EuSEM 2024 in Copenhagen brought together over 3800 participants – the largest gathering in its history – highlighting the ever growing importance of collaboration in emergency medicine. Copenhagen stood out to me as a very welcoming city, with amazing food (while most of the places close down shockingly early – finding places to eat after 8pm was quite challenging.)
Side note for anyone really interested in food: Copenhagen’s chefs are known for incorporating locally sourced produce and traditional techniques like fermentation, which is used to make food durable, but also produces unique flavors into their fine dining experience. And while the – according to most critics – world’s best restaurant of the last decade, the noma in Copenhagen, is closing down, those concepts also made it into quite a few places that can be deemed affordable for the average congress visitor.
Copenhagen’s autonomously driving metro is a quite fascinating example of well thought through automatisation and rationalisation: While there are no more drivers (and as you can imagine, the computers replacing them are quite good at being on time, so performing this job at least as good), there is human personnel present on the platform at most stations, doing tasks at which AI or computers would most likely be worse – like helping out lost tourists or making sure everyone boards the trains on time.
Coming from Austria – one of the few remaining European countries without a specialisation for emergency medicine – going to EuSEM feels both like going to a whole different world and coming home to like-minded enthusiasts and exciting input. In the end, realising how mixed the attendees’ backgrounds are, it’s also a good feeling to find out that emergency medicine is an inter-specialty and inter-professional team sport pretty much everywhere, even in countries with a dedicated specialty.
Of many dozens of great lectures, one overarching topic (passionately discussed by speakers in different sessions, in workshops as well as during dinner and drinks) and some individual talks stood out for me:
Individualised diagnostics and therapy of (out of hospital) cardiac arrest
Multiple talks focused on cardiac arrest beyond the current guidelines. With some similar topics discussed at the ERC congress in Athens (which took place only two weeks later) and ERC guidelines coming up next year, it is exciting to see how we can do evidence-guided individualised therapy beyond the guidelines, but also how it will be reflected in future guidelines.
Deborah Jaeger on drugs during cardiac arrest:
Vasoconstriction? Vasodilation?
The PARAMEDIC2 trial, published in 2018, is definitely an important landmark for our knowledge about drugs in cardiac arrest, but is also causing a dilemma for clinical reasoning: On the one hand we now know that we could give more patients a chance at recovery by achieving ROSC with adrenaline, but that this would at the same time result in more patients with poor neurological outcome, which is most likely not desirable. What it definitely did was to set the stage for a new generation of trials on catecholamines during CPR, because we obviously have found neither a good one size fits all approach nor a validated algorithm for individualised catecholamine therapy according to patient characteristics.
Deborah Jaeger discussed some of the research done since then, including some of her own work. While higher doses of adrenaline were proven inferior in the early 2000s, lower doses than today have not been tried broadly in humans. Considering the dose dependent (desirable, but also not desirable) effects of adrenaline, she and colleagues formed the hypothesis that lower doses might be favourable and validated the hypothesis in the animal model. Starting recruitment next year, an RCT testing 0.5mg adrenaline every 3-5 minutes (compared to 1mg every 3-5mg) is coming up, hopefully giving us an answer whether this might be the way to go for all our patients in cardiac arrest or some subgroups.
For patients with ultrasound-unmasked Pseudo-PEA, continuous norepinephrine (of course considering aggressive treatment of potential reversible causes) might be the way to go – this is supported by different observational or retrospective studies by Bogouin et al and Normand et al suggesting it is likely the catecholamine of choice after ROSC. A combination of vasopressin and methylprednisolone showed no benefit for neurologically intact survival for in-hospital cardiac arrest.
On the very opposite, the addition of sodium nitroprusside, also used as a vasodilator for acute hypertension in humans, has shown improved ROSC probability and higher systemic and brain perfusion in the animal model, suggesting there might be very different ways of optimising hemodynamics and perfusion during CPR.
Early amiodarone
For the subgroup of patients with shockable rhythm, there is strong evidence that defibrillation and not drugs are the prioritised intervention – but it also seems to matter how fast we apply amiodarone. An RCT by Lupton et al. found that there is significant benefit for survival to hospital discharge if amiodarone is administered early (<8 minutes from ALS ambulance arrival) compared to late (>8 minutes.) The effect of early intravenous lidocaine was not statistically significant for survival to hospital discharge, and late administration of either drug had almost no significant effect on survival to hospital discharge. The main aim of the trial was to compare effects of amiodarone, lidocaine and a placebo considering timing, so it can’t be used to rule out that the difference between the effect of lidocaine and amiodarone was due to chance. My personal take home point from this trial would be that amiodarone (also primarily recommended by current ERC guidelines) should still be our go-to antiarrhythmic during cardiac arrest, as it has (again) shown a statistically and clinically significant benefit compared to a placebo if administered early. We should also focus on timely application, definitely no later than at the third shock as suggested by current guidance, maybe in the future even earlier if possible. This could also mean lower priority for other interventions if they can’t be performed simultaneously, except most likely high quality chest compressions and an optimised defibrillation strategy, both of which have a broader evidence base suggesting a positive effect.
