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10 things you need to know to save lives (eBook)
Prepare yourself to provide fast and appropriate patient care with the critical knowledge and strategies in this guide
Sponsored by Pulsara
By EMS1 BrandFocus Staff
Ongoing preparation and training are vital in any industry, but especially in EMS. Every second counts in the prehospital environment, and it’s critical that EMS providers stay on top of the latest skills and strategies for saving
This e-book provides 10 things you need to know about four of the most time-sensitive calls you’re likely to face in the field:
STEMI
Stroke
Sepsis
Trauma
Fill out the form below for your free download to learn about the importance of recognizing subtle symptoms, choosing the appropriate intervention, identifying the best destination facility for each case and more.
Proper assessment, treatment, and transport of patients with severe trauma saves lives, here’s howMar 28, 2015
By Bob Sullivan
The following is paid content sponsored by Pulsara
Trauma is a leading cause of death for all age groups. EMS plays a pivotal role in trauma systems of care through assessment, treatment, and transport to the most appropriate trauma-care facility. Here are the top 10 things you need to know about multi-system trauma to save lives:
1. Only a few things can be fixed on scene, the rest need a trauma center.
Definitive care for multi-system trauma patients is surgery at a trauma center, and time to surgery is critical for those with serious injuries. Interventions on scene should be limited to a rapid head-to-toe exam that identifies severe injuries and the need to control of severe external bleeding, manage the airway, and ventilate or oxygenate the patient. Unless a patient is trapped, most other interventions are done during transport.
2. Know your trauma centers.
EMS transport of severely injured patients to Level I and Level II trauma centers, which have specialists and emergency surgery available, has proven to be lifesaving. Not every trauma patient requires transport to a Level I or II trauma center, though, and over-triage can overwhelm the finite resources at those hospitals. Use the CDC field triage guidelines to determine which patients can be safely taken to Level III and IV trauma centers to better distribute patient load. However, err on the side of over triage and transport to the higher-level center if there is any concern about the severity of the patient’s injuries.[1]
3. Apply pressure, then tourniquets to stop external bleeding.
External hemorrhage control begins by applying pressure to the wound with a dressing. Hold the dressing tightly on the wound, directly on the injured blood vessel. If that does not quickly control bleeding, apply a tourniquet ‘high and tight’ proximal to the wound. Adjust the pressure of a commercial device or inflate a blood pressure cuff until the bleeding stops. If bleeding continues after the maximum amount of pressure is reached, a second tourniquet may be applied proximal to the first. There is no nerve damage or risk of limb loss from tourniquets for at least two hours after application.[2]
4. Decompress a tension pneumothorax with a large and long needle.
Traumatic injury to the lung can cause a tension pneumothorax, in which air leaks into the space between the lung and chest wall and compresses the lung, heart, and blood vessels. This compromises both ventilation and cardiac output and can quickly lead to death.
Auscultate for silent or decreased breath sounds on one side, tachycardia, altered mental status, and hypotension during the primary assessment, and treat a tension pneumothorax as soon as it is recognized. This is done through placement of a needle into the second intercostal space at the mid-clavicular line of the chest, which relieves pressure in the chest and increases the size of the lung. The needle should be large bore (14 gauge or higher), and at least two inches long to ensure penetration of the chest wall. Assess for a rush of air and change in vital signs after needle placement.
5. Use capnography to detect shock.
Waveform capnography is an indirect measurement of a patient’s perfusion status. David Page describes capnography as the “smoke of metabolism.” The amount of carbon dioxide exhaled is related to cellular metabolism, which decreases in shock states. Consider internal bleeding or another cause of shock when end-tidal CO2 readings are below 35 mmHG and monitor for trends.
6. Slow down the “triad of death” during transport.
As internal bleeding progresses to shock, the combination of hypothermia, acidosis, and coagulopathy worsen bleeding. Even mild hypothermia impairs the body’s clotting mechanisms. Acidosis occurs when tissue demand for oxygen exceeds the available supply, and anaerobic metabolism is needed to produce energy. Both contribute to coagulopathy, where blood clots are broken down and the body is unable to form new ones.
