Episode 22: MAAAYYYBEEE We’re Not Great at Spotting Atypical Strokes

Listen here or download on iTunes, Podcast Addicts, or Podcast Republic.

An article from Frontline Medical News in 2014 was heavily critical of the amount of missed strokes by prehospital providers. A retrospective study that lasted from January 1st, 2010 to December 31st, 2011 reported that out of the 10,384 patients that were transported to an emergency department via EMS and that 41% of stroke positive patients were missed. To quote one of the reviewing physicians, “if a paramedic called us to say a stroke was going on, the likelihood was extremely high it was a true stroke. However, when they didn’t think it was a stroke, it didn’t mean much.” McStrokeOuch. We’ve all been taught about the Cincinnati Prehospital Stroke Scale. It works, and it’s a great assessment tool. But what about the patients that don’t present with limb ataxia, dysarthria, or facial drooping? Is there a stroke patient that might be having an atypical stroke? Well… yes, and we’re going to be getting into that now. What about the patients that we are convinced are having a stroke, but are actually experiencing something differently entirely. For today, the subject will be missed stroke activation.We’re going to be focusing on a very niche market of stroke patients today. These are the patients that don’t fit into the typical criteria that prehospital providers have pigeon-holed stroke victims in. The majority of the patients that stroke activation were missed on, were patients of atypical ages and symptoms. Well if they don’t have any traditional symptoms, do you just expect us to ask our Magic 8 Ball if they are having a stroke or not? Hold your horses… we’re getting there. Let’s start with a scenario. 

SCENARIO

You and your partner are called to the home of a mid-60s female with a report of dizziness and near syncope. As you know on the door, the patient calls out from the living room advising that the door is unlocked. She is lying on the floor complaining that “the room is spinning”. As you the story unravels, the patient tells you that she has been feeling this way for the last six hours. Your initial interview and assessment reveal no likely cause of hypovolemia, metabolic factors (i.e. hypoglycemia, diabetic/alcoholic ketoacidosis), or cardiac arrhythmias. The patient states that this is the first time that she has ever experienced symptoms like this before and denies any recent illnesses. Her blood pressure is 162/94, heart rate is 76, SpO2 is 96% on R/A with no obvious signs of distress and clear lung sounds. You assess her blood glucose and see that is 143mg/dl. She is afebrile and there are no orthostatic changes to her vital signs. The patient is A/O x4 with no limb ataxia, dysarthria, or unilateral facial drooping. She states that she has a history of hypertension and GERD, and that she is not compliant with her medications. She denies any recent trauma. As you sit her up, she cries out that her symptoms have worsened greatly and that her nausea turns to active vomiting. Sounds like it’s a just a case of vertigo, right? How do you know for sure? In the list of possible differential diagnoses, did you even consider that this could be a stroke?

WHY WE NEED TO START TAKING VERTIGO SERIOUSLY

  • A 2009 AHA article states that >25% of all patients that present with vertigo-like symptoms actually are found to have some element of posterior circulation infarcts, which is gravely concerning! How many of these patients are we not screening?!
  • A significant number of these patients did not present with limb ataxia, dysarthria, or other concerning neuro deficits (i.e. facial droop, etc). A common symptom of posterior stroke is acute dysphagia (inability or difficulty swallowing due to pharyngeal weakness)
  • A 2013 Lancet article tracked 1,141 patients and their preceding symptoms leading to posterior brain circulation infarct.Out of the studied patients, 54 of them had isolated vertigo symptoms. A statistically small percentage of around 0.05%, right? Yeah, that’s still 54 people that were either misidentified or told that nothing was wrong.

DIFFERENTIATING STROKE FROM ACUTE VESTIBULAR SYNDROME

Enter the HINTS exam.

  • Who do you perform the HINTS exam on?
    • Patients that have been experiencing hours/days of vertigo
    • Patients that are experiencing spontaneous nystagmus
    • Vertigo symptoms worsen going from lying to standing
  • Why perform the HINTS Exam?
    • Assists in differentiation between vertigo and posterior stroke
  • The Three Steps of the HINTS Exam
    • Nystagmus
      • Primary Gaze
        • Is there nystagmus at rest?
      • Lateral Gaze
        • Be careful while you are assessing for lateral nystagmus; having a singular object that you are looking at can reduce the severity of the nystagmus
        • Patients with vestibular neuritis (common cause of dizziness/vertigo symptoms) will typically experience unidirectional nystagmus… and that’s okay
        • Patients experiencing bidirectional nystagmus… not so good
      • Test of Skew
        • Covering/uncovering a patient’s eye(s)
          • Does the eye have any vertical movement when it is uncovered?
      • Head Impulse Test
        • Looking for catch-up saccade
          • Catch-up saccade is good!

