Download Knowledge Gaps Identified by the ILCOR 2015 Process

Knowledge Gaps Identified by the ILCOR 2015
Process: Implications for Future Research into
First Aid Interventions for Life-Threatening
Illnesses and Injuries
Nici Singletary, MD, FACEP
Andrew MacPherson, MD, CCFP-EM, FCFP
Presenter Disclosure Information
Nici Singletary, MD
Andrew MacPherson, MD
2015 ILCOR first aid knowledge gaps:
implications for future research
FINANCIAL DISCLOSURE:
 No relevant financial relationship (s) exist.
UNLABELED/UNAPPROVED USES
DISCLOSURE:
 None
Objectives
• Learn what knowledge gaps have been
identified in key ILCOR first aid evidence
reviews
• To identify barriers to research in first aid
• To consider ways to overcome these
barriers
What exactly is ‘First Aid’?
• There are over 7 calls to 9-1-1 every
second in the U.S.
• What happens between the time of the
injury or illness prompting that call, and the
arrival of EMS is first aid…and may mean
the difference between life and death, or
between a good or a poor outcome.
First Aid Definition
• First aid: the helping behaviors and
initial care provided for an acute
illness or injury.
• Can be initiated by anyone in any
situation.
• Goal: reduce mortality and morbidity
from acute injury and/or illness
A First Aid Provider is….
• …Someone trained in first aid who should
• recognize, assess, and prioritize the need for first
aid
• provide care by using appropriate competencies
• recognize limitations, seek additional care as
needed
• First aid assessments and interventions should be
medically sound and based on scientific evidence
or, in the absence of such evidence, on expert
consensus.
Cardiac Chain of Survival
First Aid Chain of Survival
Plan &
Prepare
Research
Recognize
Respond
-First Aid
Education & Training
Evidence-based guidelines
Respond
-EMS
Recover
Definitions
• Gaps – knowledge that is not available in
the current medical literature
• Barriers – circumstances/reasons which
make closing the knowledge gaps difficult
Research and Evidence Reviews
• Care by physicians and EMS providers is usually
based on extensive research and evidence reviews
• For First Aid, the ILCOR First Aid Task Force
reviewed evidence for 22 questions to form the First
Aid Consensus on Science with Treatment
Recommendations for 2015
• 95% of included studies were performed in the
hospital, ED, or within EMS and did not involve first
aid providers.
First Aid Chain of Survival
This is the single, biggest
‘gap’ in first aid science.
95% of included studies were performed in the
hospital, ED, or within EMS and did not involve first
aid providers.
‘Knowledge Gap” PICO
• In people diagnosed
with an acute
exacerbation of
chronic obstructive
pulmonary disease,
does prednisone [x, y
or z mg], decrease
mortality versus no
prednisone?
• In people with a
cervical spine injury,
does spinal motion
restriction [SMR] for
transport to hospital
[with a hard collar, soft
collar, spine board],
decrease mortality vs.
no SMR
Differences?
Barriers to Research
• Financial
– No research funding/perceived financial gain
• Political/Regulatory
– Restrictions (meds, equipment)
– Training/education
– Pressure to focus on a ‘hot’ topic
• Ethical
• Lack of familiarity and resources for study design
• Don’t know what research is needed
Your Task
• Identify knowledge gaps
• Identify research barriers
• Consider ways to overcome the
barriers [at the end]
Bronchodilator Use for Asthma
• Bronchodilators shown in hospitalbased studies to be effective and safe
for asthma with acute SOB
• Few prehospital and no first aid
studies
• Few studies looking at out-of-hospital
bronchodilators for other causes of
wheezing
• No studies show decrease in mortality
Oxygen for First Aid
• Oxygen First Aid courses marketed $$
• ILCOR looked at symptoms/conditions
other than chest pain that might
benefit
• Single large obs. study for DCS
• Small studies for lung cancer with
dyspnea and hypoxemia
Optimal Position for Shock
• Many studies used healthy,
normotensive volunteers
• Studies in hypotensive patients with
cardiogenic, septic or hypovolemic
shock, done in hospital and suffer
from design and risk of bias issues
Optimal Position for Shock
• Studies intended to assess for fluid
responsiveness.
• Single study looking at supine vs
upright
• Temporary improvement in vital signs/
indices with PLR 30 – 60 degreesunknown clinical benefit.
Control of Bleeding:
Tourniquets, hemostatic dressings vs direct pressure
•No human studies looking at elevation of extremity or
use of pressure points vs direct pressure
•No studies of cold therapy on open wounds/bleeding
•No studies looking at combination treatment or order
of treatment, (hemostatic dressing before tourniquet,
cold compression dressing with elevation)
Control of Bleeding Gaps
•Most hemostatic dressing studies performed on
animals
•Most tourniquet studies performed in
military/combat setting with military tourniquets
•Which tourniquet is most effective and easy to
apply?
•What is best way to teach tourniquet application?
BIG GAPS
Suggestions for Overcoming Barriers?
Summary: First Aid Knowledge Gaps
• General lack of research for first aid.
• Recommendations extrapolated from hospital,
EMS or military setting studies
• Existing research is lower quality; RCTs lacking
• Studies performed on healthy volunteers,
cadavers, or animals [not first aid population]
• Outcomes – limited number of end points
• Critical patient outcomes not followed (i.e.,
mortality, disability)
Gap Types
•
•
•
•
•
•
First Responder ‘diagnosis’ and recognition
Interventions with no special tools/devices
Interventions with devices, medication
Legalities of intervention
Compare with? Nothing?
Identify patients that don’t come to care? Mortality
rate
• System implementation
Thank you!
Recovery Position
• In an unresponsive normally breathing adult, does
positioning in a lateral, side-lying recovery position
compared with the supine position change….need for
airway management, incidence of aspiration,
incidence of cardiac arrest, mortality, spinal injury?
• No evidence to address the critical outcome of
mortality
• Existing studies often performed on healthy
volunteers and look at less important outcomes such
as discomfort
• Single study looked at the outcome of aspiration
Epinephrine for Anaphylaxis
• Persons with anaphylaxis frequently require a
second dose of epinephrine for symptoms that
do not resolve following the initial dose
• Gaps:
–
–
–
–
incidence of adverse effects from a second dose
time interval between doses
Should 2nd dose be given ‘routinely”
Does 2nd dose prehospital lower mortality?
Cardiac arrest response team
• AED location
• Facility responder staff
• Fire responder staff
• EMS staff
Problems??
Tools or Medications NOT Required for
Intervention
• Recovery Position
• Shock Position
• Stroke Recognition
Tools or Medications Needed for Intervention
•
•
•
•
•
Medical emergencies- Oxygen
Asthma/ Difficulty breathing - Bronchodilators
Anaphylaxis - Epinephrine
Hypoglycemia - sugar
Control of bleeding:
– Hemostatic dressings
– Tourniquets