UMEM Educational Pearls - EMS

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

Category: EMS

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

Posted: 8/2/2023 by Ben Lawner, MS, DO
Click here to contact Ben 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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Title: ED handoff of pediatric patients by EMS

Category: EMS

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

Posted: 7/19/2023 by Jenny Guyther, MD
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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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Title: What are risk factors in ambulance crashes?

Category: EMS

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

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