EMS Today 2018 Quick Take: Taking on EMS myths
Modern research is dispelling treatment misconceptions and out-of-date practices that are limiting the standard of care
CHARLOTTE, N.C. — Keith Wesley, MD, FACEP, medical director, HealthEast Medical Transportation; and Corey Slovis, MD, FACP, FACEP, FAAEM, medical director, Nashville Fire Department and International Airport teamed up to present, “EMS Myths: What You Think is True Can Kill Your Patient” at EMS Today.
From lights and sirens, to right sided chest leads and unintended dosing consequences, Wesley and Slovis squashed outdated practices, misinformed thinking and bad drugs in EMS with research and witty, memorable anecdotes.
Memorable quotes on EMS myths
“When it comes to an MI, you’re not good enough to read a 12-lead, nor is anyone else.” –Corey Slovis
“If your service doesn’t have protocols in place for transporting pediatric patients, you’re outside the standard of care.” —Keith Wesley
“Nitro does not improve survival in a STEMI.” —Keith Wesley
“The brittle diabetic lives on a very fine margin of safety.” —Keith Wesley
Key takeaways on EMS myths
Whether it’s due to a lack of protocols, being unfamiliar with the research, or because a treatment path is just how you’ve always done it before, Wesley and Slovis encouraged attendees to reject excuses for inferior treatments, “before they kill your people.”
Here are the top takeaways on EMS treatment myths:
1. Epinephrine is safe.
The myth: “No epi for anaphylaxis in the elderly, they’ll code.”
The reality: IM epinephrine is safe.
Wesley reviewed a number of studies that show epinephrine is not used frequently enough. While 90 percent of patients presenting with anaphylaxis are treated with antihistamines, only 19 percent of patients are treated with epinephrine before being brought to the emergency department.
Only one-third of children experiencing anaphylaxis are treated with epinephrine pre-ED (in most cases, by school nurses) and 31 percent of children that did not receive epinephrine before they arrived in the ED didn’t get it in the ED either.
Unexpectedly, the greater the organ involvement, the less likely patients are to be treated with epinephrine. “Anaphylaxis is more than wheezing,” Wesley stressed.
Thirty-one percent of children that did not get it before the ED didn’t get it in the ED either.
Epinephrine is not contraindicated in the treatment of anaphylaxis in patients with known or suspected coronary artery disease, Wesley reported. Many departments have a caution about administering epinephrine to patients over age 65, but Wesley noted the data doesn’t back it up. If you look at the numbers of patients treated with epinephrine, the risk is miniscule, actually lower than the risk of flash pulmonary edema with Narcan administration, Wesley said, and no one would dream of giving that up.
"In the very few cases where epinephrine causes hypotension, it’s an IV epinephrine dose that causes the danger. Don’t use IV epinephrine unless the patient is in arrest,” he cautioned. “IM epi is safe.”
2. Be careful with nitroglycerine
The myth: Do not use nitro in inferior myocardial infarctions, it can cause hypotension.
The reality: This one is actually not a myth, Slovis noted. You can get hypotension with nitro, and you should be careful with administering it.
But, a look at modern literature shows that nitroglycerine is just as likely to cause hypotension in anterior MIs as it is in inferior MIs. The more tachycardic the patient is, the more likely they will experience hypotension with nitroglycerine. Nitro is an excellent treatment if patients are hypertensive, he noted.
Slovis said there are five ways to diagnose an AMI:
- 1 mm of ST elevation in two or more anatomically contiguous leads.
- Reciprocal ST depression.
- Q waves.
- Compare to prior ECGs.
- Compare to next ECG in 15-30 minutes.
He advised reading three leads at a time, instead of trying to read all 12.
Nitrates are a spectacular drug, but they do not affect mortality, only pain.
3. Toss the D50
The myth: Blood sugar must be corrected; use highest glucose known to man.
The reality: The high dosage in D50 doesn’t normalize blood sugar; it causes hyperglycemia. Wesley reported that his agency, like many in the U.S., was treating diabetic blood sugar issues with high dose dextrose, and patients were experiencing an average post-treatment blood sugar of 180, up to as high as 280.
Diabetic patients live on a very fine margin of safety, Wesley noted. It’s not as simple as eat something and sugar goes up. It can take days for a patient’s blood sugar to regulate after a D50 treatment, after repeated episodes of hyper- and hypoglycemia.
Additionally, D50 has a pH of 3.5-5 and the high acidity can cause necrotic tissue loss and compartment syndrome.
In the U.K., D10 has been the standard of care for over a decade, Wesley noted. One study showed patients experienced an average sugar of 156 after D50, as opposed to 110 after D10. “That’s a good sugar,” he said.
Once his teams made the switch, most patients are waking up with a much smaller dose of D10, and the vast majority are left with physiologically normal blood sugar.
D10 easier to get and you can titrate it, he pointed out. Slovis agrees D10 should be standard of care everywhere. “There’s no reason to use D10 other than we’ve always used it,” he said.