EMS A to Z: EMTALA and Diversion

Show Notes:

From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn

 

What is EMTALA?

The Emergency Medical Treatment and Labor Act

It states that hospitals with an emergency department must provide at minimum a medical screening exam to any patient who presents for care and cannot refuse care to any patient, regardless of insurance status

Once present on hospital grounds, the hospital must treat & stabilize any presenting patient

What is Diversion?

Hospitals / emergency departments may state that they do not have the capacity to provide medical care to additional patients, for a variety of reasons:

Internal disaster

External disaster

This is system dependent

The Southern Arizona / Tucson area is a no-divert system (barring internal disasters)

EMS A to Z: Mechanical Circulatory Support Devices

Show Notes:

From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn

 

There are two types of mechanical circulatory support devices: Left Ventricular Assist Devices (LVAD) and Total Artificial Heart (TAH). 

 

Left Ventricular Assist Device:

An LVAD is a Mechanical Circulatory Support (MCS) device designed to restore blood flow and improve survival, functional status, and quality of life for those suffering from advanced heart failure.

The device is implanted in parallel with the heart, taking over a majority of its circulatory function.

An LVAD is often implanted as a temporary treatment, but is sometimes used as a permanent solution to very low cardiac output.

 

What are the reasons for VAD implantation? 

Bridge to Transplant

The patient must meet criteria to be listed for a heart transplant

Destination Therapy

The patient does not qualify for a heart transplant but meets criteria for Destination Therapy

The patient lives the rest of their life with an VAD

Bridge to Recovery

VAD for a few days or weeks, provides temporary supportto a patient expected to recover native heart function

 

What are the special considerations for LVAD patients? 

Routine assessments such as blood pressure, pulses, and pulse-oximetry may not be unattainable  

Chest compressions are usuallynot indicated 

The patients carry external equipment: a controller and power sources that operate the implanted pump though a single driveline

 

How do you assess patients with LVADS? 

Attempt to auscultate over the apex of the heart for a “whirling” or “smooth, humming” sound indicating that the VAD is working 

A cable exits the abdominal wall that connects the device to power and the control unit

Many VAD patients also have an implanted cardiac defibrillator

Blood Pressure (BP) - BP taken with a manual cuff;  Automatic BP readings are considered unreliable

Pulse - A palpable pulse is variable and clinically insignificant in VAD patients

Pulse Oximetry- Can be unreliable

Look for physical s/s of ↓ oxygenation

EKG is typically unaffected

 

What types of problems are LVAD patients at risk for? 

Bleeding complications due to blood thinner use

Arrhythmias

VAD flows may be affected

Infection (as with any implanted device)

 

How do you treat arrhythmias in LVAD patients? 

Many VAD patients have an ICD / Pacemaker

Persistent arrhythmias are treated aftercontacting the VAD coordinator 

Okay to defibrillate & cardiovert VAD patients per ACLS protocol

Okay to administer anti-arrhythmic medications per ACLS protocol

 

What are the differences between LVADs and Total artificial hearts? 

An ECG is meaningless since there is no heart

Pulse oximetry is accurate

A regular BP measurement may be obtained

Chest compressions are not performed

Cardioversion or defibrillation are not performed

EMS A to Z: Diabetic Ketoacidosis

Show Notes:

From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn

What is DKA?

Diabetic ketoacidosis is a metabolic state in which either a lack of insulin (Type 1 Diabetes) or resistance to insulin (Type 2 Diabetes) prevents the body from using glucose for energy. When that happens, the body must use alternate energy sources, such as fatty acids. This type of metabolism produces acidic ketones. When you put all of this together, you get elevated blood sugar, elevated ketones, and an acidic blood pH. 

 

Who is at risk for DKA?

DKA is more common in Type I diabetes, in which patients do not produce enough of their own insulin. It can also occur in Type II diabetes. In Type II diabetes, patients typically still make insulin, but their tissues are resistant to it. Another process that can occur in Type II diabetes is something called HHS – hyperosmolar hyperglycemic state. HHS has even higher blood glucose levels than DKA, raises the blood osmolality, and can result in severe dehydration. It doesn’t have the ketone production or acidosis typical of DKA. 

 

What are some common causes of DKA?