  • HINTS Exam leading to probable vestibular neuritis
    • Must have ALL of the above
      • Unidirectional nystagmus
      • No vertical skew
      • Abnormal HIT
  • HINTS Exam leading to probable Posterior Circulation Infarct
    • Can have ANY of these three
      • Bidirectional nystagmus
      • Vertical Skew
      • Normal HIT
  • How sensitive is the HINTS exam in differentiating between vestibular neuritis and a stroke?
    • Same AHA article published in 2009 states that the HINTS exam was 100% sensitive and 96% for identifying stroke patients that were concurrently experiencing vertigo symptoms for several hours/days
    • Not only that, but a comprehensive HINTS exam proved to be sensitive for early detection of stroke patients that early MRI

**SOAPBOX MINUTE WITH MIKE**

So what are we driving at? Maybe the reason that we are missing so many stroke positive patients is that we aren’t considering possible life threats that don’t fit into our limited understanding. By not looking for atypical symptoms or considering textbook symptoms in patient demographics that aren’t typical, we are causing harm to our patients. It’s time to start doing more aggressive follow-up and research.

Episode 21: D.O.S.E. (Direct On-Scene Education) with Captain James Carroll

Let me start off by apologizing for the buzzing in the background of this recording. IF you can get past that, the content and ideas of this presentation are incredible. We would like to thank Capt. James Carroll of Broward CO, FL for taking the time to sit down with us and explain his passion for community outreach. 

EMS-IERC DOSE

Listen here or download or iTunes, Podcast Addicts, or Podcast Republic.

What is DOSE? DOSE is an innovative attempt at eliminating sleep related infant death due to suffocation, strangulation or positional asphyxia by using First Responders to identify and remove hazards while delivering education on-scene. First Responders are trained to identify and remove hazards from an infant’s sleep space while on scene during emergency and non-emergency 911 calls. DOSE was created and developed by Captain James Carroll and Jennifer Combs, MSN, ARNP.

If you or your department is interested in implementing a program like this, contact Capt. Carroll via the D.O.S.E. website.

Episode 20: The Great Airway Debate with Dan O’Shaugnessey and Seth Bard

debate

Listen here or download on iTunes, Podcast Addicts, and Podcast Republic. 

First of all, we would like to stop and take a minute and thank Dan and Seth for their help on this episode and their dedication to resuscitation research. Secondly, although we refer to several different commercial devices throughout this episode, we have NO conflict of interest with any of these corporations, and are not being paid to plug any of these products. 

Justifying SGA Placement in OHCA

  • Does not require chest compressions to stop for placement.
  • Depending on available personnel, allows ALS providers to focus on scene oversight; i.e. defibrillation, medications, etc.
  • Taking into account that EMS is a revolving door, many providers are not proficient intubators… This is an instance that a patent airway is important regardless of type. Repeated airway attempts have been proven to lower rate of neurologically intact patients post ROSC.
  • People are obese! Obese airways can be very difficult… even proficient intubators will admit that they have had to place SGAs during an arrest because of this.

Why SGAs Fail

  • There is significant controversy about the impairment of carotid blow flow from SGA placement as opposed to ETI. Depending on what sources you look to, you will find conflicting arguments. Something to consider.
  • There are several different types of SGA devices out there; due to unfamiliarity, providers are at risk for over/underinflating them.
  • Improper technique (i.e. not controlling the tongue) can lead to occlusion of the ventilation port, rendering the device useless.

Justifying ETI During OHCA

  • Experienced providers can often intubate without interrupting chest compressions.
  • ETI definitively protects the airway better than an SGA; less reported long term effects from aspiration; i.e. pneumonia.
  • Depending on the studies you read, ETI has a markedly improved rate of neurologically intact ROSC patients.

Why ETI is a Dying Skill

  • As we mentioned previously, EMS is a revolving door. Academic standards have changed drastically with many programs only requiring two successful intubations during paramedic class.
  • A study out of Australia revealed that paramedic students require 25 attempts before reaching a 69% first pass success rate at ETI.
  • We are intubating less people thanks to devices like CPAP/BiPAP and the wide distribution of naloxone.
  • The anatomy of society is changing. We are getting bigger! Bigger airways are harder airways, and many providers are opting to just place an SGA device.
  • Depending on the material you look at, some studies show that ETI can take as long as 90 seconds!

Introducing VL to the Prehospital World

  • The British Journal of Anaesthesia found that providers with less experience are reaching higher first pass success rates with VL than with DL.
  • VL does not require chest compressions to be interrupted to place an ET during OHCA.

Why VL Fails

  • Think about the basics of introducing a camera to a wet environment; whether it is just bloody or full of secretions, cameras can be hindered. If you fail to suction, you are significantly likely to have to multiple attempts even using VL.
  • With anything mechanical, there can be malfunctions. Screens crack. Batteries die. If you don’t have a backup readily available, adverse effects can occur. You have to be proficient at your backup plan.

Summary

Resuscitation is an art form. There is no one-size fits all approach to resuscitation, and you have to remain adaptable. No two arrests are the same. As an ALS provider, your choice of airway needs to remain based on what you believe will give the patient the best outcome possible. If you have an experienced crew and are working with another ALS provider that can helps with meds and interventions, then why not intubate? If you have a less experienced crew or aren’t as great of an intubator, then why not place an SGA? Resuscitation is situational, but we have to remind ourselves that this debate cannot be about what skills you want to perform, but what is best for your patient. Despite all of the rhetoric and black/white thinking out there, I think the best answer we can offer is… it depends. Early and high quality CPR as well as timely defibrillation are really the heroes of the story, though.

