a way of life.

DENYING DEATH BENEFITS
Tragedy struck Jessamine County,
Ky., when one of its paramedics,
40-year-old husband and father John Mackey,
EMT-P, died after being hit by a car while
inspecting damage on his ambulance.
Tragedy struck again when his family real-
ized theyd only get line of duty death benefits
from the federal government, and none from
Kentucky. When firefighters and police offi-
cers die while on duty, Kentucky gives their
families $80,000, plus a tuition waiver to a
state college. Medics, however, are left out of
receiving these benefits.
Our families depend on us and its incred-
ibly scary to think about what will happen if
we dont make it home for our family, says
Keith Widmeier, BA, NRP, FP-C, EMSI, a
paramedic from Kentucky. What better way
to honor those whove given the ultimate sac-
rifice in order to protect their community
than by ensuring their family is cared for?
State lawmakers are now paying atten-
tion to this disparity as the states medics cry
out for justice. Two separate bills extending
death benefits to EMS workers are mak-
ing their way through the state legislature,
including Senate Bill 43, the John Mackey
Memorial Act.
Unfortunately, it took a tragedy like
John Mackey dying to push this bill for-
ward. Hopefully, his legacy will carry this leg-
islation through, Widmeier says. Widmeier
also encourages medics across the country to
contact their local representatives and sen-
ators to let them know all first responders
deserve equal benefits, and to show support
for this type of legislation on social media.
We give a thumbs down to states that
continue to refuse to give EMS the line of
duty death benefits afforded to other first
responders. Well hold out on giving Ken-
tucky a thumbs up for now, but remain hope-
ful that one of the proposed bills will soon
make its way into state law.
COMMUNITY CHAMPION
The lifesaving work of first responders
often goes unnoticed. Lets face itno
one is in this industry for the fame. And while
we dont do this job for the attention, its nice
for the industry and outstanding individuals
to get recognized every once in a while. Ada
County (Idaho) Paramedics Battalion Chief
Andrea Cobler is one of those individuals.
Cobler was named the best paramedic in
Idahos Treasure Valley as part of the Com-
munity Champions awards held by local
news station KTVB and Idaho Central Credit
Union. Thousands of community members
voted online for their favorite nonprofit orga-
nizations and first responders.
Its no surprise that Cobler won this award
with how much she loves her job.
For me, its not hard to be passionate about
EMS, Cobler says. Patients often describe
their event as the worst day of their lives. As
an EMS provider, I have the opportunity to
offer them a little bit of comfort and com-
passion during that time. If I can add just a
little bit of good to that worst day, then I have
done my job. How can you not get excited
about that?
We give a thumbs up to Cobler for her
continued dedication to emergency medicine
and providing quality patient care. We also
give a thumbs up to KTVB and Idaho Central
Credit Union for giving community mem-
bers the opportunity to honor EMS workers
for their contribution to the communities
they serve. JEMS

JEMS (Journal of Emergency Medical Services) (ISSN 0197-2510) USPS 530-710, JEMS is published 12 times a year, monthly by PennWell Corporation, 1421 S. Sheridan, Tulsa, OK 74112. Periodicals postage
paid at Tulsa, OK 74112, and at additional mailing offices. SUBSCRIPTION PRICES: Send $44 for one year (12 issues) or $74 for two years (24 issues) to JEMS, P.O. Box 3425, Northbrook, IL 60065-9912, or call
888-456-5367. Canada: Please add $25 per year for postage. All other foreign subscriptions: Please add $35 per year for surface and $75 per year for airmail postage. Send $20 for one year (12 issues) or $35
for two years (24 issues) of digital edition. Single copy: $10.00. POSTMASTER: Send address corrections to JEMS (Journal of Emergency Medical Services) , P.O. Box 3425, Northbrook, IL 60065-9912. Claims of
non-receipt or damaged issues must be filed within three months of cover date. JEMS is a registered trademark. PennWell Corporation 2016. All rights reserved. Reproduction in whole or in part without
permission is prohibited. Permission, however, is granted for employees of corporations licensed under the Annual Authorization Service offered by the Copyright Clearance Center Inc. (CCC), 222 Rosewood
Drive, Danvers, Mass. 01923, or by calling CCCs Customer Relations Department at 978-750-8400 prior to copying. We make portions of our subscriber list available to carefully screened companies that offer
products and services that may be important for your work. If you do not want to receive those offers and/or information via direct mail, please let us know by contacting us at List Services JEMS (Journal of
Emergency Medical Services), 1421 South Sheridan Road, Tulsa, OK 74112. Printed in the USA. GST No. 126813153. Publications Mail Agreement no. 40612608.

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1603jems_68 68 2/15/16 11:27 AM

 For more information, visit JEMS.com/rs and enter 24.

1603jems_C3 3 2/15/16 11:27 AM

 ALL INTRAOSSEOUS SITES ARE NOT EQUAL

Clinical Studies Suggest the Sternal IO Route

Improves
   




  
 Patient Outcomes 
Hoskins, Stephen L, et al: Based on the present data, we recommend that
1 sternal IO route be considered as the first choice of drug delivery during CPR
when IV access has not been established (1)

Pasley, Jason, et al: ...the sternal IO site provided the highest flow rates compared
2 with the humeral and tibial insertion sites. The sternal site was also associated with a
100% success rate for initial placement facilitated by its consistent anatomy. (2)

Burgert, James, et al: There may also be a relationship between the anatomical
3 location of the IO device and serum drug concentrations; the more distal the IO infusion
site is from the sampling site, the longer concentrations of drug take to rise. (3)

The quotes above are taken from three of the four important studies reviewed in the Clinical Review Paper by Dr. Alan
Moloff. To download the full paper and access references (1), (2), and (3), visit go.pyng.com/sternal

Download the Clinical Review Paper: go.pyng.com/sternal

For more information, visit JEMS.com/rs and enter 25.

Try FASTResponder Sternal IO at EMS Today

Booth #2927 & the Active Shooter Simulation Lab



   



1603jems_C4 4 2/15/16 11:27 AM