UMEM Educational Pearls - EMS

Category: EMS

Title: Is prehospital intubation harmful for patients who require a resuscitative thoracotomy?

Keywords: intubation, timing, trauma arrest, prehospital (PubMed Search)

Posted: 6/19/2024 by Jennifer Guyther, MD (Updated: 6/21/2024)
Click here to contact Jennifer Guyther, MD

Several studies have shown that patients who require a resuscitative thoracotomy (RT)  have a higher odds of survival if they are transported by police or in private vehicles.  This study examined 195 patients who required RT to see if prehospital intubation and out of hospital time (OOHT) affected ROSC rates.

There was no association between OOHT and ROSC and no association of OOHT and survival.  The mean OOHT for this study was only 25 minutes which is faster than other studies.  

The odds of ROSC were lower in patients who had ANY intubation attempts prior to arrival.

Bottom line: BLS airway management (or supraglottic placement) may be more beneficial for the trauma arrest patient in the prehospital setting.

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Category: EMS

Title: Prehospital obstetric events

Keywords: delivery, neonatal, OB, contractions (PubMed Search)

Posted: 5/15/2024 by Jennifer Guyther, MD (Updated: 6/21/2024)
Click here to contact Jennifer Guyther, MD

Maternal morbidity continues to increase in the US with a mortality rate in 2021 of 39.2 deaths/100,000 live births.  There has been an intense focus on training and quality improvement within hospitals, but not much has changed in the prehospital education arena.  This study aimed to quantify the complications encountered by EMS clinicians.  

In the 2018-2019 EMS dataset used, there were a total of 56,735,977 EMS activations which included 8641 out of hospital deliveries, 1712 documented delivery complications and 5749 records of newborns.

1% of the out of hospital deliveries had a documented complication for the mother.  Of these complications, 94% were for hemorrhage, 6% for abnormal presentation, 0.2% for shoulder dystocia, and 0.4% for nuchal cord.  

Few patients had medications given, including 0.4% receiving oxytocin.  no patients received prehospital blood transfusion or TXA.  Of note, in the years since this data was obtained, TXA and whole blood have started to appear on more medic units, but it is still not necessarily commonplace.

Bottom line: While still rare, prehospital delivery does occur and EMS should be prepared for any possible complications.  Medical directors should look at their jurisdictional/state protocols to see if oxytocin/TXA or whole blood should be included (if not already available).  EMS clinicians should be educated on up to date management of OB emergencies.

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Category: EMS

Title: Is a lack of recorded prehospital blood pressure an indicator of pediatric mortality?

Keywords: pediatric trauma, vital signs, blood pressure (PubMed Search)

Posted: 4/17/2024 by Jennifer Guyther, MD (Updated: 6/21/2024)
Click here to contact Jennifer Guyther, MD

The short answer is yes, pediatric trauma patients without blood pressures recorded from EMS had a higher mortality (4.3%) compared to pediatric patients that did have a recorded blood pressure (1.1%). This is based off of a prehospital study conducted in Japan.

Prehospital vital signs are left out more often in pediatric patients compared to adults. Of those vital signs that are recorded, blood pressure is the most common one left off.

There can be several barriers to obtaining a blood pressure on the pediatric patient in the prehospital setting: lack of properly sized equipment, an uncooperative child, and lack of education. However, the inability to obtain a blood pressure can also be due to the patient being more severely injured and having other skills performed or was unable to be obtained due to poor perfusion. In this study, those who did not have a recorded blood pressure also had a lower GCS score and a higher injury severity score.

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Category: EMS

Title: Supraglottics may not be SUPERglottic for E-CPR patients

Keywords: cardiac arrest, ECMO, E-CPR, mechanical ventilation (PubMed Search)

Posted: 4/3/2024 by Benjamin Lawner, MS, DO
Click here to contact Benjamin Lawner, MS, DO

BACKGROUND:
The ideal strategy for out of hospital ventilation is a matter of long standing debate and clinical controversy. To date, improved out of hospital outcomes have been associated with non invasive (BVM) and supraglottic airway (SGA) management strategies. A recent, prospective trial featured in Resuscitation offers a slightly different perspective. The trial enrolled 420 adult patients with refractory out of hospital cardiac arrest due to a shockable rhythm. The study looked at outcomes for patients who received endotracheal intubation (ETI)  or supraglottic airway placement. Importantly, the study involved a high volume cannulation center and  codified screening criteria for eCPR including:  a) ongoing arrest despite 3 shocks, b) treatment with amiodarone, c) mechanical CPR and d) anticipated time to arrival at ECMO cannulation center of <30 minutes. 

