UMEM Educational Pearls - By Ben Lawner

Patient restraint is a high risk, high liability encounter for all levels of emergency medical practitioners. Often, acutely agitated patients benefit from de-escalation. This can be difficult to achieve in a resource limited setting. McDowell et al (2023) performed a comprehensive review of patient restraint encounters. Their work describes risk factors linked to adverse outcomes. Specifically, highly agitated patients who are physically and chemically restrained can experience clinical deterioration. The review also highlighted risks to EMS clinicians as well such as: needle stick, physical inury, and downstream litigation. 

Bottom line: 

Patient restraint represents a high risk encounter. 

• De-escalation is preferred vs. physical restraint 
• Chemical restraint likely preferred vs. physicial restraint 
• Restraint can worsen agitation and contribute to acidosis, positional asphyxia, cardiac arrest, and other untoward outcomes
• DO NOT place restrained patients in the prone position 
• Policies for restraint should be vetted, socialized, and regularly reviewed with all stakeholders 

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There is room for improvement with respect to rates of meaningful neurological survival in patients experiencing out of hospital cardiac arrest. Post resuscitation blood pressure goals remain a matter of debate. Though a MAP of >65 mm Hg is often cited as "desirable" in the post cardiac arrest setting, some experts have advocated for a higher MAP goal to increase cerebral perfusion pressure and improve outcomes. 

This study was a retrospective review and meta-analysis that examined post cardiac arrest patients with MAP goals < 70 mm Hg and > 70 mm Hg. Over 1000 patients were included in the final meta-analysis. The primary outcome was pooled mortality. Secondary outcomes included neurologically meaningful survival, dysrhythmia, and acute kidney injury. The study detected no statistically significant difference in survival. Neurological outcomes were also similar between the two groups of resuscitated patients with out of hospital cardiac arrest. However, the study revealed statistically significant decreases in ICU length of stay and mechanical ventilation time. 

As with any retrospective review, there are important limitations to consider. Among them: Few RCTs were included and all of them were conducted in European countries. Generalizability may be limited given the differences in emergency medical services systems and resuscitation protocols. 

Study authors recommend tailoring resuscitation goals to the individual patient since arrest physiology, comorbidities, and other factors influence a patient's post cardiac arrest course. 

Bottom line: 
There is insufficient evidence to recommend arbitrary MAP goals in patients resuscitated from out of hospital cardiac arrest. 

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Recent advances in resuscitation science have enabled emergency physicians to identify factors associated with good neurologic and survival outcomes. Cases of persistent ventricular dysrhythmia (VF or VT) present a particular challenge to the critical care provider. The evidence base for interventions in shock refractory ventricular VF mainly consists of case reports and retrospective trials, but such interventions may be worth considering in these difficult resuscitation situations:

1. Double sequential defibrillation
-For shock-refractory VF, 2 sets of pads are placed (anterior/posterior and on the anterior chest wall). Shocks are delivered as "closely as possible."^1,2

2. Sympathetic blockade in prolonged VF arrest
-"Eletrical storm," or incessant v-fib, can complicate some arrests in the setting of VF. An esmolol bolus and infusion may be associated with improved survival.³  Left stellate ganglion blockade has been identified as a potential treatment for medication resistant VF.⁴

3. Don't forget about magnesium! 
-May terminate VF due to a prolonged QT interval 

4. Invasive strategies
-Though resource intensive, there is limited experience with intra-arrest PCI and extracorporeal membrane oxygenation. Preestablished protocols are key to selecting patients who may benefit from intra-arrest PCI and/or ECMO. ⁵

5. Utilization of mechanical CPR devices 
-Though mechanical CPR devices were not officially endorsed by the AHA/ECC 2010 guidelines, there's little question that mechanical compression devices address the complication of provider fatigue during ongoing resuscitation. 

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Hyphema is an urgent ophthalmologic condition. Due to the high risk of rebleeding and increased intra-ocular pressure, strict follow up with an ophthalmologist is warranted. SELECTED low grade hyphemas in reliable patients may be managed on an outpatient basis. Some pointers that may be helpful for the EM inservice exam: 

• Measurement of intra-ocular pressure (IOP)  is crucial to proper treatment and prognosis.
• Many drugs are available to lower IOP, these are generally used in association with opthalmologic consultation
  ->acetazolamide (has potential to "sickle" RBC's)
  ->aminocaproic acid
  ->B blockers
• Hyphema > 5 days are associated with high incidence of synechiae formation
• Avoid NSAIDs/ ASA
• Eye patching,  HOB (head of bed) elevation recommended
• Corneal bloodstaining indicates a poor prognosis
• Incidence of rebleeding estimated at 30-40%
• Graded from 0-IV. Grade IV hyphemas cover the entire anteror chamber; often called, "8 ball" or "blackball" hyphema. Grade 0=only visible on slit lamp.
• Trauma is most common etiology
• Low IOP and trauma? ---> Rule out globe rupture! 