Sources and Extra Reading

Episode 19: Protecting Our Own Part II… The Injured Firefighter

KC FF Down

Listen here or download on iTunes, Podcast Addicts, or Podcast Republic. 

As we mentioned in Episode 15 (our first installment of the Protecting Our Own Series), this episode would not have happened without the effort put in by our friend Casey Cassidy. He’s truly a resuscitationist and constantly focuses on how we can improve our responses to extremely stressful environments. 

This episode was intended to cater, primarily, towards medics that have never worked in a fire service before. If some of the elements of this seem like review at first, we apologize. We just want everyone to start off on the same page.

ARRIVING ON THE SCENE

  • Check in with the Incident Commander
    • They will most likely have a specific location for you to stage, keeping you out of harm’s way as well as you keeping you out of the way of any operations that are ongoing.
    • If you have the ability to speak with a safety officer, they will have updates on any injuries, firefighters who need to rehab, etc.
    • Make sure you have your equipment ready to go. Hope for the best, plan for the worst.
      • Get your stretcher setup, your monitor ready… Make sure you have everything you need for an arrest or a major trauma…
    • Set up a rehab station.
      • Make sure your FF are staying hydrated!
      • Monitor vital signs and see if your people are starting to experience any fatigue.
      • Most departments, at least locally, have a two bottle limit; meaning that if you have blown through two O2 tanks, you aren’t allowed to go back into the interior fire.

KNOWING THE REAL ENEMY

  • According to a study done by the National Fire Protection Association, 56% of all firefighter fatalities in 2014 were due to a cardiac etiology.
    • As much as you want to watch out for signs of CO or cyanide inhalation, you need to remain the most vigilant for the firefighter that looks fatigued.
    • There have been reported cases of CO inhalation resulting in STEMIs…
  • Casey mentioned in one of our talks the importance of treating every unresponsive firefighter in full turnout gear like a full arrest until proven otherwise.
    • If you think about it, you are unable to assess adequate ventilation or presence of carotid/femoral pulse due to excessive barriers.
  • We stole a video from the Firefighter Down: CPR site showing how to do CPR on a firefighter while removing their gear. It’s amazing. If you haven’t watched it yet, stop this episode and go watch it. You won’t be sorry.

HYPOVOLEMIA, HEAT EXHAUSTION, AND HEAT STROKE

  • Firefighting, especially during the warmer months, is extremely taxing on the body. Due to excessive physical exertion, firefighters are prone to hypovolemia, as well as heat stroke and heat exhaustion. It’s paramount to monitor your patients for signs of hypovolemia
  • Heatstroke and Heat Exhaustion
    • Start the active cooling process as quickly as possible; remember that cold fluids used (typically for ROSC and therapeutic hypothermia) are extremely discouraged in this instance!
      • Cold packs to the groin, axilla, and neck
      • Large bore IVs and NS/LR bolus (depending on what’s available)
      • Get them out of their gear and into a cooler environment
    • Things to monitor for:
      • ALOC
      • Seizures
      • Possible airway complications
      • Cardiac arrhythmias

CARBON MONOXIDE AND CYANIDE EXPOSURE

  • CO and Cyanide work very similarly, in that they both bind to hemoglobin and inhibit the hemoglobin’s ability to carry oxygen into systemic circulation
  • Signs and Symptoms
  • If you have the ability, it would be worth considering transporting these patients to a hyperbaric chamber.
  • Prior to entering these scenes, it is extremely important to remember that your safety can be in jeopardy; act wisely.
  • Treatment:
    • If available, consider Amyl Nitrate
    • Maintain airway patency
    • Supportive care and ACLS for the arrested patient
    • Remove the patient from the scene ASAP
      • Particles of the CO/Cyanide can absolutely be found outside of the structure

DECONTAMINATION

  • It is not your role as the provider to be offering patient care to a patient that is not decon-ed. Stay out of the hot zone! Don’t add another patient to the scene.
  • Remove any gear that could be decontaminated prior to packaging the patient; you don’t need toxic chemicals in a confined space.

UNDERSTANDING THE ROLE OF HUMAN FACTORS ON SCENE

  • There will be plenty of sympathetic surge going on during scenes like this; the best thing you can do is to find calming mechanisms for yourself
    • Simulation training has been found to reduce stress simply by preparing participants for real-life scenarios.
    • Don’t forget about tactical breathing
  • Crowd control is a quintessential part of this scene
    • Bystanders are not the only people on the scene that you should be concerned about; first responders that are not involved should be put to work doing other things.
    • The last thing you need is someone who is just twiddling their thumbs and feeling aimless to start criticizing the rescue crew…
  • Removing extra, unnecessary equipment
    • By taking off SCBA, turnout gear, etc., you eliminate clutter in an already tight environment.
    • Remove any undue sounds from the scene; the last thing you need are alarms to be sounding that don’t even need to be there. Reduce the noise, reduce the stress.

WE’RE DONE… NOW WHAT?

  • These scenes are extremely stressful… If you need help, ask for it. Inquire about your department’s CISM policies, or just reach out to someone that has been through it before. Talk.
  • Sit down with all of the departments involved; in a non-judgmental manner address the areas that you feel could have run smoother and assess how to do it better. God forbid, you might need to do it again…
  • If you haven’t listened to it, yet, take a listen to EMCrit‘s talk on how to handle a stressful resuscitation when it’s over. It will change the way you handle these situations.

