EMS A to Z: The Patient Handoff

Show Notes:

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

A 2014 position statement from ACEP, NAEMSP, NAEMT, NASEMSO states that: 

“Clearly defined processes for the contemporaneous face-to-face communication of key information from emergency medical services (EMS) providers to health care providers in an emergency department (ED) are critical to improving patient safety, reducing medicolegal risk, and integrating EMS with the health care system.” 

The MIST format is one of the most commonly used, standardized, formats for patient handoff:

Developed by The Southwest Texas Regional Advisory Council (STRAC))

M: Mechanism of illness / injury

I: Injuries or inspection

S: Vital signs & glucose 

T: Treatment 

What is a good structure for the handoff? 

Nurse calls "EMS Time Out"

Patient movement and conversations stop

EMS delivers patient report

Receiving nurse completes form

Nurse provides EMS patient sticker

Patient moved to hospital bed

The Central Ohio Trauma System rolled this out over 2 years with training of the EMS agencies, receiving facilities – initially looking at handoffs pre-implementation, and then post implementation: 

In Phase II, 46% of the hand-offs were recorded at less than 60 seconds versus 21% in Phase I

All vital signs were reported in 80% of Phase II compared to only 20% of Phase I

Demographics were captured at rate of 92% in Phase II versus 69% in Phase I

In Phase I, the longest hand-off was 15 minutes and in Phase II, it was 6 minutes.

EMS A to Z: End-Tidal CO2

Show Notes:

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

 

What is EtCO2? 

End-tidal CO2 is the CO2 level at the end of exhalation. It is a product of:

Cellular metabolism

Patients in shock will have a decreased cellular metabolism and CO2 production, with lower ETCO2 observed at normal respiratory rates 

Circulation 

Poor perfusion / circulation can decrease ETCO2 as it is not being circulated to the lungs and alveoli to be exhaled

Ventilation 

Hypoventilation can increase ETCO2and hyperventilation can decrease it 

 

Article with great explanation: 

https://www.jems.com/patient-care/how-to-read-and-interpret-end-tidal-capnography-waveforms/ 

 

How is it monitored? 

Via a nasal cannula or in-line device for a BVM, iGel, or ETT

 

What are the prehospital uses of ETCO2?

Confirming airway placement:

A numerical value and appropriate waveform should both be seen

Monitoring CPR quality:

ETCO2 should be > 20 with good CPR

Monitoring patients at risk for airway compromise:

Opiate overdose

Evaluating critically ill patients:

Low ETCO2 can indicate poor perfusion in conditions like sepsis 

 

What is a good framework for thinking about ETCO2? 

Consider the PQRST model:

Proper

Simply indicates that we should know what is normal for a given patient: i.e. a healthy, young patient, vs a COPD patient 

Quantity

What is the appropriate value?

Rate

What is the respiratory or ventilatory rate? Is it appropriate or expected?

Shape

What is the shape of the waveform?

Trending

Is the value trending upward or downward? What does that indicate?

 

How do I interpret the number and the waveform? 

The normal value for ETCO2 is between 35 – 45 

The normal waveform looks like a rectangle with rounded edges. It is flat and at 0 during inhalation and then rises rapidly during exhalation to a plateau; ETCO2 is measured at the end of that plateau, just before inhalation.

The shape of the waveform can indicate different respiratory pathologies, for example, obstructive pathologies like asthma may have a “shark fin” appearance with a down sloping, longer plateau due to the obstructive process. 

(see the attached article for examples of normal and abnormal waveforms)

Source: https://www.jems.com/patient-care/how-to-read-and-interpret-end-tidal-capnography-waveforms/  

 

What difficulties with ETCO2 have been seen in the field and how to troubleshoot? 

ETCO2 should never be 0. If it’s reading 0, then the airway is not in the correct place and the patient is not being appropriately ventilated 

A dotted line on the monitor indicates the ETCO2 is not working / reading: Consider disconnecting and reconnecting, trying a different device, etc.

 

In the age of COVID, any additional precautions or concerns with ETCO2? 

Remember to place a mask over the patient’s nose, mouth, and nasal cannula

Remember to place a viral filter between the patient and the ETCO2monitor: This should not interfere significantly with the reading.

