EMS A to Z

EMS A to Z: Post-Resuscitation Care Show Notes: From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn What is the best next step to take once identifying a cardiac arrest patient has ROSC?  Hemodynamic support: Patients with ROSC are typically in “shock” with unstable vital signs, hypotension, hypoxia, etc. Obtaining vitals and identifying how to support the patient's hemodynamics is key. IV fluids Dopamine: Dosing range is 5 – 20mcg/kg/min --> There are a number of ways taught to dose dopamine (the clock method, etc.). As an example, if you choose to start your dose at 10mcg/kg/min, in a 80kg person that's 800mcg/min. If your concentration is 1600mcg/mL (standard), then that's 0.5mL/min or 30 drops / min if you're using 60cc tubing.  Dopamine is incredibly titratable. Keeping 30 drops a minute (1 drop every 2 seconds) in the back of your mind is a great starting point for *most* patients, and you can increase / decrease based on BP from there. The key is starting dopamine early! Most of these patients will still have a little epi circulating and can crash precipitously when that wears off if another vasopressor hasn't been started. What are other considerations for evaluation / treatment?  ECG: A post-ROSC ECG can help identify a STEMI, which may change your transport destination.  Airway: A functional iGel / SGA can stay in place. Support respirations with BVM in sync with patient's breathing to the best of your ability. ETCO2: Monitoring ETCO2 can clue you in to an airway displacement, or hemodynamic compromise indicating impending re-arrest. CAUSES: Of course we're thinking about causes during the arrest, but don't forget to consider things like hypothermia, renal failure / hyperkalemia, etc. That treatment could be initiated in the prehospital setting. Are there things we're NOT doing for ROSC patients now?   Therapeutic Hypothermia: Now our goal is largely to prevent fever.      Music by lemonmusicstudio from Pixabay

EMS A to Z: Cold Related Illness Show Notes: From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn Let's break the group of “cold-related illnesses” down, because it contains more than just hypothermia...  Hypothermia Frostbite / frost nip Freezing injury to the tissues (facial structures, extremities) Degrees can be estimated, like burns, once thawing / rewarming has occurred Chillblains Capillary damage from repeated exposure to cold temperatures / wind Trench foot / immersion foot  Non-freezing tissue injury due to feet being continually exposed to moisture and cool temperatures  Carbon monoxide poisoning    What temperature actually defines hypothermia?   Hypothermia is a core body temperature < 35C (95F) There are degrees of hypothermia based on temperature and symptoms With mild hypothermia, the patient still maintains some temperature regulatory mechanisms, like shivering, but may have confusion and vital sign abnormalities With moderate hypothermia, thermoregulation is less effective and cardiac dysrhythmias can begin to occur In severe hypothermia, coma can occur with severely aberrant vital signs and arrhythmias Often resuscitation / defibrillation is ineffective until rewarming can occur    How do we manage these patients?   The WMS published recommendations with an update in 2019 (https://www.wemjournal.org/article/S1080-6032(19)30173-5/fulltext). The key factors are identifying the degree of hypothermia expected based on patient presentation and initiating treatments: Rewarming Remove from the cold environment Remove wet clothing / wrap with foil blanket, layers Calorie replacement Shivering uses a lot of energy Fluid replacement Cold induced diuresis can occur and patients can become volume down CPR/resuscitation/airway management if indicated Interestingly if the temperature is measured < 30C, only one shock is advised for VF and no vasoactive drugs until > 30C   Although we frequently think of exposure related hypothermia, non-environmental hypothermia can occur: Recall that hypothermia can occur in ill or injured patients even if the ambient temperature is quite warm. Patients with critical illness or sepsis, particularly the elderly, can lose their ability to thermoregulate and have hypothermia rather than fever in response to their illness. On a recent shift I had two patients with DKA who were very sick and both hypothermic, even without exposure to a cold environment.  Our trauma patients are also at risk of developing hypothermia, which is part of the trauma triangle of death, and should be prevented or treated aggressively.    What about carbon monoxide poisoning?  Carbon monoxide exposure / poisoning rises in colder months when individuals are using indoor heat. Indoor propane or other gas heaters are risky.  Carbon monoxide is odorless and tasteless, making it difficult to detect without functioning carbon monoxide alarms (which aren't cheap). Symptoms may include headache, dizziness, weakness, nausea, vomiting, confusion, progressing to coma and death due to asphyxia. If an entire family (or pets) are all experiencing symptoms, this should be on your radar!  Carbon monoxide binds to hemoglobin in place of oxygen; this is why standard pulse oximeters are inaccurate in carbon monoxide poisoning.  Patients should be transported to the hospital and provided supplemental oxygen. Supplemental O2 increases the rate at which carbon monoxide is cleared from the body. Some patients may benefit from hyperbaric therapy.   