If you have any questions, gripes, or concerns, let us know in the show notes. We hope this helps.

Episode 18: Caring for the Autistic Patient with Jen Knapp

Autism-Word-Brain-Image

Listen here or download on iTunes, Podcast Republic, and Podcast Addicts. 

A major “thank you” to Jen Knapp for coming in and talking with us today about something deeply personal. We hope that this talk causes all of us to reflect on the way we approach these situations and opens a dialogue to caring for patients with special considerations. 

COMMON MISCONCEPTIONS ABOUT AUTISM

  • Autism is often lumped into the “mental illness” category; Autistic patients have a higher likelihood of developing additional mental illnesses (i.e. anxiety, ADD/ADHD, etc), but Autism is not a mental illness in and of itself.
  • Despite the stereotype, Autistic patients are not naturally violent; the agitation is typically a result of unidentified stressors by the provider.
  • Not all Autistic patients have the same triggers.
  • Autism does not signify lack of intelligence; however, there is significant difficulty understanding nuanced language.

OPTIMIZING YOUR ASSESSMENT

  • If there is a caregiver present, talk to them. They will most likely understand how the patient copes with stress, how to deescalate frustrating situations, and also have a general understanding of other co-morbidities.
  • Explain what you are doing before you do it.
  • Don’t speak it riddles. Be clear. Be concise. Be brief.
  • Limit the amount of people in the room. Numbers are not your friend in this instance; too many cooks in the kitchen tends to lead towards escalated tempers and misunderstanding.
  • If you have the ability to limit noises (i.e. radios, sirens, etc) or flashing scene lights, do it.

RECOGNIZING AND APPROACHING CONFLICT

  • Repetitive motions are typically a sign of increased agitation; the motions are an attempt to sooth the ongoing anxiety; once you recognize this stop what you are doing and reapproach the situation in a slower manner, allowing the patient time and distance.
  • If the patient is severely agitated, genuinely ask yourself if this is a behavioral outlet or a danger to the patient. If the behavior makes you uncomfortable, but it isn’t endangering the patient, the best thing to do is to let the behavior run its course.
  • Time and respect will do the most in diffusing these situations once they’ve escalated. Attempting to assert dominance will only worsen things.
  • The majority of this is common sense, but take a second and think about the last time you dealt with a combative of agitated patient… How did you handle it?

FINAL THOUGHTS

  • Caring for an Autistic patient can be a challenge; recognize that their caregivers might need your support just as much, if not more than the patient.
  • Slow down! Everyone involved in emergency medicine is time focused… This an opportunity to pump the brakes and care for the patient as a whole, and not just focus on a specific malady.

If you liked what Jen had to say, think about coming out and listening to her at the Indiana Emergency Response Conference in Indianapolis from August 24th-27th!

Episode 17: The Field Amputation with Jon Mansfield

Amputation Jpeg

Listen here, or download on iTunes, Podcast Addicts, or Podcast Republic. 

Our thanks to Jon Mansfield for taking the time to sit down with us and talk about a “once in a lifetime” run. In this episode, Jon made several references to the fact that this is not a procedure that he had ever contemplated before, or was ever taught. Kudos to all involved for coming together to make the tough decisions that resulted in a life saved.

THE SCENE

  • This was not a flippant decision that was made.
  • Several hours of grueling extrication took place before this procedure was even an option.
  • The patient was buried under several layers of debris, a cargo trailer, and pinned in the crumpled cab of a semi truck.
  • The patient’s leg was badly mangled and intertwined with machinery in the vehicle.
  • Crew was watching patient actively decompensate during extrication and knew that if they waited any longer, the patient would surely die.

WHAT IF I HAVE NEVER BEEN TAUGHT TO DO IT?

  • Historically, paramedics haven’t fared well performing skills outside of their scope of practice.
  • The crew involved knew there was the possibility of all of them losing their jobs and still decided to act.
  • Jon contacted medical control at the nearest Level II Trauma Center, explained the scene explicitly, and told them all of the work they had done thus far to extricate the patient without success.
  • After detailing all of this, Jon requested that a surgeon or ED physician make the scene to perform the actual amputation; none were available. Medical control advised Jon that he could perform the procedure.
  • Understanding the gravity of the situation, Jon contacted his on-duty supervisor, his director, and medical control over a recorded line to insure everyone was on the same page.
  • Exhausting all other options, Jon receives the go ahead from all avenues to perform the procedure with guidance from medical control.

THE PROCEDURE

  • Jon echoes that almost all ALS providers are prone to missing the BLS skills in this situation, reevaluates for airway patency and hemorrhage control.
  • Gains large-bore IV access in the antecubital; small fluid bolus initiated.
  • Attempts prehospital conscious sedation; opted not to fully knock down patient due to airway complications in a confined space. Administered 5.omg midazolam.
    • Side Note: Jon was working out of a small pharmacological tool box, but we would suggest that if you have access to ketalar (Ketamine) that this agent would probably be preferable in an instance like this. Not only do you have the dissociative properties, but also some element of analgesia. You are much less likely to tank a blood pressure with Ketamime than Versed.
  • Commercial tourniquet placed proximal to the amputation site; Jon states that he could hear the patient moan when cranked down on the tourniquet. If tourniquets are used properly, they are supposed to hurt, and require aggressive pressure to fully insure hemorrhage control.
  • Cut away remaining skin and adipose tissue with a scalpel; used a large-tooth sawzall to cut through the actual femur. Jon equated cutting through the tibia/fibula with attempting to cut through a log; the saw didn’t do all of the work.