Insulin noncompliance / underdosing

Infection

MI

 

How do we identify DKA in the prehospital setting?

Typical symptoms may include nausea, vomiting, abdominal pain, possibly symptoms of a precipitating infection. If DKA is severe, altered mental status or respiratory compromise may occur.

Our assessment may reveal a patient with tachycardia, hypotension, and increased respiratory rate. You may notice signs of dehydration with dry mucous membranes, or kussmaul breathing, which is a deep, rapid respiratory pattern.

Obviously elevated glucose can clue you in as well, however there are cases of what’s known as “euglycemic DKA” when the patient is in DKA with a relatively normal BGL. This can happen if a patient is in a starvation type state, have an insulin pump, recent administration of insulin, or be taking a certain class of diabetic medications (the SGLT2 inhibitors). You can recognize them as they end in “flozin”. 

 

How do we treat DKA in the prehospital setting?

IV fluids are the first place we start. These patients are often quite dehydrated, so volume resuscitation is the first step. In addition, there are some significant electrolyte abnormalities – namely hypokalemia – that can occur in DKA and we want to make sure that we know the patient’s acid base status and potassium levels before we initiate the other mainstay therapy in the hospital, which is obviously insulin.

 

What are some specific considerations in pediatric patients?

DKA can be the first presentation of diabetes in a pediatric patient. Diabetes can present in children, typically between ages 4-7, however some can present later, in the 10-14 range. We are seeing pediatric patients, more adolescents, developing type II diabetes, however it’s less likely that these kids will present in DKA.

A pediatric patient with DKA may have altered mental status, nausea, vomiting, appear dehydrated and lethargic. A blood glucose should be checked in these kids. Initiating IV fluid resuscitation is also appropriate, starting with a 10mL/kg fluid bolus.

EMS A to Z: Ketamine for Pain 

Show Notes: 

From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn 

What is ketamine?  

It’s an NMDA receptor antagonist. It has does-dependent effects, but at “anesthetic” doses it acts as a dissociative anesthetic – meaning that the patient is dissociated from their environment.  

Ketamine also acts as an analgesic at lower doses without the dissociative effects of higher doses.   

 

So, does it work? How does it compare to morphine, which we’re all more familiar with...   

It does! It can actually be added to morphine for better and longer lasting pain control, but there’s not great evidence that one is superior or inferior to the other.   

 

We’re familiar with the side effects of opiates: hypotension, respiratory depression, nausea... what are some side effects of pain dose ketamine?  

At a pain dose, side effects like dizziness and nausea are most common. Ketamine can also cause some hypertension and tachycardia. At higher doses we think about things like emergence reactions, hypersalivation, emergence reactions.   

 

What patients may benefit from receiving ketamine rather than opiates?  

Patients with allergies to opiates  

Patients with hypotension   

Patients with a history of opiate abuse  

 

What is the correct dose of ketamine?  

0.2mg/kg    

Doses above this can increase the side effects including agitation, HTN, tachycardia...   

 

There are some myths about ketamine... can you give ketamine in patients with head injury?  

Yes, it has been debunked that ketamine increases ICP and worsens head injury in these patients.   

 

What about in patients with a history of psychiatric disease?  

Older studies demonstrated an increase in psychotic type symptoms at sub-dissociative (or pain dose) ketamine, however these symptoms abate when the ketamine wears off and do not appear to be long-lasting. 

 

Music by: Scott Holmes Music, “Brit Pop”

EMS A to Z: BLS and ALS Transports

Show Notes:

From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn

 

What does our Administrative Guideline state regarding ALS v BLS transports? Simply, patients to be transported via BLS must meet all of the BLS criteria and NOT meet any of the ALS criteria.

 

BLS Criteria: 

- Minimal risk of airway compromise during transport  

- Normal work of breathing  

- No acute neurologic deficit  

- GCS >13 - No significant environmental exposure or trauma  

- Not more than one vital sign out of BLS range 

 

NOT meet any ALS Criteria:  

- Receiving IV fluids or medications  

- Receiving cardiac monitoring (all patients greater than 35 years old with non-traumatic chest pain should receive cardiac monitoring)  

- Severe pain requiring repeat doses of pain medication  

- At risk of rapid deterioration (impending chidlbirth or HTN >160 SBP in pregnancy, life-threatening OD, angioedema, anaphylaxis etc.)  