EMS A to Z: Traumatic Brain Injury 2022 Update 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

EMS A to Z: Neonatal Fever Show Notes: From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn   Definition of a neonate: An infant that is < 30 days old (from their expected gestational date), meaning that if they were born 21 days early, you subtract those days from their current age.   What are some of the reasons we may see these newborns?  Fever  Fussiness Respiratory symptoms  BRUE Vomiting / spitting up  Rash  Poor weight gain    When assessing neonates, are there any specific considerations?  Pediatric assessment triangle Appearance Circulation  Work of breathing  Vitals: HR, RR, SpO2, Temp Reference normal vitals for age (don't let that HR of 150 scare you)  Glucose    What if you have the following case:   10-day old female with 1 day of nasal congestion, just developed a fever of 101.4 per parent's thermometer, calls EMS, says she has a pediatrician appointment tomorrow but isn't sure if she should wait There are some other factors that may be good to note: Sick contacts Feeding Urine / stool output Birth history  While those (along with the patient's appearance, vitals, etc.) can be helpful, the bottom line is that any neonate with a fever needs transport to the ED    Why?   These patients are at a high risk of bacterial infection (10-20%) with associated increased morbidity  Neonates have poorly developed immune systems that cannot “fight” even simple infections like urinary tract infections as an older child or adult can They have increased risk that infections will become systemic – spread to the bloodstream or cerebrospinal fluid In the ED, these kids will get bloodwork, including cultures, lumbar punctures, antibiotics, and admitted to the hospital   There is some nuance to this with guidelines from the American Academy of Pediatrics, however from the pre-hospital standpoint the idea is simple: these patients need ED eval https://publications.aap.org/pediatrics/article/148/2/e2021052228/179783/Evaluation-and-Management-of-Well-Appearing    Can they go to their pediatrician's office?  These

EMS A to Z: Febrile Seizure Show Notes: From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn   You're dispatched to a 14-month-old male with “seizure”. You arrive to find a no longer seizing, but somewhat post-ictal child laying in his parent's arms. Further history suggests that he had been sick with a fever, runny nose, and cough for the past 2 days and had an episode of “shaking” that lasted about 60 seconds prior to your arrival and spontaneously resolved. He's otherwise healthy. You take vitals and find him to be febrile, slightly tachycardic for age. As you continue your assessment, he wakes up more and becomes fussy, fighting you off, and clinging to his parent.     What likely happened? What should you do?  Sounds like a possible febrile seizure with rapid return to baseline Any ill-child, particularly who isn't at neuro baseline should get a BGL checked   What about medications? Antipyretics? Benzos?  Children who are seizing upon arrival, or have a 2ndseizure in your care should receive an age / weight appropriate dose of midazolam, per the AGs  Antipyretics (like acetaminophen or ibuprofen) can be administered; but evidence that they prevent seizure reoccurrence is sparse A single study from Japan, in 2018, did demonstrate a decrease in recurrent seizure with acetaminophen use to treat fever Murata S, Okasora K, Tanabe T, Ogino M, Yamazaki S, Oba C, Syabana K, Nomura S, Shirasu A, Inoue K, Kashiwagi M, Tamai H. Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode. Pediatrics. 2018 Nov;142(5):e20181009. doi: 10.1542/peds.2018-1009. Epub 2018 Oct 8. PMID: 30297499.   Can parents keep these kids at home?  It's not unreasonable for a child with a likely viral illness, single, resolved, simple febrile seizure to stay at home with supportive care and close follow up Concerned parent? Poor access to EMS / medical care? Anything not “simple” about the case? Transport. 

EMS A to Z: Pediatric Respiratory Illness Show Notes: From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn Introduction  I've worked a couple of pediatric ED shifts recently and had a feeling of dejavu with every new patient presentation... 14-month-old with congestion, cough, increased work of breathing, and fever. Fortunately, most of my patients were doing well overall, despite their illness, but that's not always the case and little kids with difficulty breathing can be scary to care for!   Let's break down the assessment of these kiddos, review some relevant differential diagnosis considerations, and consider how to treat them in the prehospital setting.  Assessment Sick vs. not sick Pediatric Assessment Triangle  Mental status: normal, decreased activity, lethargy Work of breathing: mild, resp distress, resp failure Circulation: color, capillary refill Breath sounds / Chest exam Upper airway sounds Lower airway sounds Retractions Nasal flaring  Tachypnea / bradypnea  Grunting  Differential Considerations Bronchiolitis Occurs typically fall / winter -> spring; October – April Children < 2 y/o  Symptoms: cough, congestion, fever, increased work of breathing, “wheezing”, tachypnea, poor feeding, dehydration  Treatment: suction, suction, suction, oxygen if hypoxic, occasionally high-flow or CPAP if severe, IV fluids if dehydrated / not tolerating PO   Things like steroids, albuterol, etc. Do not work Antibiotics are not necessary Croup Occurs typically fall / winter Children 6 mo to 3 years, but can be seen up to age 5 Symptoms: barky cough, fever, congestion, may have stridor  Sore throat, drooling, and difficulty swallowing is not typical of croup  Severity (Westley Croup Score): level of consciousness, cyanosis, air entry, retractions, stridor Treatment: Nebulized epinephrine, steroids  Cool / cold air may help Pneumonia Can occur in healthy children as well as some at increased risk: chronic lung disease, cystic fibrosis, immune compromise  Symptoms: fever, cough, +/- increased work of breathing, retractions, asymmetric coarse breath sounds Can look very similar to viral illness  Reactive Airway Disease / Asthma  Asthma not typically diagnosed until > 2 years of age, but some children will have evidence of reactive airway disease / wheezing prior to that age Asthma presents with wheezing, increased work of breathing  If respiratory rate is slowing, mental status is declining, this is indicative of respiratory failure Treatment: albuterol, ipratropium, steroid, magnesium, IM epi  Other Foreign body, epiglottitis, etc.  What about the sick kids in respiratory failure?  Support oxygenation and ventilation with BVM and supplemental O2 IV access may be obtained for fluid bolus if evidence of poor circulation (severe tachycardia, poor capillary refill, etc.)    Music: Brit Pop, Scott Holmes Music   