POST-AMPUTATION CARE

  • It is incredibly easy after an emotionally taxing scene for our minds to shut down and not be aware of any other potential dangers that might present themselves to our patients or ourselves.
  • Following the amputation, the crew still had approximately a 10 minute transport time to the trauma center where they had to immobilize the patient, maintain the patient’s airway, manage other presenting injuries, as well as titrate fluid boluses to manage the patient’s vital signs.
  • If you have access to tranexamic acid, now is the time to use it (within your protocols).
  • Don’t forget to look out for the basic things; i.e. gauging the stages of shock in your patient.
  • Prevent the lethal triad to the best of your ability.
  • “Napoleon stated that the moment of greatest danger was the instant immediately after victory, and in saying so he demonstrated a remarkable understanding of how soldiers become physiologically and psychologically incapacitated by the parasympathetic backlash that occurs as soon as the momentum of the attack has halted and the solider briefly believes himself to be safe.”- Dave Grossman, On Killing

If you are interested in seeing more footage of the accident, check out this video.

Episode 16: A Novice’s Introduction to the Dialysis Patient

Peritoneal Dialysis

Listen here or download on iTunes, Podcast Addicts, or Podcast Republic. 

I’m going to start this podcast with a disclosure. This is not an episode for the advanced provider. We are not going to delve into a lot of the critical care aspects of the dialysis patient in this episode. This show is mainly geared towards better explaining the importance of understanding dialysis equipment, the process of dialysis, and some special considerations to have with dialysis patients. Have I said dialysis too many times? I did? Dialysis. There I said it again. Let’s get to it. 

**SOAPBOX MINUTE WITH MIKE**

Starting off the show notes with a soap box minute should tell you guys how frustrated I am with the state of education in EMS. If I hear one more person tell a new medic that “that’s just something you need to learn on the job”, I am going to have a stroke. Genuinely sick patients are not guinea pigs. They’re people. Not only that, they’re people that need your help. Encountering a critically ill dialysis patient is not the time or place for on the job training. If there is something you don’t understand, find information on it before you are put into a position where you have to treat it. Rant over.

WHY ARE PATIENTS ON DIALYSIS

There are an estimated 1 in 10 Americans that have some sort of chronic kidney disease, and are on dialysis or are candidates for dialysis therapies. For patients on dialysis, their kidneys can no longer filter waste products or process medications. These patients now require specialized equipment to do the job of the kidneys.

HEMODIALYSIS

There are three primary types of vascular access used in hemodialysis that prehospital providers will come in contact with.

1. Arteriovenous Fistulas

AV Fistula

AV Fistulas are a surgically created connection between an artery and a vein, and are constructed directly from the patient’s own tissue. The downside of this type of access is that it takes several months to mature. 

2. Arteriovenous Grafts

AV Graft

 AV grafts are used when the patient’s vessels are too small or are unavailable to develop a fistula. After placement, grafts are accessible more quickly than fistulas and can be used in about two weeks. They’re constructed out of synthetic material, but they do not last as long as fistulas.

3. Central Venous Access

ICU_IV_1

Central lines are typically located in the subclavian region, and are used for emergent treatment. The downside to these is that they are significantly more prone to infection and thrombosis than the other two types of access. In following episodes, we will show you how to access central lines in critically ill dialysis patients. (Remember that if yo don’t have a protocol to do this, this procedure is something that you need to consult with medical control over.)

PERITONEAL DIALYSIS

Better Peritoneal Dialysis

Peritoneal dialysis is an alternative to hemodialysis, often allowing patients to do treatment at home, or while sleeping. The process usually takes about 4-5 hours; there’s a bag of dialysate (fluid solution comprised on patient’s electrolyte needs) that is injected directly into the peritoneal cavity. While in the peritoneal space, the fluids absorbs excess waste products and drains into a collecting bag when finished. This truly a gross oversimplification of the process, but for our intents and purposes, this is what to look for.

COMPLICATIONS

Venous Access Hemorrhage

This is a pretty straightforward problem, but it’s easy to overcomplicate. Direct pressure over the access site is the best way to stop the bleeding. Unfortunately, many of these patients are on anticoagulants and hemorrhage control can take a long time. There are some times when you have a critically ill dialysis patient with an access hemorrhage and not enough hands to do more than bleeding control. A friend of the show, Ken Hendricks, suggested the use of a tourniquet and a 4×4 or ABD pad to hold direct pressure over the site. It’s important to remember that you are not using the tourniquet as a tourniquet, but simply to hold direct pressure. Don’t crank down on the tourniquet!

Thrombosis

While most patients are receiving anticoagulant therapy while on dialysis, it’s important to remember that they can still form clots in their venous access. Keep CVA/TIAs, MIs, DVTs, PEs, etc. in your differential diagnosis when clinically relevant.