OUTCOMES:
Compared to patients in the SGA group, patients receiving ETI demonstrated: 

  • Significantly higher Pa02
  • Significantly lower PaC02
  • Significantly higher pH 
  • No significant differences in lactic acid level 
  • Improved neurological outcomes (CPC score)

In accordance with the study institution's cannulation criteria, more patients in the SGA group were deemed ineligible for ECMO. 

BOTTOM LINE:
In this single center study, patients who received ETI as a primary strategy for out of hospital airway management were more likely to meet ECMO eligibility critera and exhibit improved oxygenation and ventilation.

While this is not necessarily a practice changing article, it illustrates the complexities inherent in out of hospital cardiac arrest management. EMS has largely transitioned from a “scoop and run” cardiac arrest strategy to a plan that emphasizes treat in place. For patients who may benefit from E-CPR, additional research is indicated to shed light on best out of hospital resuscitation (and airway management)  practices.

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Category: EMS

Title: What can we learn from suicide related cardiac arrests?

Keywords: Suicide, EMS, prevention, causes (PubMed Search)

Posted: 3/20/2024 by Jennifer Guyther, MD (Updated: 6/21/2024)
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7,365 suicide related cardiac arrests were included in this study that included a several year study period in Queensland Australia.  Cardiac arrests where resuscitation was attempted by EMS and where circumstances were concerning for suicide were included.  ROSC rates were 28.6% with survival at 30 days being only 8%.  30-day survival for medical cardiac arrests in this jurisdiction was 16.4%.  Overdose and poisoning had the best survival rate (19.9%), while hanging and chemical asphyxia were the worst (7.3 and 1.1% respectively).

Bottom line: Survival rates for suicide related out of hospital cardiac arrest were worse compared to other causes of medical arrest.  Suicide prevention should become a focus with emphasis on early identification and treatment of people at high risk of suicide.  While EMS is well trained on the management of cardiac arrest, training should also emphasize suicide risk assessment and identification.

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Category: EMS

Title: Should there be a different set of vital sign "norms" for EMS?

Keywords: vital signs, age, pediatric, prehospital intervention (PubMed Search)

Posted: 2/21/2024 by Jennifer Guyther, MD (Updated: 6/21/2024)
Click here to contact Jennifer Guyther, MD

Vital signs in children can be difficult to remember since they vary with age.  Using a standardized card or app (such as PALS) can help EMS clinicians remember the values.  Most pediatric vital sign reference ranges were derived from samples of healthy children in the outpatient setting (ie PALS).  This study attempted to validate a range of pediatric vital signs that were more accurate in predicting the need for prehospital interventions compared to the standard PALS vital sign ranges. The thought was that by using EMS data, these vital sign ranges could better alert EMS to patients in need of acute intervention.

The authors used a large EMS database to determine the vital signs for the patients age and correlated that to prehospital interventions (including IV, medication, EKG, advanced airway management, ect).  They used the <10% and >90% for the age values (termed "extreme" vitals signs) as a cut off to be considered abnormal.  Using the EMS derived values, 17.8% of the encounters with an extreme vital sign received medication.  If the PALS abnormal vital sign range was used, only 15.2% of those patients were given medications.  Overall, encounters with an extreme vital sign had a higher proportion of any intervention being performed compared to other vital sign criteria (i.e. only 33.7% with PALS).

These extreme vital signs also had a greater accuracy in predicting mortality.

Bottom line: While vital signs are based on physiology that does not change based on location, using a seperate criteria for the EMS population, can improve discrimination between sick and sicker patients and hopefully allow EMS to recognize and intervene on sicker patients sooner.

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Category: EMS

Title: Can paramedics accurately risk stratify patients with acute chest pain?