Use blankets and heat in the ambulance to keep trauma patients as warm as possible, even in warm ambient temperatures. Administer 100% oxygen via NRB mask or bag-valve-mask to maximize oxygen delivery to tissues. Tranexamic acid impedes the breakdown of formed clots, and has been shown to reduce mortality in certain trauma patients when administered early.[2] This medication is being adopted by some EMS systems for hemorrhagic shock.
7. Be permissive with hypotension.
The once taught practice of infusing normal saline or lactated ringers to increase the blood pressure in hemorrhagic shock patients is now believed to cause harm. IV fluids dilute the body’s natural clotting factors and contribute to acidosis, and higher pressure may cause the existing clots to “pop.” If used, administer only enough fluid to maintain a radial pulse and mentation.
8. Beware of blood thinners and beta-blockers.
Patient’s taking blood thinners, such as Coumadin and Plavix, have impaired clotting capability and are at risk of internal bleeding from relatively minor injuries. Beta-blockers, including atenolol and metoprolol, may mask the signs of tachycardia and diaphoretic skin seen in patients in shock. It is important to know what medications are in these classes and consider their effects in your assessment findings.
9. The rules about spinal immobilization are being rewritten.
Positioning patients flat on a spine board reduces respiratory capacity, causes pain, and increases the likelihood of pressure ulcers. An assessment of spinal pain and neurologic deficits should be used to determine if spinal immobilization is needed rather than just considering the mechanism of injury.
Many EMS systems have stopped using a long spine board and rigid cervical collar for spinal immobilization, even if a spinal injury is detected, and transport patients in a position of comfort with a soft cervical collar. Follow local protocols regarding spinal immobilization and be ready for changes in the near future.
10. Pain management is important.
Acute pain damages the immune system, hinders wound healing, and can lead to chronic pain, in addition to the suffering it causes.[3] Administration of fentanyl has been shown to effectively reduce pain, and does not cause hypotension or respiratory depression associated with other narcotics.[4] Deliver pain medications by IV, IO, or IN routes and reassess the patient’s pain. Early pain management by EMS can mitigate this harm, as well as improve the patient’s experience.
Bonus: Look for internal bleeding and shock with ultrasound and lactate
A two-minute exam with an ultrasound probe is commonly used in hospital to detect internal abdominal bleeding and collapsed lungs. Anaerobic metabolism in shock states produces lactic acid, which can be detected with point-of-care lactate meters before other vital sign changes. Both ultrasound and lactate have been incorporated into some EMS systems to identify these conditions, initiate treatment, and determine the most appropriate hospital destination. Look for wider adoption of these assessment tools in the near future.
References:
1. Sasser SM, Hunt RC, Faul M., et al. Guidelines for field triage of injured pateints: recommendations of the National Expert Panel on Field Triage, 2011. CDC MMWR 2012, January 13; 61(1): 1-23.
2. Prehospital Trauma Life Support Committee of the National Association of Emergency Medical Technicians in cooperation with the Committee on Trauma of the American College of Surgeons. PHTLS: Prehospital Trauma Life Support. 8th ed. Burlington, MA: Jones and Bartlett
3. Thomas SH, Shewakramani S. Prehospital trauma analgesia. J Emerg Med 2008; 35(1): 45–57.
4. Krauss WC, Shah S, Thomas SH. Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia. J Emerg Med, 2011; 40(2): 182–7.
About the author:
Bob Sullivan, MS, NRP, is a paramedic instructor at Delaware Technical Community College. He has been in EMS since 1999, and has worked as a paramedic in private, fire-based, volunteer, and municipal EMS services. Contact Bob at his blog, The EMS Patient Perspective. https://www.ems1.com/sponsored-article/articles/2144635-Trauma-10-things-you-need-to-know-to-save-lives/
Properly understanding, detecting, and treating STEMI saves lives, here's howFeb 6, 2015
The following is paid content sponsored by Pulsara
EMTs and paramedics play a crucial role in rapid detection, treatment, and transport of STEMI[1] patients to the most appropriate hospital. Here are the top 10 things you need to know about STEMI to save lives:
1. Time is muscle - and mortality
The longer it takes for a patient to receive reperfusion therapy, the higher the risk of death or a reduced quality of life. When a coronary artery is completely blocked, irreversible damage to heart muscle occurs until reperfusion. Opening the blood vessel and restoring blood flow is done in the hospital with emergency angioplasty or thrombolytic medications.