Sepsis

This is a moment where we need to reflect on our aseptic technique. I’m not trying to be sanctimonious, but lack of proper cleaning can contribute infection. Sepsis needs to be on the radar for the dialysis patient that presents with hypotension, tachycardia, ALOC, etc.

EKG Monitoring

There are several reasons for this. Patients on dialysis experience severe electrolyte imbalances that can often lead to arrhythmias, i.e. prolonged QT intervals progressing into ventricular rhythms. There are a few links here concerning hypo/hyperkalemia, hypo/hypernatremia, and hypo/hypercalcemia.

Sedation and Analgesia

Dialysis patients tend to experience delayed relief from sedation and analagesia agents due to impaired kidney function. Remember to closely monitor patients for signs of ALOC and respiratory depression especially when giving multiple doses of opioids and benzodiazepines. Medications tend to process through the kidneys slower and build up more potency when multiple round are given. It is suggested that clinicians use shorter acting agents because of this.

I know that this was a longer post than usual, and we will get onto more excited topics next time. As always, leave your concerns and gripes in the comments, and have a great day!

Episode 15: Protecting Our Own Part I… The Injured Police Officer

Police car wreck

Listen here or download it on iTunes, Podcast Addicts, or Podcast Republic. 

We’d like to start off with saying a special thanks to Casey Cassidy for his insight and dedication to this epidemic, and for helping with this podcast. If you ever get a chance to sit down and chat with Casey, it will be well worth your time. 

This is not a fun situation to think about. If we were truly honest, I think this situation scares the living hell out of us. Nobody wants to uncover his/her friend from a mangled vehicle, or put a tourniquet on his buddy’s arm after they’ve been shot. If you pick up a newspaper, get on the internet, or watch t.v. for any amount of time, you will see that violence against public safety is on the rise; there is no question about it. Whether intentional attacks or unintentional threats from distracted drivers, this is an unfortunate reality we have to come to terms with. The only way we can hope these situations will go well is if we begin to train for them. Today, we will be focusing primarily on assisting the injured police officer. So let’s get to it…

ENTRY INTO THE SCENE

  • Find a way to calm yourself down!
    • Whether you think you will be able to handle it or not, this is a high stress situation.
    • Tactical breathing
    • Develop a primary plan with your partner before you get on scene. If you have an idea of what needs to be done,  you are less likely to just be caught up in the chaos of the moment.
  • There are hazards everywhere!
    • MVCs
      • Nothing majorly different than any other MVC scene
        • Wires, fluids, etc.
      • Remember that in this situation, while all of us are drawn first to the injured officer(s), there is the potential for other patients. Don’t get tunnel-visioned.
      • This is a situation that might make you exceedingly unpopular, and you need to prepare yourself for maybe needing to be the bad guy… What if the officer isn’t the most critical patient? Are you going to transport them first anyway? 
    • Crowds.
      • Everyone is rubber necking to see what the commotion is.
      • Scenes like this require immediate stabilization; everyone is emotional and not operating with full attention to detail of surrounding dangers; i.e. bystanders, fire, active shooter, news crews, etc. The more people you have on scene, the more risk you have for further injury.
        • Get people out of the way
        • People standing with hands in pockets are only complicating the scene; delegate
        • Appoint specific people for crowd control
        • Get off scene and don’t dick around. Seriously. If you can do it en route do it. There are several reasons for this. 
          • Trauma: It’s a surgical disease, and you starting an IV on scene isn’t worth the delay.
          • Public/Responder perception: When people perceive that you aren’t moving quickly enough, they think you don’t understand the weight of the situation.
  • This is a crime scene.
    • Everything you took is evidence. While this shouldn’t affect your treatment that you render, you need to keep this in the back of your mind.
    • If you can avoid it, try not to cut directly through a bullet hole, etc.
    • Be careful where you place your equipment; i.e. don’t throw your first in bag on a murder weapon, etc.
    • This is mostly common sense stuff, but you’d be surprised at the stupid stuff we do when we are under stress.

INITIAL CARE

  • If you aren’t in the habit of stripping down your trauma patients, we highly advocate you start. Trauma that might not show up initially can as time goes by. It’s good to have a before and after picture. It’s just good care.
  • Duty belts and vests get in the way.
    • Tourniquets/pelvic binders aren’t effective if a gun is in the way; vests inhibit in depth chest/abdomen assessment, EKG placement, listening to breath sounds, needle decompression, CPR… You get the point.
  • Shootings to center mass; even if the officer is up walking around and the vest took the brunt of the damage, remember that blunt trauma can still cause internal abdominal hemorrhage, cardiac arrhythmias, pneumothoraces, etc.
  • Don’t be afraid to pack a wound or use a tourniquet; they save lives.