Keywords: ACS, PE, risk stratification (PubMed Search)

Posted: 1/17/2024 by Jennifer Guyther, MD (Updated: 6/21/2024)
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The 2nd most common reason for EMS activation is chest pain.  In this study, paramedics were asked to complete the HEAR (history, EKG, age, risk factor) score, EDACS (ED Assessment of chest pain score), the Revised Geneva Score and the PERC (Pulmonary embolism rule-out criteria) for all patients older than 21 who presented with chest pain.  The positive and negative likelihood ratios (LR) of the risk scores in relation to 30 day MACE and PE risk were calculated.

837 patients were included in this study with 687 patients having all 4 scores completed.   The combination of HEAR/PERC had the best negative LR (0.25) for ruling our MACE and PE at 30 days.   However, these scores, alone or in combination, were not sufficient to exclusively guide treatment or destination decisions.  Adding biomarkers (ie troponin or Ddimer to the prehospital setting) could improve the usefulness of these scores.

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BACKGROUND:
Critical care transport teams are tasked with extending specialized care to the bedside. Given the uptick in COVID and ARDS cases, there are increasing demands for the transport of patients proned for respiratory compromise. An air medical service in British Columbia (BC) published their experience with transporting intubated patients in the proned position. The BC service utilizes 2 trained flight paramedics and conducts transports via pressurized fixed wing and non pressurized rotor wing aircraft.  The small, retrospective study of 10 patients demonstrated feasibility of this practice. No extubations were recorded in the study population. 6/10 patients experienced >6% increase in oxygen saturation and no medical lines were disconnected during transport.  

BOTTOM LINE:

  • Proning patients for air medical transport is possible but incorporates significant logistical and educational challenges 
  • Evidence base for proning in air medical transport is insufficient to inform comprehensive conclusions about risks and benefits

BALTIMORE, MD SPECIFIC PEARL:

  • Currently, one local helicopter service  will accomplish missions involving proned patients. Therefore, attention to optimizing vent settings prior to transport is imperative

BONUS AVIATION ENTHUSIASTC SPECIFIC PEARL: 

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Attachments

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US hospitals have traditionally been concerned that without an ambulance diversion protocol that they would be overrun with EMS arrivals.  EMS had been concerned that without diversion there would be extended wait times at the hospital.  This study looked at EMS arrivals one year (2021) before the elimination of diversion and compared the number to one year after diversion elimination (2022).  

This study of a single level 1 trauma center showed that there was NO difference between the number of EMS arrivals per day (84 vs 83, p = 0.08), time to room for ESI 2 patients, time to head CT in acute stroke patients OR ambulance turn around time (16 min vs 17 min, p = 0.15).

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Category: EMS

Title: There's a Doctor on Board! Physician Staffed EMS and Trauma Care in Japan

Keywords: EMS, trauma, emergency medical services, (PubMed Search)

Posted: 12/6/2023 by Benjamin Lawner, MS, DO (Updated: 6/21/2024)
Click here to contact Benjamin Lawner, MS, DO

BACKGROUND
 
EMS systems differ in staffing and composition. The Japanese model utilizes “doctor cars” which bring a physician and nurse to the scene of a critical patient encounter. Personnel on the “doctor cars” are able to perform advanced therapies such as REBOA, finger thoracostomy, and chest tube thoracostomy. As physician EMS fellowships continue to expand in the United States, it is helpful to examine the utility of physician response incorporated into prehospital emergency care. 

 
THE STUDY

A nationwide retrospective cohort study including over 370,000 patients examined the impact of Japan “doctor cars” upon in hospital survival. Doctor cars responded to 2361 trauma patients, and traditional Ground Emergency Medical Services (GEMS) units cared for 46,783 trauma patients.  The study’s primary outcome was survival to discharge.  

The adjusted odds ratio for survival was significantly higher in the exposure group served by the doctor cars. The study suggests that there may be a role for augmenting ground EMS personnel in the response to critical injuries. Via logistic regression, the study controlled for multiple other variables such as age, sex, prehospital vital signs, out of hospital time, and injury severity score (ISS).  

  • At hospitals caring for >50 trauma patients per year, the impact of doctor cars upon in hospital survival was not statistically significant 
  • Not surprisingly, patients cared for by the doctor car team had a longer time to hospital arrival 
  • Adult patients with higher ISS scores had a significant improvement in survival  

BOTTOM LINE
 
This study is far from definitive but contributes to a growing body of literature addressing how EMS physicians integrate into prehospital systems.