- Patient meets SAEMS anatomic or physiologic trauma criteria (http://saemscouncil.com/wp-content/uploads/2018/12/BLS-Transport-SO-SAEMS-approved-10-16-18.pdf): 

 

 

Why do we require these patients to be transported ALS? 

Simply, these conditions may benefit from interventions such as: IV placement and medication administration, IV fluid administration, procedures such as cardiac monitoring, cardioversion, pacing, etc. 

 

What does the evidence say? 

The OPALS study is one of the largest studies examining the outcomes between BLS and ALS transport. 

After the introduction of ALS transport in Ontario, Canada the outcomes of cardiac arrest, trauma, and respiratory distress did not improve.

 

That doesn’t sound like any patients should be transported ALS!  

Not so fast...

There are actually benefits to ALS evaluation and management:

The ability to perform and interpret an EKG, identify a critical arrhythmia and treat it, recognize a STEMI and notify & transport to an appropriate receiving facility can shorten time to reperfusion therapy, which does improve outcomes. 

Recognizing and treating sepsis with early fluid resuscitation can also improve mortality.

Stabilizing a critically ill patient with IV access, fluid resuscitation, oxygen application, etc. May help prevent the dreaded “EMS witnessed cardiac arrest”

 

The key here is to recognize the importance of great BLS care in critical conditions like cardiac arrest and trauma, as well as to utilize the addition of ALS interventions to identify and treat the conditions that benefit from them. 

 

That’s really our goal with these ALS criteria – to screen for conditions that may benefit from ALS care. 

 

Music provided by: Scott Holmes Music, “Brit Pop”

EMS A to Z: Spinal Motion Restriction

Show Notes:

From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn

Today we are going to discuss the indications for and techniques used in spinal motion restriction. Let’s start by defining SMR, what does that actually mean? 

SMR refers to stabilizing and restricting movement of the spine with the goal to prevent worsening of any possible fractures, ligamentous injuries, or spinal cord injuries.

When is SMR indicated? 

In blunt trauma patients with any of the following high-risk features:

Any altered mental status (GCS 65 

Axial load injuries (diving injuries, spearing tackle), sudden acceleration/deceleration, lateral bending forces to neck/torso.

Remind us what the field trauma triage criteria are? 

http://saemscouncil.com/wp-content/uploads/2020/06/Trauma-Triage_6.16.20.pdf 

 

So, if the patient meets NONE of those criteria AND meets the Low Risk criteria, they can be transported without immobilization... 

Minor mechanism - equivalent to simple rear end collision 

No neck pain on scene 

No midline cervical tenderness 

Ambulatory on scene at any time

 

Does SMR require the use of a backboard? 

No; backboards should ideally be used for extrication only.

 

Can patients with isolated suspected cervical spinal injury be transported seated?  

Patients should be transported flat, if possible, but slight elevation of the head of the gurney can be accommodated. Sitting fully upright is not recommended.

 

Remember to take care when moving the patient who requires spinal motion restriction, as any patient movement creates risk for spinal injury.  

 

Is spinal motion restriction indicated in penetrating trauma? 

Not usually, however if there is concern for spinal injury or neurologic deficit present, it may be indicated. 

 

For additional reference, see the position statement released by NAEMSP.  

https://naemsp.org/home/news/spinal-motion-restriction-in-the-trauma-patient-%E2%80%93/#:~:text=The%20goal%20of%20both%20SMR,of%20the%20potentially%20injured%20spine.&text=Indications%20for%20SMR%20following%20blunt,back%20pain%20and%2For%20tenderness

EMS A to Z: The MARCH Algorithm

Show Notes:

From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn

The MARCH approach to patient assessment: 

M – massive hemorrhage: evaluate for and stop all significant bleeding with direct pressure, tourniquet, or pressure dressing

A – airway: assess for airway obstruction, then chin lift to open airway; consider NPA, ETI, cricothyrotomy depending on resources, practice environment, etc.

R – respirations: assess work of breathing and oxygenation, then provide supplemental oxygen, assist ventilations, needle decompression  

C – circulation: evaluate circulation and begin resuscitation 

H – head injury / hypothermia: evaluate for TBI / neurologic disability, prevent or treat hypothermia  

I like to add “naked” to the end, making it “march naked” to remind us that we need to fully undress / assess trauma patients, and then cover them back up immediately to prevent hypothermia as we’ve discussed. 

