Jounal Club-June 2009

[ERDoc]

The last journal article didn't go over too well, so I'll give it one more try. This month this discussion will be about prehospital steroids for asthma. Here is the article.

http://www.ncbi.nlm.nih.gov/pubmed/1458209...Pubmed_RVDocSum

Feel free to discuss.

[itku2er]

Ok I am missing something here All I could see was the abstract. How do I get it to put up the whole story so I can read it.

From the abstract was the thinking that people that recieved steriods prehospital less likely to need hospitalization, than the ones that didnt get them till they were in the ER. Well where I live we are rural and have alot of retired coal miners and life long smokers so sterioids are a big thing in this area. Solmedrol is the one most utilized here in this area.

Good topic DOC, I would really like to read the whole thing.

[CBEMT]

Sounds good to me. We had Solu-Medrol in our protocols for years. Now we've been switched to Solu-Cortef.

Good to see some validation for what we've already been doing. Thanks Doc.

Edited June 7, 2009 by CBEMT

[WelshMedic]

Whilst the study is promising in terms of cortico-steroids in the pre-hospital arena, I'm not yet ready to hang out the flags. The trial is of limited value due to it's size and the number of enrolled patients. I do think, however, that it is statistically significant that the steroids were given within a far shorter mean time in EMS than in the ER.

Terri also makes a good point, this study does not include (nor did it intend to, to be fair) the majority of patients in this category by virtue of the fact that it excludes COPD. I deal with far far more COPD pts than juvenile asthma. I am willing to suggest that pre-hospital cortico-steroids are of benefit here too, but this study does not address that.

It is also a few years old. Are there any more recent studies that back this up? (I know, I'm lazy; I should look it up myself).

WM

Edited June 7, 2009 by WelshMedic

[HERBIE1]

Based on the abstract, I am inferring that because the patient received the steroids sooner, they did not decompensate as much as if the treatment was administered in the ER, they stabilized quicker, and their rates of admission were less. Intuitively, this makes sense-more aggressive treatment would mean a better outcome for the patient. Although the study excluded COPD'ers and smokers, in my system we have more than enough patients who merely have asthma with no other complicating diseases so I would like to see this implemented here.

To me, this seems like the current trend- more prehospital care vs waiting until the patient arrives in the ER. Because of the inherent intertia of providing most ER care, for example, we can provide analegesics to a patient sooner- vs getting triaged, registered, seen by a nurse, seen by an MD, awaiting orders and administering the pain medication.

On a slight tangent, a few years ago we began using a combination of atrovent and albuterol in COPD patients, knowing that unless we have an extended transport time, the benefits of the atrovent will generally be seen after the patient arrives at the emergency room.

Thus, my question is- is the wave of the future providing treatment that is more beneficial to the patient in the long term vs simply emergency mitigation and stabilization? If so, that means that our scope of practice will rapidly expand whether we like it or not. I have no problem with that, as our roles have been evolving at an exponential rate over recent years anyway.

[fiznat]

It is a severely underpowered study, especially considering the fact that there were confounding circumstances such as epinephrine treatments in the steroid group. The results technically do achieve statistical significance, but 4 patients admitted versus 11 patients isn't exactly policy-changing evidence. I do appreciate that this work is getting done, though. Prehospital medicine needs more rigorous study- just, hopefully, the large/prospective/randomized/blinded kind as much as possible.

[Scott]

Might not be a bad thing to have in the tool box. However, as this has been a fairly recent addition to the SOP for Paramedics (within the past couple of years), there probably is not a lot of records available in which to review, it is still not utilized on a regular basis, and to be honest, I am not sure services are even carrying this on the rigs. The vast majority of medics will still utilize the standard Epi, Albuterol, etc..I have used Mag Sulf. as a smooth muscle relaxer on a couple occasions with severe asthmatics and had excellent results. That being said, although it is written in the protocols to consider, many docs are still not fully on board with the Mag Sulf. issue.

[Kiwiology]

I did read one or two articles about it a while ago randomly on the interweb one Saturday at 1 or 2am (yeah, my life is boring) and all said significantly improved outcomes for patients who has prehospital steriods or corticosteriods.

One small service here currently has hydrocortisone the rest of us have ventolin and adrenaline only.

I'd love to see us get some steriods in our tool box!

[fiznat]

We are carrying Solumedrol for acute asthma... Is that uncommon? Standing orders for 125mg IVP. We also carry atrovent, albuterol, epi, and mag.

Edited June 12, 2009 by fiznat

[FireMedic65]

Excellent article and a great idea ERDoc with doing this. It's always nice to read up on new studies and having people in trenches discuss them.

We have been using solu-medrol for years here. For adults 125mg IV and peds 2mg/kg IV. This is after using neb treaments and cpap/bipap. If no change or improvements, contact medical command. If the patients systolic is under 90, you must contact medical command before administration of corticosteroids.

http://www.dsf.health.state.pa.us/health/l...ve_11-01-08.pdf Pages 42-44 for those who want to see.

From my experiences, being first hand, word of mouth, and outcomes in the hospital, it is a great thing.

Edited June 12, 2009 by FireMedic65