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Category: EMS

Title: EMS and the management of pediatric agitation

Keywords: mental health, excited delirium, agitation, sedation, ketamine (PubMed Search)

Posted: 11/15/2023 by Jennifer Guyther, MD (Updated: 6/21/2024)
Click here to contact Jennifer Guyther, MD

This is a retrospective review of pediatric patients with mental health presentations to EMS in Australia.  For children 12 or older, EMS has standing orders for midazolam for mild to moderate agitation and ketamine for severe agitation.  Patients younger than 12 require medical consultation prior to administration.
14% of pediatric EMS calls in this study were for mental health problems.  In 8% of the 7816 pediatric mental health EMS encounters, patients received either midazolam (about 75%) or ketamine (25% of cases). 11% of patients who received midazolam had an adverse event while 37% in the ketamine group had an adverse event.  Adverse events included airway obstruction requiring jaw thrust, OPA or NPA placement, BVM or desaturations requiring oxygen. No serious adverse events occurred in either group.
Police accompanied EMS in 82% of these cases.  Patients who received medication management were more likely to have autism spectrum disorder, post traumatic stress disorder, intellectual disability, psychiatric disorder or history of substance abuse.
Bottom line: Pediatric mental health is a significant global problem where further research is needed.

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Category: EMS

Title: EMS, Documentation, and Continuation of Care in Stroke Patients

Keywords: Stroke, EMS, medical record linkage, prehospital (PubMed Search)

Posted: 11/3/2023 by Benjamin Lawner, MS, DO
Click here to contact Benjamin Lawner, MS, DO

BACKGROUND: Prehospital (EMS) clinicians are positioned on the front lines of health care. With respect to stroke identification and treatment, early recognition is essential to positive outcomes. Considerable variability exists within EMS documentation. Despite considerable variability in documentation, the establishment and tracking of core stroke metrics serves as a benchmark to gauge performance and outline strategies for improvement. 

METHODS: Authors conducted a retrospective, observational analysis of EMS encounters (2018-2019) which ultimately received a diagnosis of an "acute cerebrovascular event." Hospital based diagnoses included: hemorrhagic stroke, ischemic stroke, or transient ischemic attack. The data set was comprised of a statewide EMS documentation and a state wide acute stroke registry. Authors examined compliance with six core performance metrics which included measurement of blood glucose, documentation of last known well time, and on-scene time < 15 mins for patients with suspected stroke. During the 18 month study, almost 6000 encounters met criteria for inclusion. 

RESULTS: EMS documentation remains a significant source of variability. EMS crews were largely compliant with blood glucose measurement. However, last known well time had the lowest (24%) documentation rate. Patients diagnosed with subarachnoid hemorrhage had the lowest rate of compliance with metrics. 

BOTTOM LINE: Accurate prehospital stroke diagnosis remains a challenge. Consistent data collection and benchmarking remains an important first step in the evaluation of performance. Higher NIHSS scores and ischemic strokes are linked to higher rates of metric compliance. 

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Category: EMS

Title: Which type of BVM provides appropriate tidal volumes in the back of an ambulance?

Keywords: BVM, tidal volume, TV, ALS, BLS (PubMed Search)

Posted: 10/18/2023 by Jennifer Guyther, MD (Updated: 6/21/2024)
Click here to contact Jennifer Guyther, MD

The typical bag valve mask ventilator (BVM) for adults has a reservoir volume between 1500-2000 mL depending on the manufacturer while the volume is between 500-1000 mL for a pediatric BVM.  When trying to obtain the recommended tidal volume of 6-8 mL/kg (500-600 mL for the typical adult), one thought was that a pediatric BVM could be used with adult patients so as to avoid iatrogenic barotrauma.  This has been studied on manakins using an oral pharyngeal airway, supraglottic airway and endotracheal tubes (ETT) and has been successful.  This study attempted to obtain the same results in the back of a moving ambulance.  Paramedics and EMTs, squeezing pediatric and adult BVMs with one hand, bagged adult manakins in the back of a moving ambulance (without lights and sirens).  The average tidal volume was recorded using various types of airways (i-gel, King airway and ETT).