 

Let’s review bleeding control:

How do you properly place a tourniquet?

Where does it go: proximal to the injury, but it doesn’t have to be as high as the adage of “high and tight” would suggest.

You may have to undo the tourniquet to place it, depending on the injury.

Making it as tight as possible with the velcro is ideal, and then tightening further with the winless. 

The tourniquet should be tight enough that a distal pulse is no longer palpable, or if in an amputation, the bleeding has stopped. 

Remember to time it if you can.

A tourniquet can be on for at least 2 hours, possibly longer, without significant tissue damage.

They are PAINFUL; administer pain meds if you can. 

How do you properly pack a wound or place a pressure dressing? 

If you have a deep, bleeding wound, and cannot keep direct pressure using a finger, then you may need to pack the wound and / or place a pressure dressing.

If packing the wound, clean gauze should be directed to the depth of the wound bed and continue to be layered in the wound until the entire cavity is filled tightly. Make note of how many rolls of gauze you used.

If using a pressure dressing, use folded or packed gauze to create a focal point for the pressure, then wrap the ace around. 

What can we do for pelvic injuries?

A pelvic binder may help reduce bleeding and prevent further injury in a pelvic fracture.

A pitfall with placing pelvic binders is that we often place them too high; they should sit over the greater trochanter / essentially the top of the femur, not the top of the pelvic bones. 

Chest

While we can relieve a tension pneumo in the field, the other chest injuries / sources of bleeding typically require the bright lights and cold steel of an ED / OR.

EMS A to Z: The Dyspneic Patient

Show Notes:

From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn 

Intro: 

Over the last year, EMS systems have experienced a lot of change and challenges. When COVID-19 was first declared a pandemic, we saw an overall decrease in call volumes and ED visits across the nation, as well as changes in our prehospital guidelines and treatments. Working during this pandemic, without a doubt, changed how we think about patient encounters for respiratory complaint. The differential diagnosis for shortness of breath, cough, or fever became much smaller in our minds as everything became “suspected COVID.” 

As we begin widespread vaccination with overall declining case numbers, I wanted to take a few minutes to remind us about some of the other things that can make a patient dyspneic, and some prehospital therapies that we may begin re-employing. Does anyone else miss nebs? I miss nebs. I know that the “data” suggests they aren’t significantly more effective than inhalers, but patients love them, I love them, respiratory therapy may not love them, but that’s ok.  

Let’s go through a few cases to remember our undifferentiated dyspnea differential diagnoses – say that 5 times fast!  

 

Case 1) 

Dispatch: 54M with dyspnea, leg swelling. You arrive to find an age-appropriate, obese appearing male, seated in his dining room, in mild-moderate respiratory distress. On your assessment, you note that he has increased work of breathing, diminished breath sounds with possibly some crackles, and lower extremity edema that goes all the way up under his gym shorts. He tells you none of his pants fit anymore, and he can only wear his house slippers... His vitals are: HR 97, RR 24, BP 170/90, SpO2 88% on RA; improves to 94% on 6L NC. His wife reports a history of hypertension. 

What is your most likely diagnosis, and some others to consider? 

CHF

ACS / arrhythmia 

Pneumonia

COPD/asthma

PE

Pneumothorax

The patient agrees to be transported to the hospital. In the back of the truck, however, he continues to be tachypneic and have increased work of breathing.  

What other therapy / ies can we give him? 

Nitro

ASA

CPAP

Just a quick reminder, nitro works in CHF by dilating blood vessels – predominately veins – and reducing the amount of venous return to the heart, making it easier for the heart to pump out the blood that’ it’s getting. The heart is like a water balloon, if it’s over-filled, some of the elasticity or squeeze is lost. Nitro also lowers BP, so it’s not recommended in patients with hypotension. CPAP works in CHF in a few different ways: first, it stents open alveoli at the end of a breath, to allow better oxygen / CO2 exchange – thereby improving hypoxia and work of breathing. It also increases the intra-thoracic pressure, which decreases blood return to the heart – similar to the nitro that we just mentioned.  