SPECIAL CONSIDERATIONS

  • Securing the Weapon
    • If you don’t know how to properly disarm a holster, don’t. Best rule of thumb, have an officer secure the weapon. It will be checked in as evidence, anyways. Don’t interfere with the process.
  • Secondary Weapons
    • Most officers carry a second weapon; check for ankle/armpit holster, knives, etc. It’s important to remember that you really should not deliver a patient to the ED with a weapon. Bad things just have a tendency to happen.
  • The Unconscious Officer
    • If the officer you are working on is unconscious, realize that if he/she wakes us, they will most likely still be in the throws of sympathetic surge and will probably want to fight because it is the last thing they remember.
  • Basic Information
    • Talk to your officers about wearing their basic demographics, med history, and blood type on the inside of their vests for more rapid treatment

SUMMARY

  • Everyone is amped up on these scenes; there are a few way that we can combat that stress.
    • Train specifically; whether it’s mayday drills for fire, ambulance crashes for EMS, officer shootings for PD, we need to train specifically.
    • When you are encountered with a new type of stress, you sink to the level of your training… Just imagine how bad it will be if you haven’t had any training at all.
  • Plan for failure; not everyone has a happy ending. Officers, Medics, and FFs DIE on the job; fact of life. We need to be preparing that this could be a reality in our own departments. None of us are invincible.
    • For these scenes to go as smoothly as possible, it is imperative for all departments to train together.

Sorry for the downer episode, but it is important to talk about. We’ll be talking about happier subjects (kind of) next go round.

Episode 14: The Suspected Pulmonary Embolism Patient

Blood Clot PE

Listen here or download it on iTunes, Podcast Addicts, and Podcast Republic. 

You get called out to a complaint of difficulty breathing for a 20yof. The patient is writhing on the couch, clutching her chest, complaining of shortness of breath. She is hyperventilating, looks supremely anxious, and says she cannot catch her breath. You’re thumbing through her medications, she has a history of anxiety. She’s on birth control. No other gross co-morbidities or noticeable medications. The family states that she hasn’t taken her Xanax today… You attempt to coach her through her breathing, but it just isn’t working. This should just be a simple run… Isn’t she just having a panic attack? You give her 1mg of lorazepam… Why isn’t her breathing improving? Her blood pressure starts to drop… Her heart rate increases… Her mentation deteriorates… Did we ever stop to think about other causes of her hyperventilation? Her anxiety? In my humble opinion, pulmonary embolisms are one of the most looked over differential diagnoses in the prehospital field. So what can we do to better recognize this phenomenon? Let’s start with who is at risk for PEs.

WHAT IS A PULMONARY EMBOLISM

  • Could either manifest as a blood clot, air embolism, or fluid/fat embolism (i.e. from extravasated amniotic fluid during delivery), that enters in circulating volume and lodges in the pulmonary artery.
    • So… Moment of sobriety. We are all very cavalier about the risks we take with any type of invasive procedure… especially IV access. Careless technique or incomplete flushing of tubing can subject our patients to emboli…

RISK FACTORS

ASSESSMENT OF THE SUSPECTED PE PATIENT

There are some typical landmarks that we usually assess for, but bear in mind that not every patient is a textbook example… So here’s what we can look for. 

  • Dyspnea
    • Despite the significant shortness of breath, you will often find clear/= lung sounds
  • Cyanosis
    • Starts off as acrocyanosis and can progess to cyanosis of the chest and face
    • Cyanosis that does not improve despite high flow oxygen therapy (or high quality CPR in the arrested patient) is a classic PE sign.
    • The absence of cyanosis should not exclude a PE from your list of suspected illnesses.
  • Chest Pain
    • Typically reported to be “sharp” in nature and exacerbated by deep inspiration
  • Syncope/Near Syncope
  • Palpitations
  • Nausea & Vomiting
  • Diaphoresis

INITIAL TREATMENT FOR THE PE PATIENT

It’s important to remember that the pulmonary embolism patient is experiencing a form of obstructive shock; so keep your initial treatment simple. We are attempting to protect the patient from the lethal triadHigh flow oxygen, making sure that your patient stays warm, and rapid transport are essential. As the severity of the PE increases, you are going to notice the progression of obstructive shock. Anxiety. Tachypnea. Tachycardia. Narrowing pulse pressures. Hypotension. Bradycardia. Arrest. It’s important to remember that PE patients progress down this road very quickly, and it’s not uncommon to encounter the “talking arrest”.

How long has it been drilled into our heads that extremely hypotensive patients should receive large boluses of fluid? I know I’m guilty of this, and I know that I am not the only one. Let’s break down the set up of a PE… The clot lodged in the pulmonary artery creates significant back pressure in the right ventricle. Hypovolemia is not the problem, the obstruction is the problem. As the obstruction gets worse, the right ventricle becomes larger, compressing the left ventricle, inhibiting left ventricular output.

So where do we start? I genuinely believe a 250ml NS bolus won’t harm the situation, but fluid bolus is not the end solution. If you work in a system with extended transport times (or even services that don’t), this might be a situation that warrants a call to medical control for orders for heparin or a fibrinolytic if no standing order exists.

If fluids aren’t necessarily indicated, what can we do to enhance blood pressure? The common fallacy in prehospital care is that we need to treat hypotension. Like all types of shock, permissive hypotension is completely acceptable in this instance. What we need to be titrating to is mean arterial pressure. Typically in a normal adult patient, that will be about 65mmHg. A wonderful article from EMCrit/PulmCrit suggests this might be the time to consider early pressor initiation.