Volumes delivered with the pediatric BVM were significantly lower than the tidal volumes with adult BVMs across all airway types suggesting that in the moving ambulance, using pediatric BVMs on an adult patient would not be appropriate.

The I-Gel and King airway provided similar tidal volumes which were not statistically different than volume delivered through the ETT.

EMTs consistently delivered 50% less tidal volumes compared to paramedics. The authors suggested that perhaps the additional training and pathophysiology knowledge that paramedics have could also be important with a skill that is considered basic. 

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Category: EMS

Title: EMS Overdose Response: Better with Bupe ?

Keywords: Emergency medical services, harm reduction, buprenorphine, overdose (PubMed Search)

Posted: 10/5/2023 by Benjamin Lawner, MS, DO
Click here to contact Benjamin Lawner, MS, DO

BACKGROUND:
Emergency Medical Services (EMS) systems, especially those within urban jurisdictions, struggle to effectively meet the needs of patients experiencing complications of substance use. The exceedingly high burden of disease, coupled with potentially life-threatening sequelae of substance use stresses EMS systems beyond capacity. The current paradigm of naloxone administration and subsequent refusal of care places patients at an increased risk of death and other complications such as aspiration. EMS agencies, in collaboration with area hospitals, public health experts, and addiction medicine specialists are devising novel mitigation strategies to reduce morbidity and mortality. “Leave behind” naloxone, peer outreach, and 911 diversion programs are part of a more over-arching strategy that links patients to longer term, definitive health care resources within the community. EMS-administered buprenorphine has emerged as a novel treatment modality for prehospital patients. This study examined outcomes of patients who were a) experiencing symptoms of opiate withdrawal and b) given buprenorphine by a credentialed EMS paramedic. Patients included in the buprenorphine cohort scored >5 on the clinical opiate withdrawal scale (COWS), regained “full decisional capacity” after being resuscitated from an overdose, and were > 18 years of age. The study excluded pregnant patients and those who took methadone within 48 hours prior to an EMS encounter. After consultation with an EMS physician, patients received 16 mg of sublingual buprenorphine. Paramedics could administer ondansetron and an additional 8 mg of buprenorphine for continued symptoms. Finally, the study cohort was matched to a similar group of patients who were treated by “non buprenorphine equipped” ambulance. Outcomes of interest included: rates of repeat overdose, likelihood of transport, and follow up with addiction medicine/substance use resources. The study was conducted in an urban EMS system with robust EMS physician oversight and advanced life support transport units.


RESULTS:
Patients receiving buprenorphine did not experience a reduction in repeat overdose. However, they were less likely to be transported. The buprenorphine cohort, predictably, was much more likely to be enrolled in a substance use treatment program within 30 days of the initial encounter. Paramedics spent more time on scene with the buprenorphine cohort.  Though far from a conclusive study, the manuscript adds to a growing body of literature that attests to the feasibility of paramedic administered buprenorphine.

BOTTOM LINE:
Though far from a conclusive study, buprenorphine administration by EMS paramedics is feasible. The increased linkage to care and decreased rates of transport will hopefully motivate EMS systems to consider novel strategies for harm reduction. The study authors opine that buprenorphine may “be a promising…link to long term recovery.”

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Category: EMS

Title: What are the barriers for laypeople to be trained in CPR?

Keywords: cardiac arrest, CPR, bystander (PubMed Search)

Posted: 9/20/2023 by Jennifer Guyther, MD (Updated: 6/21/2024)
Click here to contact Jennifer Guyther, MD

Prior studies have shown that CPR education is associated with a greater willingness to perform CPR.  This was a review of 23 studies to determine factors that enable and hinder a layperson from learning CPR.
 
Enabling factors included having witnessed someone collapse in the past, awareness of public AEDs, certain occupations and legal requirements for training (i.e. mandatory high school CPR training).
 
Married people were more likely to be trained than those that were not married and people with children younger than 3 years were less likely to take a BLS course.  
 
Barriers that were found to impact people taking CPR classes included lower socioeconomic status and education level, and advanced age and language barriers.  
 
Bottom line: CPR education sessions should target groups with these identified barriers.