Further Reading:
Deborah Jaegers excellent narrative review on drug therapy in cardiac arrest – please consider it was published one and a half years ago, so some evidence discussed here isn’t included
Ultrasound, Definition of cardiac activity & Pseudo-PEA
Justus Wolff‘s talk on ultrasound during cardiac arrest highlighted two major pitfalls (while also showing many benefits,) the more obvious being the effect on the duration of chest compression pauses and overall CPR coordination and quality. He suggested an eight second countdown for acquisition of a loop in the subxiphoid view, leaving a two second margin to the maximum of ten seconds according to current ERC ALS guidelines. Good preparation and team briefing are obviously of utter importance for well coordinated rhythm checks.
The second, less obvious, pitfall was impressively revealed when Justus asked the audience to assess loops for cardiac motion to differentiate between “real” PEA and Pseudo-PEA: The audience was almost split in half for one of the loops showing no to minimal uncoordinated wall motion, but mainly valvular movement, while there is actually a rather clear answer: Some trials looking at Pseudo-PEA named what they were looking for (maybe even more appropriate) cardiac contractility, as all of them only considered it movement if there were visible differences in the diameter of the left ventricle. While there is for now no clear evidence-based pathway (but some suggestions, see above), misinterpretation like this could lead to inadequately paused chest compressions or unnecessarily prolonged resuscitation depending on the context.
Defibrillation strategies, eCPR & more
Double sequential defibrillation and vector change defibrillation were also hot topics, but there’s little to add to the summary of Sheldon Cheskes’ talk in Graz, Austria, earlier this year. eCPR seems to be getting even more traction, but we are still missing evidence showing clear patient centred benefits.
Lung ultrasound
While Giovanni Volpicelli highlighted the rise of lung ultrasound during the past decades, and hinted that in the future there might even be ways to assess lung hyperinflation with ultrasound, which is for now not an established application, Stig Holm Ovesen remarkably reminded the audience that “Diagnosis is not an end in itself” – a quote from Harvey V. Fineberg in an editorial about computed tomography on the rise in the late seventies.
With colleagues he did a scoping review categorising the primary outcome of lung ultrasound studies according to Fryback and Thornbury levels of evidence, an hierarchical scale from technical efficacy (1), diagnostic accuracy efficacy (2), diagnostic thinking efficacy (3), therapeutic efficacy (4) to patient outcome efficacy (5) and societal efficacy (6). The vast majority of more than 300 studies was classified as level 2, with only twelve observational studies and six randomised controlled trials being classified als level 4 or 5. This leaves us with an abundance of evidence on diagnostic accuracy, but very little knowledge about therapeutic consequences and patient outcome. It’s pretty safe to assume that lung ultrasound is here to stay, but it’s a task for all LUS providers to critically reflect on if and how we can use the proven diagnostic accuracy to improve patient journeys and outcomes.
Prehospital POC blood testing
Multiple short oral communications focused on prehospital point-of-care (POC) blood (gas) testing, including two by Carlos del Pozo Vegas from Spain, in which he reported that in his local ambulance service point of care blood testing is performed for most patients for different indications. At the same time, different manufacturers in the industry exhibition showed devices capable of bringing blood gases as you know them from the emergency department (with modern devices providing much more than only blood gases, but also different metabolic or renal parameters) and high sensitive troponin to the roadside. Working in an ambulance system myself in which we’ve had access point of care blood gases for around 20 years, I wouldn’t want to miss the additional diagnostic capabilities that POC blood testing provides. Not only for differential diagnosis in respiratory distress or optimising ventilation in ventilated patients, but also for example lactate after unexplained TLOC or in potential sepsis, or electrolytes in heart rhythm disorders including VF.
To broadly implement prehospital POC blood testing in the best possible way, it will be necessary to critically consider in which cases there would be therapeutic consequences and potential for improved patient outcomes, and in when it might only cause additional delay, costs and increase the carbon footprint.
Gender Medicine & EM
One cornerstone of emergency medicine – in most systems – is to provide equally good care to all patients seeking help in an emergency department. While we strive to meet this high standard, shockingly often we do not succeed in this.
Yonathan Freund mentioned his and his colleagues’ article on the effect of patient gender on the decision of ceiling of care in simulated cases, a survey-based study to which more than 3000 emergency physicians responded. For female patients, a lower ceiling of care (e.g. no intubation and invasive ventilation) was chosen significantly more often, compared to male patients. The effect was even more pronounced for female physicians. This exemplifies the dire need for more research into this to understand why we tend to treat patients in such a different way, and as a harsh reminder to rethink every similar decision we make and to ensure we make those decisions together with our patients guided by evidence, and only by our – obviously skewed – gut feeling.
What I also consider very interesting about this study is that while the difference in treatment is quite obvious, I personally wouldn’t be able to tell which gender actually got the “better” treatment. While at first sight a higher ceiling of care might seem desirable, it might not be aligned very well with the patient’s wishes and prognosis in many cases. Because of our obviously existing bias, we might actually be not providing the best possible care or giving the best possible advice to patients of all genders.
Personal thoughts
On a more personal note, I am thankful I got the opportunity to present an ePoster about a recurrent ventricular fibrillation case – by chance very much in line with the congress’ overarching theme of individualised pathways in cardiac arrest.
Also, the competition team from my hometown Graz, representing the local medical university and the local hospital trust, and comprised of colleagues from Medizinercorps Graz, won the competitive, but also cooperative simulation contest after a mass-casualty final scenario they solved together with the second-placed team from France.
Next year’s EuSEM congress is taking place in Vienna, Austria, from the 29th of September to the 1st of October 2025 – I would be thrilled to see many of you there!
vb
David Purkarthofer