DIAGNOSTIC TESTS FOR THE PE PATIENT

So that’s it for now. This a topic that could go on for hours, days, months, years, decades, centuries… Okay. Fine. I’ll stop.

ADDITIONAL READING

Episode 13: Capnography (Beyond ETI Confirmation) with Jayson McConnell

Listen here, or download on iTunes, Podcast Addicts, or Podcast Republic. 

Sampling Cannula

Look through your standing orders and protocols for the usage of EtCO2. You will probably (hopefully) find ETI or Supraglottic airway confirmation… Do you see anything else? Unfortunately, there are very few services out there that utilize one of the greatest diagnostic tools we have: waveform capnography.  So if this is such a great diagnostic tool, which patients should we be using this on? Any trauma, cardiac, respiratory, overdose, arrest, or illness that just has that “sick” look. This is a crash course on capnography and some of the major uses we should be using it for. 

ETCO2 AND DETECTING BRONCHOCONSTRICTION

Allow me to paint a clearer picture using a scenario that isn’t altogether too uncommon. You and your partner are dispatched to a mid-70s female patient that is seated in her recliner and obviously dyspneic. You notice the swollen ankles and the array of medications sitting in a bin next to her. As you begin to rifle through the container, the patient, in between breaths, tells you that despite using her rescue inhaler and a nebulizer treatment, she isn’t improving. The patient takes Lasix, Diltiazem, Coumadin, Albuterol, Metoprolol…and the list goes on. By simple deduction, you’ve figured out that the patient has several co-morbidities, including CHF and COPD. So what are you going to treat for? You listen to the patient’s lung sounds and hear coarse wet sounds in the bases, but also hear expiratory wheeze in the upper lobes. Could anything else besides bronchoconstriction create a wheezing sound? Cardiac asthma? If only there was something we could use to differentiate between cardiac asthma and bronchoconstriction…

WAVEFORM CAPNOGRAPHY WITH NO BRONCHOCONSTRICTION

Normal Waveform Capnography

WAVEFORM CAPNOGRAPHY REVEALING BRONCHOCONSTRICTION

Bronchoconstriction EtCO2

ETCO2 AND DETECTING POOR CARDIAC OUTPUT

Okay, so you can use EtCO2 to differentiate between cardiac asthma and COPD exacerbation…big deal. What else can this tell us? Well, I’m glad you asked. EtCO2 is one of the most reliable prehospital indicators of cardiac output. Normal ranges of EtCO2 are typically between 35-45mmHg (although you’ll hear some argument from some saying that there is a slight discrepancy between waveform capnography and actual blood gas CO2 values). As cardiac output decreases, so does your EtCO2. Conversely, as cardiac output increases, so does your EtCO2. EtCO2 is a tool that allows you to monitor a patient’s responsiveness to colloid/blood therapy and pressor resuscitation. It’s time to consider using routine EtCO2 in sepsis, trauma, suspected PE or anyone showing signs and symptoms of shock.

WAVEFORM CAPNOGRAPHY REVEALING POOR CARDIAC OUTPUT

Poor Cardiac Output EtCO2

ETCO2 IN TRAUMA

Decompensating trauma patients need to be monitored with EtCO2. A great example of the usefulness in the trauma patient is in the case of tension pneumothorax and cardiac tamponade; due to the increased intrathoracic pressure or fluid in the pericardium, the heart’s ability to perfuse the body is greatly inhibited. EtCO2 monitoring shows in real time, the effectiveness of thoracostomy or cardiocentesis.

What about the head injured patient? The majority of us were taught early on in our EMT-Basic classes to hyperventilate the head-injured patient. We now know that hyperventilating these patients leads to decreased ICP and cerebral blood flow, leading to higher mortality rates. The truth of the matter, is that ventilatory management of these patients is a balancing act, and EtCO2 monitoring is the only reliable indicator that you are keeping the patient from experiencing respiratory alkalosis or acidosis. Improper ventilatory management can be the tipping point between life and death. If we are really honest with ourselves, all of us have experienced at one time or another hyperventilating a patient due to our own stress. By monitoring EtCO2, we have real time data showing us what we need to do for our patients. Try to keep your head injuries between 30-35mmHg.

ETCO2 IN NARCOTIC OVERDOSE

I think all of us are a little too quick to pull the narcan trigger in narcotic overdose. This is a personal opinion, completely. Remember that mild bradypnea does not always mean that the patient is not being ventilated adequately.

CURARE CLEFT

Essentially, the curare cleft is an indicator that your patient is exhibiting spontaneous respiratory effort despite the insertion of an endotracheal tube, supraglottic airway, or surgical airway. The dip in the waveform is essentially the diaphragm of your patient that is “waking up” from deep sedation or the paralytics you have given.

curare cleft EtCo2

SOAP BOX MINUTE WITH MIKE

There are some realistic limitations to what EMS services can provide to our patients. Financial shortage is a real problem. Lack of education should never be what’s holding your service back, though. I have heard several people say that they are afraid to implement EtCO2 into widespread system usage because it would take too long to train all of their employees into using it correctly. We have a duty to our patients to provide the best care possible under every circumstance. EtCO2 is one of the most reliable diagnostic tools available to the prehospital provider, and we need to be utilizing it to its full potential.

ADDITIONAL READING