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Hyperkalemia in non-crush traumatic cardiac arrest... how can we best mitigate the effects?
Bicarb?
Calcium?
How much? How fast? How often?

What would you consider and push and when?

See how the discussion went, only at SOMA:
https://somed.specialoperationsmedicine.org/

Next Generation Combat Medic Journal of Special Operations Medicine U.S. Army John F. Kennedy Special Warfare Center and School U.S. Army Special Operations Command U.S. Army Special Operations Aviation Command Special Forces Medics Ragged Edge Solutions

A 2025 study published in Nature Communications compared 5 mg intramuscular (ZIMHI) to 4 mg intranasal (Narcan) naloxone in healthy opioid-naïve individuals and chronic opioid users experiencing fentanyl-induced apnea.

The study used a randomized, crossover, open-label design in a controlled clinical setting, simulating a real-world fentanyl overdose while ensuring patient safety and precise data collection.

Key findings:
- Faster Onset: IM naloxone reversed apnea in a median of 2.3 minutes, compared to 3.4 minutes with IN naloxone in opioid-naïve individuals (p = 0.002).
- Fewer Doses Required: IM reversal required a median of 1.5 doses vs. 2 doses for IN (p = 0.0002).
- More Reliable Absorption: IM naloxone produced higher peak plasma concentrations and more consistent pharmacokinetics.
- Fewer Rescue Interventions: IV rescue naloxone was needed in 0% of IM cases vs. up to 40% of IN cases in chronic opioid users.

Full story linked in comments ⬇️

What is a topic you would like to be discussed further to better understand? Any and all I will go over starting with the most requested.

Second ETI Attempt vs Cricothyrotomy: When Should We Switch Gears?

Airway management is not just about skill, it is about decision timing and trajectory.

One of the most difficult calls in trauma or progressive airway compromise (burns, inhalation injury, worsening stridor) is not HOW to manage the airway, but WHEN continued intubation attempts stop helping and start hurting.

What the Evidence Shows

Endotracheal Intubation (ETI): Success Drops With Each Attempt

Prehospital and emergency department studies consistently show that first-pass success matters and outcomes worsen as attempts accumulate.

* After 1 failed intubation attempt, rescue success remains relatively high (81%)

* After 2 failed attempts, success drops to 71%
* After ≥3 attempts, success falls to 67%

(Sakles et al., 2015)

More importantly, complication rates increase dramatically with repeat attempts:

≤2 attempts cause9% major adverse events

≥3 attempts cause 35% major adverse events

* Multiple attempts are associated with a **4.5-fold increase** in complications, including:

* severe hypoxia
* hypotension
* dysrhythmias
* vomiting/aspiration
* need for emergency surgical airway

(Hasegawa et al., 2012; NEAR Registry)

Each attempt causes more airway trauma, edema, bleeding, and oxygen debt, particularly dangerous in trauma or swelling airways where anatomy is already deteriorating.

Pros of a second ETI attempt

* Familiar and widely practiced
* Definitive airway if successful
* Reasonable when oxygenation improves and anatomy remains stable

Cons

* Statistically decreasing success
* Exponentially increasing complications
* Repeated attempts worsen the airway you’re trying to save

Cricothyrotomy: Rare, but Highly Effective When Timed Correctly

While cricothyrotomy is infrequently performed in civilian EMS, outcomes are strong when it’s done early and deliberately, not as a last-ditch maneuver.

* Surgical cricothyrotomy success rates consistently reported between 82–100%
* Systematic reviews show a **pooled success rate 88%
* Needle cricothyrotomy success is significantly lower (40–60%), making surgical cric preferred

(Langvad et al., 2023)

Military medical systems, which encounter more destructive airway injuries, tend to perform earlier surgical airways, often avoiding the prolonged hypoxia seen with delayed civilian crics.

Pros of early cricothyrotomy

* High success despite upper airway obstruction
* Avoids repeated trauma from failed ETI attempts
* Definitive solution in a closing airway

Cons

* Rare procedure and skill fade without training
* Technically intimidating
* Outcomes worsen if delayed until cardiac arrest

The Real Question: Airway Trajectory

This is NOT an ETI vs cric debate, it is about recognizing WHEN the trend is failing.

Ask yourself:

* Is oxygenation improving or worsening?
* Is stridor static or progressing?
* Is anatomy stable or actively closing?

Worsening stridor + dropping SpO₂ + failed ETI = a shrinking window

Each additional attempt = lower success, higher harm

A second attempt can save a life, but so can recognizing when it’s time to stop trying.

Technique matters.
Timing matters.
Trajectory matters.

I’m interested to hear how others approach this decision across different systems and training environments.