2. The best hospital may not be the closest
Angioplasty, also known as percutaneous coronary intervention (PCI) is the most effective method of reperfusion.
However, PCI is not available at every hospital. STEMI patients who arrive at a non-PCI center must be transferred or given thrombolytic medications, which are less effective and have more side effects. STEMI patients should be taken to a PCI center if transport time is less than 90 minutes, even if other hospitals are closer.
3. Cast a wide net to catch a STEMI
STEMI care starts with recognition, which requires capturing a 12-lead ECG as early as possible on any patient with a possible ACS.
Perform a 12-lead ECG with the first set of vital signs on any patient with ONE of these symptoms: chest discomfort (often described as a heaviness or pressure that may radiate into the left arm, jaw or shoulder), shortness of breath, nausea, vomiting, weakness, or diaphoresis. STEMIs can lurk in unsuspecting places, especially in elderly, female, and diabetic patients. They also evolve and may not be on an initial ECG, so keep the leads connected and perform additional 12-leads during transport.
4. 12 leads are good; 15 may be even better
The 12-lead ECG primarily views the septum and left ventricle of the heart, where most STEMIs occur. But a standard 12-lead may not detect ST elevation affecting the right or posterior walls of the heart. View those regions by moving one lead to the right side of the chest, and two leads underneath the shoulder blades after the initial 12-lead is complete. Alternatively, you can check the posterior by looking at the anterior leads.
15-leads increase the sensitivity of STEMI detection and localizes the infarct, which guides treatment.
5. Clear a path to reperfusion therapy
Prehospital 12-lead ECGs have been shown to reduce the time to reperfusion in hospitals. A STEMI alert may be activated based on a transmitted ECG to the emergency department or a paramedic’s interpretation of the 12-lead and calling in a STEMI alert.
At PCI centers, the cath lab must be prepared, staff called in during off-hours, and elective procedures delayed. When these tasks are done prior to arrival, EMS may bypass the ED with STEMI patients and go directly to the cath lab for faster coronary reperfusion. You will need to notify the hospital early so they can marshal the resources they’ll need.
6. ASA ASAP
After time to reperfusion, the next most important interval is time to aspirin. Aspirin inhibits platelet aggregation that would make the clot larger, thus slowing down damage to the heart muscle. Chewing and ingesting 160-320 mg of aspirin is a pre-arrival instruction in many 911 call centers and BLS protocols.
7. Easy on the O's
One long-standing treatment that has fallen out of favor is routine oxygen administration. High flow oxygen has been shown to cause vasoconstriction, which increases infarct size. Only administer oxygen to ACS patients who are short of breath and only enough to titrate the pulse-ox reading to 94%.
8. Take a load off the left heart (or prime the pump on the right)
When the heart muscle is dying from an infarct, easing its workload may slow infarct progression. Nitroglycerine, available in sublingual tabs, spray, paste, or an intravenous infusion, accomplishes this through vasodilation, which decreases preload and afterload.
A damaged right ventricle can reduce preload to the left ventricle, which could be made worse if nitroglycerine is administered. When a right-side STEMI is identified, the treatment of choice is a fluid bolus to increase contractility. Use nitroglycerine with caution, if at all, with a known right-side infarction.
9. Not all ST Elevation is an MI
Other causes of ST elevation include pericarditis, benign early repolarization, bundle branch blocks, hypertrophy, and pacemakers. Be aware of these subtle differences in ECG interpretation to prevent an inappropriate STEMI activation. While a certain degree of over triage to the cath lab is acceptable, false activations drain hospital resources that could be utilized elsewhere.
10. Excellent STEMI care requires a systems approach
An EMS performance benchmark paper states that for every fifteen STEMI patients who receive a prehospital ECG, aspirin, and transport to a PCI facility, one stroke, second MI, or death is prevented[2]. Successful STEMI systems of care require cooperation from EMS, multiple hospitals, and departments within hospitals.
To provide the best care to the STEMI patient, EMS services need to get the right patients to the right facilities, and a clear path to reperfusion must be in place at those facilities. Early activation of the receiving hospital is critical. Hospitals must mobilize resources. Spending seconds to notify the hospital early saves muscle, morbidity and lives.
