Ep 106 - Succ vs Roc in Hyperkalemia

This is a special version of the EMS Lighthouse, live from Ashland, OR. We are joined by Mike Verkest and Dr Ritu Sahni from The EMS Show, and Jimmy Apple from The EMS Avenger at the State of Jefferson Conference in Southern Oregon. We had a blast and covered a to of ground. I hope y'all enjoy!

Dr Remle Crowe returns to the podcast to discuss three new papers with Dr Jarvis: Two papers on epinephrine in cardiact arrest (including one on trauma!) and one on pulse oximetry in hypoxemic patients with darker skin. We might nerd out a bit on methodology, tacos, and have a few book recommendations.Citations: Martin DS, Doidge JC, Gould D, et al.: The impact of skin tone on performance of pulse oximeters used by NHS England COVID Oximetry @home scheme: measurement and diagnostic accuracy study. BMJ. 2026;January 14;392Witt CE, Shatz DV, Robinson BRH, et al.: Epinephrine in Prehospital Traumatic Cardiac Arrest—Life Saving or False Hope? Prehospital Emergency Care. 2026;January 2;30(1):153–61.Lilien EJ, Ashburn NP, George TS, et al.: Single Dose Epinephrine Protocol Is Associated With Improved Survival of Older Adults With Out‐Of‐Hospital Cardiac Arrest. Academic Emergency Medicine. 2025Perez CP: Invisible Women: Data Bias in a World Designed for Men. New York, NY, Abrams Press, 2019.O’Neil C: Weapons of Math Destruction: How Big Data Increases Inequality and Threatens Democracy. New York, NY, Crown Publishing Group, 2017. • 6. Perkins GD, Ji C, Deakin CD, et al.: A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2018;August 23;379(8):711–21.

We were all taught succinylcholine is contraindicated in hyperkalemia because it can cause potassium release, exacerbating the problem. But does it? Does it really?Dr. Jarvis discusses a recent paper that seems to compare mortality within 24 hours of RSI in hyperkalemic patients between those intubated with succ or rocuronium. And then we discuss methods.. including the Table 1 Fallacy. Citations:1.     Simmer PE, Perza M, Cho YD, et al.: Hyperkalemic emergency department patients intubated with rocuronium or succinylcholine: Retrospective study of clinical outcomes. The American Journal of Emergency Medicine. 2026; February;100:154–64.2.     Cole JB, Knack SKS, Driver BE: The value of P-values in “Table 1.” The American Journal of Emergency Medicine. 2026; February;100:182–6.3.     Pappal RD, Roberts BW, Mohr NM, et al.: The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department. Ann Emerg Med. 2021;77(5):532–44.4.     ‘Rick & Jerry’ Pass the Baton | Emergency Physicians Monthly. Available at https://epmonthly.com/article/rick-jerry-pass-the-baton/. Accessed January 25, 2026.

You've read about how this groundbreaking trial on ketamine vs etomidate for RSI "Changes Everything!" on the socials. Or perhaps "it's horribly biased and unnecessary... we're already knew all this!". Why? Well.. social media. Listen in as Dr Jarvis discusses not just this trial, but what the evidence landscape was before it was released. Why was it done, how was it done, what does it show, and how can we integrate it into our practice?Citations:1. Casey JD, Seitz KP, Driver BE, et al. Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults. N Engl J Med. Published online December 9, 2025.2. Jabre P, Combes X, Lapostolle F, et al. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet. 2009;374(9686):293-300. 3. Matchett G, Gasanova I, Riccio CA, et al. Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med. 2022;48(1):78-91. 4. Koroki T, Kotani Y, Yaguchi T, et al. Ketamine versus etomidate as an induction agent for tracheal intubation in critically ill adults: a Bayesian meta-analysis. Crit Care. 2024;28(1):48. 5. Yeh RW, Valsdottir LR, Yeh MW, et al. Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial. BMJ. 2018;363:k5094. doi:10.1136/bmj.k5094