EMS A to Z: Case Series – Cricothyrotomy

Show Notes:

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

Indications:

Cricothyrotomy is indicated in the “can’t oxygenate, can’t ventilate” scenario

Conditions that may cause this scenario may include:

Airway obstruction (foreign body)

Facial trauma

Airway edema

Head/neck malignancy

Difficult airway anatomy

Equipment:

A commercial kit

Individual components

ETT (size 6) or tracheostomy tube

Scalpel

Bougie / forceps

Securing device / tape

Procedure:

Palpate cricothyroid membrane

Vertical incision through the skin

Vertical, followed by horizontal incision through the cricothyroid membrane

Insert digit, bougie, or forceps into the trachea

Insert ETT or tracheostomy tube

Inflate balloon

Confirm placement with auscultation, ETCO2

Ventilate

Contraindications:

Pediatric patients

EMS A to Z: Hyperthermia

Show Notes:

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

Heat related illness falls into categories including:

Mild illness, such as heat cramps

Heat exhaustion:

Characterized by fatigue, nausea, malaise, dizziness, headache, diaphoresis, flushed skin, tachycardia.

Temperature usually < 104F

Heat stroke:

Characterized by the above symptoms including neurologic abnormalities such as altered mental status and seizures; can also have anhidrosis, shock, and hypotension.

Temperature usually > 104

Can be divided into categories:

Environmental / classic

Think about this in elderly or comorbid patients who are unable to adequately control their environment.

Drug / toxin

Examples include sympathomimetic toxicity, anticholinergic toxicity, serotonin syndrome, neuroleptic malignant syndrome

Exertional

Athletes or workers who exert themselves in hot environments, particularly without acclimatization

How is it treated?

Cool the patient!

Best strategies include: moving to a cool or shady area, removing excess clothing, wetting the skin, providing air movement or a breeze.

Patients may require more aggressive measures such as ice baths, transport to a hospital, IV fluids, etc.

Don’t forget to widen your differential and consider other etiologies of elevated temp / altered mental status such as infectious concerns, seizure, hypoglycemia, etc.

EMS A to Z: Termination of Resuscitation

Show Notes:

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

When can a cardiac arrest be terminated on scene WITHOUT resuscitation or electrical confirmation?

In an apneic and pulseless patient who is:

Decapitated

Decomposed  

Burned beyond recognition  

Has extrusion of brain matter  

Has removal of lower half of body  

In rigor mortis  

Has absent signs of life with a valid DNR order present 

The Dead on Scene Administrative Guideline allows us to terminate resuscitation without medical direction in some instances:

In a MEDICAL cardiac arrest:

If unwitnessed or prolonged downtime & asystole or PEA

If witnessed; after 20 min. of resuscitation, asystole or PEA & ETCO2 < 20

In a TRAUMATIC cardiac arrest:

If blunt trauma & asystole or PEA < 40

If penetrating trauma; asystole or PEA < 40 & > 15 min transport time to trauma center.

Remember your critical cardiac arrest interventions!

Medical arrests: good CPR & early defibrillation

Traumatic arrests: rapid transport if indicated, interventions like needle decompression if indicated

EMS A to Z: The DNR Order

Show Notes:

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

What is a DNR?

A Do Not Resuscitate order is exactly that – a prehospital medical order directing EMS providers to withhold resuscitative measures, like CPR and intubation, if the patient is in cardiac arrest.

To be valid a DNR must be:

Signed by the patient, a physician, and a witness (or notarized).

Have a photo or description of the patient.

It is typically on orange paper, but photocopies are accepted if otherwise valid.

What other forms might we see?

POLST and MOLST forms are more detailed and communicate the patient’s wishes as far as resuscitation as well as long-term care (dialysis, medical nutrition, etc.).

While these are not necessarily specifically intended for prehospital providers; they do communicate the patient’s wishes and we strive to respect those.

Advanced Directives or a Living Will are legal documents prepared, often far in advance of an illness, that detail the patient’s wishes for end-of-life care (among other things).

They can be lengthy but are valid if present and available.

If in doubt (for example: no paperwork present, but family says “they’re DNR!”); begin BLS resuscitation and call medical direction for assistance!