Endnotes
1. ST-elevation myocardial infarction, known as STEMI, is an acute coronary syndrome (ACS) that is diagnosed with a 12-lead ECG. When the ST segment in at least two leads covering the same area of the heart is elevated 1 mm or more above baseline and a patient has symptoms of an ACS, this indicates that heart muscle is dying from a blocked artery. STEMI is usually caused by a plaque rupturing in a coronary artery forming a thrombus, which blocks blood supply to cardiac muscle.
2. Myers JB, Slovis CM, Eckstein M, et al. Evidence based performance measures for emergency medical services systems: a model for expanded EMS benchmarking. Prehosp Emerg Care, 2008; 12: 141–51.
About the author:
Bob Sullivan, MS, NRP, is a paramedic instructor at Delaware Technical Community College. He has been in EMS since 1999, and has worked as a paramedic in private, fire-based, volunteer, and municipal EMS services. Contact Bob at his blog, The EMS Patient Perspective.
About the author
Bob Sullivan, MS, NRP, is a paramedic instructor at Delaware Technical Community College and works as a field provider in the Wilmington, Del. area. He has been in EMS since 1999, and has worked as a paramedic in private, fire-based, volunteer and municipal EMS services. Contact Bob at his blog, EMS Theory to Practice.
https://www.ems1.com/mobile-data/articles/2098450-STEMI-10-things-you-need-to-know-to-save-lives/
There are two types of strokes: ischemic and hemorrhagic. With ischemic strokes, a clot forms in a cerebral artery that interrupts blood supply to a section of the brain, causing tissue death and inflammation. Treatment is aimed at removing the clot and restoring blood flow.
Stroke: 10 things you need to know to save livesProperly understanding, detecting, and treating strokes saves lives, here's howMar 11, 2015
The following is paid content sponsored by Pulsara
EMS plays a critical role in identifying, treating, and directing stroke patients into a system of care. Here are 10 things you need to know about stroke:
1. A pipe is clogged or burst open
With hemorrhagic strokes, a cerebral blood vessel ruptures and causes bleeding in the brain. In addition to tissue death in the affected area, increasing pressure in the cranium harms other areas of the brain. Only 15 percent of strokes are hemorrhagic, but they account for 40 percent of stroke fatalities. Treatment is aimed at repairing the damaged blood vessel and removing accumulated blood.
2. Stroke scales rule in, but do not rule out
Strokes often present with motor deficits on one side of the body – the one opposite of the side of the brain affected. Two tests or scales are used to detect the presence of stroke; the Cincinnati Prehospital Stroke Scale and the Los Angeles Motor Score.
Ask the patient to smile to assess facial droop on one side, repeat a short phrase to assess for slurred speech or aphasia, and hold their hands in front of their face and close their eyes to check for pronator drift. A stroke is likely if the patient has ONE of these findings – facial droop, slurred speech, or pronator drift.
The Los Angeles Motor Score includes a checklist of other possible causes of conditions to rule out, such as a history of seizures or hypoglycemia, and assesses equal grip strength.
However, negative assessment findings in these scales do not rule out a stroke. Ischemic strokes affecting the cerebellum may cause a sudden loss of balance or vertigo. Hemorrhagic strokes may cause a severe headache, unequal pupils, confusion, seizures, or vomiting. Consider a stroke while assessing patients with these signs and symptoms.
Note that while two scores are listed here, there are multiple scores available and they are specific to your local protocols. Rapid Arterial oCclusion Evaluation (RACE) is another such scale, which can assist in determining large vessel occlusion in the field, an increasingly important identification.
3. Time is brain - and determines treatment
The brain is extremely sensitive to hypoxia and increased intracranial pressure. Nearly 2 million neurons die each minute that blood is blocked to the brain, and the likelihood of permanent disability or death increases the longer it takes to restore blood flow[1].
EMS plays a critical role in identifying stroke patients, the time their symptoms began, transporting patients to the most appropriate facility, and streamlining their care once they arrive. Treatment in the hospital hinges on identifying the type of stroke, which is done by CT scan.
Most hospitals initiate a “stroke alert” to assemble specialty resources and reserve the CT scanner before the patient arrives. In ideal stroke systems, EMS transports the patient directly to the CT scanner and transfers patient care there.