Right on the heels of the release of the 2025 AHA guidelines, including one on preferentially using IVs over IOs, comes two RCTs in the same edition of NEJM that compare intial attempts with IVs to IOs in out of hospital cardiac arrest. Dr Jarvis discusses these two papers while answer a listeners question, and tries to put this, and early epinephrine, into context. And he might throw in some commentary about the AHA's recommendations on mCPR and Heads Up CPR.Citations:1. Couper K, Ji C, Deakin CD, et al. A Randomized Trial of Drug Route in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2025;392(4):336-348. doi:10.1056/NEJMoa24077802. Vallentin MF, Granfeldt A, Klitgaard TL, et al. Intraosseous or Intravenous Vascular Access for Out-of-Hospital Cardiac Arrest. N Engl J Med. 2025;392(4):349-360. doi:10.1056/NEJMoa2407616

ACOG, the American College of Obstetricians and Gynecologists, recently published EMS guidelines for treatment of hypertension in pregnancy/pre-eclampsia, eclampsia, and postpartum hemorrhage. Drs. Jenna White and Christopher Zahn join Dr Jarvis to discuss the science behind these recommendations as well as how to implement them into our practice. Citations:1. https://www.acog.org/programs/obstetric-emergencies-in-nonobstetric-settings2. Vuncannon, D. M.; Platner, M. H.; Boulet, S. L. Timely Treatment of Severe Hypertension and Risk of Severe Maternal Morbidity at an Urban Hospital. American Journal of Obstetrics & Gynecology MFM 2023, 5 (2), 100809. https://doi.org/10.1016/j.ajogmf.2022.100809.3. Gupta, M.; Greene, N.; Kilpatrick, S. J. Timely Treatment of Severe Maternal Hypertension and Reduction in Severe Maternal Morbidity. Pregnancy Hypertension 2018, 14, 55–58. https://doi.org/10.1016/j.preghy.2018.07.010.

You use ketamine. I use ketamine. We all use ketamine. But… how safe it is, really? A new study out of Toronto suggests 30% of patients who receive ketamine have adverse events, a rate higher than seen in the ED. What are we to make of this? I bring Dr Remle Crowe on to discuss…Citations:1.     Kwong JL, Verbeek PR, Leong YC, Turner L, Huiskamp M, Drennan IR, Francom S, Ropp S, Cheskes S: Paramedic use of ketamine for severe agitation and violence. Can J Emerg Med. doi: 10.1007/s43678-025-00963-w (Epub ahead of print).2.     Fernandez AR, Bourn SS, Crowe RP, Bronsky ES, Scheppke KA, Antevy P, Myers JB: Out-of-Hospital Ketamine: Indications for Use, Patient Outcomes, and Associated Mortality. Annals of Emergency Medicine. 2021;78(1):123–31.3.     Brown LH, Crowe RP, Pepe PE, Miller ML, Watanabe BL, Kordik SS, Wampler DA, Page DI, Fernandez AR, Bourn SS, et al.: Adverse events following emergent prehospital sedation of patients with behavioral emergencies: A retrospective cohort study. The Lancet Regional Health - Americas. 2022;May;9:100183.