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Category: EMS

Title: Arresting and Agitating Pitfalls in Patient Restraint

Keywords: cardiac arrest, chemical restraint, ketamine, agitation, delirium (PubMed Search)

Posted: 8/30/2023 by Benjamin Lawner, MS, DO
Click here to contact Benjamin Lawner, MS, DO

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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Category: EMS

Title: What are the barriers to 911 being able to direct hands only CPR instructions to callers?

Keywords: Hands only CPR, bystander CPR, directions (PubMed Search)

Posted: 8/16/2023 by Jennifer Guyther, MD (Updated: 6/21/2024)
Click here to contact Jennifer Guyther, MD

Bystander CPR increases out-of-hospital CPR survival and direction by 911 telecommunicators increases the frequency of bystander CPR.  The majority of 911 centers use Medical Priority Dispatch System which walks 911 telecommunicators through a series of questions that give different instructions based on the caller's answers.  Studies have shown out-of-hospital cardiac arrests are only recognized between 79-92% of the time and telecommunicator instructions for CPR can take between 176-285 seconds.

This study reviewed recorded 911 calls of patients who were found to be in cardiac arrest. Calls where the caller was not with the patient and confirmed overdoses were some of the call types that were excluded.

Out of 65 reviewed calls, 28% were not recognized during the actual call.  When they were reviewed, 8/18 of the calls were deemed to be recognizable.  Themes that were noted were: incomplete or delayed recognition assessment (ie uncertainty in breathing), communication gaps (callers were confused with instructions or questions), caller emotional distress, delayed repositioning for chest compressions, non essential questions and assessments, and caller refusal/hesitation or inability to act.

Bottom line: In addition to bystander CPR training, education on the process and questions involved in calling 911 could be helpful in an emergency.  

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Category: EMS

Title: Is a Higher MAP Better for Patients with Out of Hospital Cardiac Arrest?

Keywords: Cardiac arrest, resuscitation, emergency medical services (PubMed Search)

Posted: 8/2/2023 by Benjamin Lawner, MS, DO
Click here to contact Benjamin Lawner, MS, DO

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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Category: EMS

Title: ED handoff of pediatric patients by EMS

Keywords: handoff, communication, adverse outcomes (PubMed Search)

Posted: 7/19/2023 by Jennifer Guyther, MD
Click here to contact Jennifer Guyther, MD

Ineffective handoff communications have been shown to occur in up to 80% of medical errors.  Previous studies have shown that up to 1/3 of pertinent information is lost during the handoff of trauma patients.  Interruptions, lack of listening and ED team preoccupation with their own patient assessment have been associated with adverse outcomes.
This study reviewed videotaped footage of pediatric critical care resuscitations and the handoff between the ED and EMS.  Inefficient communication occurred in 87% of handoffs, including 51% of cases with interruptions by staff, 40% with questions from the ED leader about information that had already been given and 65% requesting information that had not yet been communicated.
Bottom line: Allow for an uninterrupted hand off from EMS followed by closed loop communication and asking any additional questions.

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Category: EMS

Title: What are risk factors in ambulance crashes?

Keywords: ambulance, crash, response, fatality, collision (PubMed Search)

Posted: 6/22/2023 by Jennifer Guyther, MD
Click here to contact Jennifer Guyther, MD

Between 2010 and 2020, there were 279 fatalities related to ambulance accidents.  In up to 50% of accidents, EMS is not at fault.  The use of lights and sirens and intersections have been previously shown to be the most common risk factor for accidents.  There is a national push for a more judicious use of lights and sirens.  
Most ambulance crashes are minor, but up to 1/3 of crashes can result in significant injury or significant damage to the vehicle.  This study attempted to relate driver demographics and aggressive driving behavior to ambulance crashes using a vehicle telematics system.  The agency in this study responded to about 130,000 calls per year and the incident rate of any crash was 2.1/100,000 miles and the incident rate of a serious crash was 0.63/100,000 miles.  Injuries occured in 8% of the 214 crashes over the 3 year study period.  One third of the cases resulted in significant vehicle damage.  Female sex and age 18-24 were found to be independently associated with a collision.
Bottom line: Transporting patients via ambulance, especially when lights and sirens are used, is not a risk free event.  Even if injuries do not occur, the impact of damage to the vehicle can significantly impact the EMS system.

 

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