General indications for "very urgent" ophthalmologic consultation:

• Severely impaired visual acuity=greater rebleeding risk
• Patient with known SCD or sickle cell trait
• Visible blood staining of cornea
• High grade, covering > 1/3 of anterior chamber
• Delayed presentation (risk of synechiae / vision loss due to IOP) 

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BACKGROUND: 

For the first time since its publication, the centers for disease control has dedicated an entire issue of their Morbidity and Mortality Weekly Report to an emergency medical services topic. Vol 55 RR-1 reviews the, "Guidelines for Field Triage of Injured Patients." The report represents a consensus opinion of national experts in EMS, EM, and trauma care. It outlines which patients may be best served via transport to a trauma center.

CRITERION LINKED TO SEVERE INJURY  (Consider transport to nearest TRAUMA CENTER) 

• GCS < 14, SBP < 90 mm Hg, RR < 10 or > 29 per minute (or less than 20 for infants) 
• Penetrating wounds to neck, torso, head
• Flail chest, two or more proximal long bone fractures
• Proximal extremity amputation
• Paralysis
• Open or depressed skull fracture
• Older patients on anticoagulation

From the MMWR: "The National Study on the Costs and Outcomes of Trauma identified a 25% reduction in mortality for severely injured patients who received care at a Level I trauma facility." 

EXTRAS: 

The remainder of the report details the triage decision making process, explains trauma center capabilities, and provides an interesting and detailed review of trauma transport criteria. Link to the current issue is attached.

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5801a1.htm

To echo Dr. Rogers' fantastic airway tips:

When considering an intubation or managing an emergent respiratory concern, keep the "P"s of intubation in mind:

1. P osition:  No intubating on the floor!  Don't get sucked into the patient's oropharynx! Maintain an appropriate distance. Align the airway axes. Sniffing position is utilized for non traumatic adult airways; this involves flexion of the lower c-spine and a bit of extension at the upper cervical levels. Take off cervical collars. Use pillows / blankets to align the external auditory canal (EAC) with the sternal notch to help w/visualization. Cricoid pressure is NOT designed to facilitate passage of the ETT- it MAY help prevent excessive gastric insufflation.

2. P reparation: Two tubes. Two blades. Two intubators. Plan B(ougie) or Plan C(cric). Though your emergency airway plans may differ, think of ALL airways as potentially difficult ones. Respect the epiglottis. 

3. P reoxygenation: 100% via NRBM when possible to ensure oxygenation and nitrogen washout. In patinets with at least some reserve, this will help to avoid pulse ox pitfalls. True RSI does NOT involve positive pressure ventilation.

4. P remedication: Know your sedatives in advance. Etomidate ? Ketamine ? Diprivan ? Whatever your agent of choice, know indications and drug dosages. Emergent RSI is a less than ideal time to access Epocrates.

5. P aralysis:  This is pretty much the point of no return. Administration of paralytics commits you to securing a patient's airway. Both rocuronium and succynylcholine can be dosed at 1 mg/kg IV.

6. P ass the tube: What Dr. Rogers said.

7. P osition confirmation: Direct visualization of the tube through the glottic opening coupled with end tidal Co2 is ideal.

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The Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke Study (PHANTOM-S) was a randomized prehospital  clinical trial. On certain days, a dedicated Stroke Emergency Mobile (STEMO) responded to possible ischemic stroke incidents. Outcomes measured included time to thrombolysis and adverse events such as intracerebral hemorrhage. As opposed to usual prehospital care, a STEMO ambulance was equipped with a CT scanner, point of care laboratory, and a neurologist. According to the study, STEMO use resulted in reduced time to treatment (tPA) without adverse events. 

Though this trial did not specifically measure clinical endpoints, it addresses issues central to the delivery of specialized prehospital care:

1) Are there certain conditions which might warrant a tailored, super-specialized EMS response?
2) Are EMS systems capable of delivering definitive care to the patient as opposed to delivering the patient to definitive care? 

Stateside study has already started.  The Houston Fire Department, in partnership with UTHeath, has already loosed a "Mobile Stroke Unit" on the streets. Like the STEMO, the specialized ambulance will be University hospital based, carry a neurologist, and have the capability to administer tPA. 

STEMO pictures courtesy of the "NeuroEMS Blog"
http://www.neuroems.com/2014/05/14/tpa-in-the-truck-results-of-the-phantom-s-trial/

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