We've covered pre-oxygenation strategies and intubation alot on this podcast, mayber more than anyting else. We covered the definition of FPS in E74, the DEVICE trial on DL vs VL in E75, and the PREOXI trial of NIV vs Mask Pre-oxygenation in E86. Now we have another Preoxygenation paper, this one that reports no difference between preoxygenation with BVM and face mask. WTAF? Better listen, because it turns out words matter, definitions are... definitional, and we absolutely MUST read more than just the abstract.  Citations:1.     Gottlieb M, Alexander R, Love AK: Comparison of Preoxygenation Strategies for Intubation of Critically Ill Patients. Annals of Emergency Medicine. doi: 10.1016/j.annemergmed.2025.06.621 (Epub ahead of print).2.     Chou CD, Palakshappa JA, Haynie H, Garcia K, Long D, Gibbs KW, White HD, Ghamande S, Dagan A, Stempek S, et al.: Association of Two Preoxygenation Approaches With Hypoxemia During Tracheal Intubation: A Secondary Analysis. Annals of Emergency Medicine. doi: 10.1016/j.annemergmed.2025.06.003 (Epub ahead of print).3.     Pitre T, Liu W, Zeraatkar D, Casey JD, Dionne JC, Gibbs KW, Ginde AA, Needham-Nethercott N, Rice TW, Semler MW, et al.: Preoxygenation strategies for intubation of patients who are critically ill: a systematic review and network meta-analysis of randomised trials. The Lancet Respiratory Medicine. 2025;July;13(7):585–96.4.     Gibbs KW, Semler MW, Driver BE, Seitz KP, Stempek SB, Taylor C, Resnick-Ault D, White HD, Gandotra S, Doerschug KC, et al.: Noninvasive Ventilation for Preoxygenation during Emergency Intubation. N Engl J Med. doi: 10.1056/NEJMoa2313680 (Epub ahead of print).5.     Prekker ME, Driver BE, Trent SA, Resnick-Ault D, Seitz KP, Russell DW, Gaillard JP, Latimer AJ, Ghamande SA, Gibbs KW, et al.: Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2023;June 16;389(5):418–29.6.     Trent SA, Kaji AH, Carlson JN, McCormick T, Haukoos JS, Brown CA, National EARI: Video Laryngoscopy is Associated With First-Pass Success in Emergency Department Intubations for Trauma Patients: A Propensity Score Matched Analysis of the National Emergency Airway Registry. Ann Emerg Med. doi: 10.1016/j.annemergmed.2021.07.115 (Epub ahead of print).

The 2017 NEJM study, ALPS, compared amiodarone, lidocaine, and placebo for refractory shockable rhythms in adults with out of hospital cardiac arrest. They found no significant difference in survival to hospital discharge or functional survival between any of the arms. If that study has left you confused, you’re not alone. And you’re in luck. Tanner Smida joins us again to discuss his latest paper using something called target trial emulation to assess the difference in ROSC and survival to discharge between amiodarone and lidocaine. This is a great discussion of his paper, the methodology, and how we can put his results into the context of ALPS.Citations:1.Smida T, Crowe R, Price BS, Scheidler J, Martin PS, Shukis M, Bardes J: A retrospective ‘target trial emulation’ comparing amiodarone and lidocaine for adult out-of-hospital cardiac arrest resuscitation. Resuscitation. 2025;March;208:110515.2. Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, Leroux B, Vaillancourt C, Wittwer L, Callaway CW, et al.: Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2016;May 5;374(18):1711–22.3.Hernán MA, Robins JM: Using Big Data to Emulate a Target Trial When a Randomized Trial Is Not Available: Table 1. Am J Epidemiol. 2016;April 15;183(8):758–64.

We just got a new paper that compares initial treatment with adenosine compared with diltiazem for the treatment of adults with SVT in the ED. Wouldn’t it be great if it turned out that diltiazem was just as effective, if not more effective, as adenosine without the crappy feeling? Yeah, that’d be great, but what do we do with statistically insignificant results. Is there, perhaps, a way to save this “insignificant” paper? Fear not, Bayes is here! Yes, that’s right, Dr. Jarvis is grabbing this new paper and diving straight back into that deep dark rabbit hole of Bayesian analysis. Citation:1.     Lee CA, Morrissey B, Chao K, Healy J, Ku K, Khan M, Kinteh E, Shedd A, Garrett J, Chou EH: Adenosine Versus Fixed-Dose Intravenous Bolus Diltiazem on Reversing Supraventricular Tachycardia in The Emergency Department: A Multi-Center Cohort Study. The Journal of Emergency Medicine. 2025;August 1;75:55–64.