The patient is given sublingual nitro and placed on CPAP. His work of breathing, SpO2, and BP all improve en route to the ED, and he’s ultimately admitted for his likely heart failure.  

 

Case 2)  

Dispatch: 25F with shortness of breath and wheezing. You arrive on scene to find an age-appropriate female in the living room of her apartment in moderate-severe respiratory distress. On your assessment you note tachypnea, increased work of breathing, and diffuse coarse wheezes throughout her lung fields. Her vitals are: HR 130, RR 30, BP 110/70, SpO2 92% on RA. She is speaking in 2–3-word phrases, and says she has asthma, had been doing well until today, when these symptoms developed pretty quickly. She tried her home inhalers without relief.  

What is your most likely differential diagnosis, and some others to consider? 

Asthma

Anaphylaxis

Viral respiratory illness

Pneumonia

PE

Pneumothorax

Arrhythmia 

The patient requests transport to the hospital, and you appropriately start nebulized albuterol / ipratropium in the ambulance, while working on an IV for fluid bolus, solumedrol. I

EMS A to Z: 2020 AHA Guideline Updates

Show Notes:

From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn

Cardiac Arrest:

In 2015, 350,000 individuals had OHCA in the US. Less than 40% of adults receive layperson-initiated CPR, and fewer than 12% have an automated external defibrillator (AED) applied before EMS arrival.

EMS Highlights: 

Adults/Pediatrics: 

Importance of early CPR and defibrillation

CPR quality monitoring

Audio feedback if available

ETCO2 if available

IV may be preferred to IO if available

Early epinephrine in non-shockable rhythms

Prioritizing defibrillation over epinephrine in shockable rhythms

Shock x 3 prior to antiarrhythmic 

Early epinephrine in pediatrics

Neonates:

Neonatal warming, drying, stimulating, skin to skin with mom is priority

Neonatal suctioning only recommended if suspected airway obstruction due to meconium 

PPV for HR < 100

CPR for HR < 60

IO may be used for med admin

Epinephrine may be used if no response to CPR / PPV

Fluid bolus may be used 

Community Health:

Focus on debrief for providers and family members of patient suffering cardiac arrest

Focus on booster CPR training for layperson

Focus on naloxone admin by layperson

EMS A to Z: Anaphylaxis

Show Notes:

From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn

 

Diagnostic criteria for anaphylaxis:

Anaphylaxis is highly likely when any ONE of the following three criteria is fulfilled: 

1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula) 

AND AT LEAST ONE OF THE FOLLOWING: 

A. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, hypoxemia) 

B. Reduced BP* or associated symptoms of end-organ dysfunction (eg, hypotonia, collapse, syncope, incontinence) 

2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to a LIKELY allergen for that patient (minutes to several hours): 

A. Involvement of the skin mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula) 

B. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, hypoxemia) 

C. Reduced BP* or associated symptoms (eg, hypotonia, collapse, syncope, incontinence) 

D. Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting) 

3. Reduced BP* after exposure to a KNOWN allergen for that patient (minutes to several hours): 

A. Infants and children - Low systolic BP (age-specific)* or greater than 30% decrease in systolic BP 

B. Adults - Systolic BP of less than 90 mmHg or greater than 30% decrease from that person's baseline 

Source: uptodate.com

Why do people get anaphylaxis? 

Something triggers a large scale, systemic release of immune cells in response to something our body has, usually incorrectly, identified as dangerous. 

What are the most common allergens causing anaphylaxis? 

In kids, it’s more likely food (peanuts, tree nuts, shellfish, milk, egg)

In adults, it’s more likely an insect sting or medication (antibiotics, NSAIDs)

What all can we do to treat anaphylaxis?  

Epi, epi, epi!  

01mg/kg of IM epinephrine is the mainstay of treatment (to a max dose of 0.5mg in adults) 

The dose can be repeated in 3-5 minutes if ineffective 

Some patients may require an IV epinephrine drip to be started if severe 

Adjuncts like: IVF, albuterol, antihistamines (benadryl), steroids can help treat the symptoms  

What if a patient uses their home epi-pen, but they’re feeling much better by the time you arrive? 

We recommend that these patients be transported and evaluated, at minimum a brief obs period in the ED in case there is what’s called a “biphasic reaction” occurs, and a prescription for a new epi pen are needed