4. Be objective and get creative to establish “time zero”
Treatment options depend on the time the patient was last seen at their baseline, which may be different from the time stroke symptoms were first noticed. Stroke teams depend on accurate information obtained by EMS from the scene, which can be challenging when patients have baseline deficits or the onset of symptoms was not witnessed.
Ask and report objective findings, such as “the patient normally has left arm weakness, but now he cannot speak.” Get creative to determine when the patient was last seen acting normal. Use television shows, scores of sporting events, or cell phone logs as a reference. The patient's entire hospital course may depend on the EMS investigation.
In addition, it is extremely important to determine whether the patient is on anticoagulants, as well as gather family and witness contact information to share with the hospital.
5. Be aware of mini-strokes and mimics
A transient ischemic attack (TIA) occurs when stroke symptoms spontaneously resolve. TIA patients are at high risk for stroke and require hospital evaluation, but may not need a stroke team response.
Other stroke mimics include Bell’s palsy, behavioral disorders, and seizure. Inquire about these conditions and report them to the receiving facility, but err on the side of treating the patient as if they are having a stroke.
6. Air needs to go in and out
Stroke patients may lose their ability to swallow, which poses a risk of aspiration and hypoxia. Assemble suction and use suction as needed. Only administer enough oxygen to achieve a pulse-ox reading of 94%. Hyperoxia causes vasoconstriction and worsens damage from the stroke[2].
7. Check blood sugar
Hypoglycemia can mimic stroke symptoms. Administer dextrose to a patient with a blood sugar less than 60 mg/dl and reassess. Hyper glycemia is harmful for strokes, however, so only administer dextrose if hypoglycemia is confirmed.
8. Start a large-bore IV, but easy on the fluids
An IV, preferably 18 gauge, can be used in the hospital to inject contrast dye during a CT scan and to administer thrombolytics; reducing time to diagnosis and reperfusion. Don't delay transport to obtain an IV.
9. Thrombolytics, endovascular intervention, or neurosurgery: The 3 options
Three primary treatment options are available for strokes. IV thrombolytic medications are an option for ischemic strokes to dissolve the clot. These carry a risk of causing intracranial bleeding, and must be given within 4.5 hours of symptom onset. They also have several contraindications, including use of blood-thinners or history of GI bleeding.
Endovascular procedures similar to cardiac catheterization may be an option to treat both types of strokes. A catheter, fed into an artery, can remove a clot or repair ruptured blood vessels, and may be done on patients who are not candidates for thrombolytics. Neurosurgery may be needed for hemorrhagic strokes, or for bleeding after thrombolytics are given.
All of these procedures carry risks, which for some patients outweigh the potential benefits. Depending on risk factors and the severity of the stroke, supportive care and rehabilitation may be the chosen course of treatment.
10. Know your stroke centers
Advanced stroke treatments and rehabilitation are not available at every hospital. Thrombolytics may be administered at hospitals designated as primary stroke centers, which also have an on-site neurologist, dedicated stroke teams, and have demonstrated protocol compliance.
Hospitals designated as comprehensive stroke centers also provide endovascular procedures and neurosurgery. Thrombolytics may be administered at hospitals designated as “stroke capable,” often with remote assistance before transfer to a stroke center[2].
Patients transported to certified stroke centers have been shown to receive treatment faster and have better outcomes[2]. EMS providers must know which level of care is offered by the hospitals in their area, and which is the best option for patients.
References:
1. National Stroke Association. Understanding stroke. Stroke.org, 2014. retrieved from: http://stroke.org/understand-stroke/recognizing-stroke/signs-and-symptoms-stroke
2. Jauch EC, Cucchiara B, Adeoye O, et al. Part 11: Adult Stroke. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2010; 122: S818–28.
About the author:
Bob Sullivan, MS, NRP, is a paramedic instructor at Delaware Technical Community College. He has been in EMS since 1999, and has worked as a paramedic in private, fire-based, volunteer, and municipal EMS services. Contact Bob at his blog, The EMS Patient Perspective.
About the author
Bob Sullivan, MS, NRP, is a paramedic instructor at Delaware Technical Community College and works as a field provider in the Wilmington, Del. area. He has been in EMS since 1999, and has worked as a paramedic in private, fire-based, volunteer and municipal EMS services. Contact Bob at his blog, EMS Theory to Practice.
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