EMS A to Z: Traumatic Brain Injury

Show Notes:

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

A traumatic brain injury for our purposes is defined as: any traumatic injury to the head with loss of consciousness or GCS 94%.

Avoiding hyperventilation in head injuries severe enough to require mechanical ventilation (aim for a respiratory rate in adults of about 10 / minute, or once every 6 seconds). Monitor ETCO2 with a goal of 40.

EMS A to Z: Amiodarone

Show Notes:

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

Mechanism of Action:

Amiodarone is classified as an antiarrhythmic drug. It is a “dirty drug” in that it acts on multiple different receptors including sodium channels, potassium channels, beta-receptors, and calcium channel receptors.

Overall, amiodarone prolongs what’s called the “refractory period” in which the cardiac musculature is unable to contract or generate another beat. Prolonging this period works to prevent tachyarrhythmias, like Vtach or Vfib.

Indications:

Amiodarone is indicated for tachyarrhythmias including: Vtach, Vfib, Afib with RVR, depending on the circumstance and patient presentation.

We can divide the indications into two major categories: cardiac arrest and non-cardiac arrest.

The AHA recommends considering amiodarone or lidocaine in cardiac arrest with a shockable rhythm after the 2nd shock has been delivered. Our AGs allow for administration of amiodarone / lidocaine for refractory VTACH / Vfib not responding to defibrillation. 

Administration of amiodarone should not take priority over good cardiac arrest care, like CPR and defibrillation.

Side Effects:

Rapid administration of amiodarone can cause hypotension.

Amiodarone can prolong the QTc interval.

What about lidocaine? 

Lidocaine also acts on the sodium channel to prolong the refractory period but does not have many of the other effects of amiodarone.

A NEJM study of amiodarone vs lidocaine vs placebo in OHCA did not show significant mortality benefit overall to either medication; this is consistent with prior studies as well. Both medications seem to terminate the rhythm and improve survival to admission and did improve survival to discharge in patients with a witnessed arrest. It’s possible that the study wasn’t large enough to detect a small difference in survival.

Fast Facts:

Amoidarone can be administered IV or IO, so drill away.

The initial dose is 5mg/kg or up to 300mg initially in cardiac arrest with a follow up dose of 2.5mg/kg up to 150mg if a 2nddose is needed. 

In patients with a pulse, the dose is 2.5mg/kg up to 150mg given over 10 min.

EMS A to Z: Caring for Minors

Show Notes:

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

All patients require consent to treat; consent is essentially “permission” to provide medical care, transport, etc. and requires a person > 18 (or certain minors) who has “decision making capacity”

e.g., they are able to understand their current illness or injury and have an informed discussion about the recommended treatments and alternatives.

A&O x 3 does not necessarily mean the person has decision making capacity!

Minors who can consent for themselves:

Emancipated (married, homeless, military…), minors who are pregnant or seeking care for a reproductive issue, minors who are seeking care for substance abuse.

In an emergency situation, we can utilize “implied consent” to provide lifesaving treatment.

If the patient is on a school trip or at school, a school official can provide consent as well.

When in doubt or in a tricky situation, medical direction can help!

EMS A to Z: Lift Assist Calls

Show Notes:

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

Calls for “lift assistance” are common, particularly in the elderly, obese, and/or comorbid populations.

Evaluating these patients for a medical cause of their fall or a traumatic injury secondary to the fall is extremely important.

10% of elderly fall patients will have a clinically significant injury such as a fracture or TBI or clinically significant illness requiring admission.

1% of these patients will die within 2 weeks.

So, the next time you’re dispatched for a “lift assist,” consider the possible causes of a fall or injuries from a fall like:

Syncope, arrhythmia, hypotension, hypoglycemia, etc.

Inadequate home support / need for assistance

Traumatic injuries such as a fracture / dislocation / TBI / skin tear

Resources for elderly fall patients:

The  Pima Council on Aging provides an on-line guide to resourcesfor older adults and a Helpline at (520) 790-7262. They have a "Falls Free" site with resources to help. 

The Arizona Falls Prevention Coalition is designed to provide information, advice, helpful hints and tips to help prevent falls and fall injuries by the elderly in Arizona; sponsored by the AZDHS.