References

Hasegawa, K., Shigemitsu, K., Hagiwara, Y., Chiba, T., Watase, H., Brown, C. A., & Japanese Emergency Airway Network. (2012). Association between repeated intubation attempts and adverse events in emergency departments: An analysis of a multicenter prospective observational study. *Annals of Emergency Medicine, 60*(6), 749–754. [https://doi.org/10.1016/j.annemergmed.2012.04.005](https://doi.org/10.1016/j.annemergmed.2012.04.005)

Langvad, S., Hyldmo, P. K., Nakstad, A. R., & Sandberg, M. (2023). Success rates and complications of prehospital cricothyrotomy: A systematic review. *Prehospital and Disaster Medicine, 38*(3), 305–313. [https://doi.org/10.1017/S1049023X23000261](https://doi.org/10.1017/S1049023X23000261)

Sakles, J. C., Mosier, J. M., Chiu, S., Keim, S. M., & Stolz, U. (2015). A comparison of outcomes between rescue intubations and successful primary intubations in the emergency department. *Academic Emergency Medicine, 22*(6), 674–683. [https://doi.org/10.1111/acem.12665](https://doi.org/10.1111/acem.12665)

Wang, H. E., Kupas, D. F., Hostler, D., Cooney, R., Yealy, D. M., & Lave, J. R. (2005). Procedural experience with out-of-hospital endotracheal intubation. *Critical Care Medicine, 33*(8), 1718–1721. [https://doi.org/10.1097/01.CCM.0000171530.61959.89](https://doi.org/10.1097/01.CCM.0000171530.61959.89)

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I see a lot of posts asking “Am I ready to test?” or “What’s the best app for the NREMT?”
Honestly, most of the time the issue isn’t the app, it’s how the app is being used. You can have access to every study resource out there and still struggle if your study approach isn’t dialed in.
If anyone is interested, I’m happy to help explain how to properly use almost any NREMT prep app to actually prepare for the exam. It does require work, but the method is very effective.
I take the NREMT every two years for recertification and have passed every time. More importantly, the study habits I use don’t just help you pass the test, they carry forward as you progress in your EMS career.
If you’d like help learning how to use testing apps more effectively and improve your overall study habits, let me know. Happy to help others succeed. We can do a zoom and also go over any questions you have. . This will take place on Friday 16 Jan at 7pm CST.

Zoom Link:
ABC EMS Solutions is inviting you to a scheduled Zoom meeting.

Topic: How to use the Apps Properly
Time: Jan 16, 2026 07:00 PM Central Time (US and Canada)
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A 68-year-old man with known hypertension and type 2 diabetes suddenly develops drooping on the left side of his face and difficulty speaking. According to his spouse, he was acting normally about 30 minutes earlier. He can follow instructions but becomes visibly irritated because his speech is unclear. His vital signs include a blood pressure of 170/90 mmHg, heart rate of 110 beats/min, respiratory rate of 18 breaths/min, and oxygen saturation of 98% on room air. Capillary blood glucose is 120 mg/dL. Based on this presentation, what immediate prehospital interventions should be initiated prior to transport?

Choose the three most appropriate responses.

A. Perform a prehospital 12-lead cardiac rhythm assessment

B. Expedite transport to the closest facility equipped for acute stroke care

C. Provide advance notification to the destination hospital with suspicion of stroke and pertinent assessment details

D. Give 324 mg of aspirin by mouth, ensuring it is chewed

E. Position the patient with the head elevated approximately 30 degrees

F. Accurately record the patient’s last time observed at neurological baseline (“last seen well”)

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Free Tutoring 3pm today CST.

ABC EMS Solutions is inviting you to a scheduled Zoom meeting.

Topic: Free Tutoring EMT/ Paramedic
Time: Dec 28, 2025 03:00 PM Central Time (US and Canada)
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Pushing an "Amp of Bicarb" should no longer be standard practice.

A new systematic review and meta-analysis looked at 126,013 out-of-hospital cardiac arrest patients and asked a simple question: Does sodium bicarbonate improve outcomes when used during cardiac arrest?

The answer: not routinely.

Across 11 studies, there was no improvement in ROSC, survival to admission, survival to discharge, or neurological outcomes when sodium bicarbonate was given as part of standard resuscitation efforts.

That doesn’t mean it has no place in EMS. It remains appropriate for hyperkalemia, tricyclic antidepressant toxicity, or profound metabolic acidosis, but routine use for undifferentiated cardiac arrest isn’t supported by current evidence.

This study reinforces something critical in prehospital medicine:
🔍 If we want to improve survival, we need high-performance CPR, early defibrillation, airway and ventilation management, and timely access to definitive care. Medications alone are not the magic bullet.

Check out the study here:https://www.handtevy.com/wp-content/uploads/2025/11/Effectiveness-of-Sodium-Bicarbonate-Administration-in-Out-of-Hospital-Cardiac-Arrests-An-Updated-Systematic-Review-and-Meta-Analysis.pdf

With better reporting on timing, dosing, ETCO₂, and airway strategy, we may learn more about when sodium bicarbonate could help, but for routine use, the science isn’t there.
Evidence matters. Protocols should evolve with it. 💙

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