EMS A to Z: TXA Show Notes: From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn   What is TXA? TXA is the abbreviation for tranexamic acid; a lysine derivative medication which acts to displace plasminogen from fibrin and inhibit fibrinolysis In plain language, this means that it prevents the breakdown of blood clots that the body has already formed How is TXA administered?   The standard dose is 1g over 10 minutes as slow IV push or in 100mL of saline Faster administration reportedly may cause hypotension (which is bad for our already hypotensive trauma patients) Potential Indications:   Traumatic injury with hypotension or shock index > 1 (HR / BP) within 3 hours of injury Relevant trials:  MATTERS CRASH2 STAAMP Postpartum hemorrhage WOMAN trial TBI CRASH3 Why is this relevant? TXA was recently added to the scope of practice for paramedics in Arizona, so you may see this added to your guidelines / protocols and drug box    

EMS A to Z: Tachydysrhythmias Show Notes: From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn Patients with tachydysrhythmias may present in several ways:  Palpitations Chest pain Dyspnea Lightheadedness / dizziness Altered mental status Syncope Weakness / fatigue Nausea  How do we assess / evaluate these patients?  What are the patients characteristics and history? Is this a healthy 24-year-old or a medically comorbid 70-year-old? We can think about prior arrhythmias, coronary artery disease, renal disease (electrolyte abnormalities!), medications (digoxin!) Is this patient “stable” or “unstable”? Patient appearance (altered, pale, diaphoretic) Vital signs (HR, BP, RR, SpO2) ECG findings Rate Wide / narrow complexes Rhythm – regular / irregular  For the assessment, focus on evidence of cardiac / end organ dysfunction from hypoperfusion as a result of the arrhythmia!    What is a strategy for assessing the ECG in these patients?  Rate  Rhythm regularity  Complex width  What specific rhythms can we see and how can we distinguish them? Regular rhythm with narrow complexes: Sinus tachycardia SVT Atrial flutter with RVR Irregular rhythm with narrow complexes: Atrial fibrillation with RVR Wide complex tachycardia: Ventricular tachycardia Polymorphic ventricular tachycardia (torsades) What therapies are available?  Treat the underlying cause, if known Example: a patient with obvious sepsis and sinus tachycardia or a-fib with RVR will likely benefit from treatment of the sepsis: IV fluid bolus, etc. Example: a patient with v-tach / torsades and renal failure would benefit from magnesium and calcium with concern for hyperkalemia Medications: consider adenosine (first line for SVT), calcium channel blockers (diltiazem, first line for atrial fibrillation with RVR), amiodarone(not typically first line) Cardioversion: Synchronized at 120J then 200J if unsuccessful initially - if the patient is unstable! What about patients with pacemakers?  Pacemakers may malfunction and you may need to cardiovert patients with pacemakers in that scenario Remember to place the external pads 10cm away from the pacemaker battery box as palpated, usually in the left upper chest wall   Credits: Music: Scott Holmes Music Sound effect: zapsplat.com

EMS A to Z: Bradydysrhythmias Show Notes: From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn   How may these patients present? (Hint: Vaguely) Palpitations Chest pain Dyspnea Lightheadedness / dizziness Altered mental status Syncope Weakness / fatigue Nausea  How should we assess these patients?  Patient characteristics/history Patient appearance Mental status General appearance (pale, diaphoretic, cyanotic) Vital signs ECG Rate Rhythm / regularity QRS complex  What are potential causes of bradycardia?   Coronary artery disease / MI Ischemia can affect the AV node, electrical conduction system causing bradycardia Medication effects Calcium channel blockers, beta-blockers Electrolytes Hyperkalemia  Types of bradycardia:  Sinus bradycardia AV block Junctional / ventricular rhythms How should we treat these patients?  Unstable patients: Transcutaneous pacing Pad placement: anterior-posterior if able Starting joules: can start low and titrate up to capture Target rate: 70 - 80 Electrical capture can be seen on the ECG monitor with pacing spikes followed by wide complexes Mechanical capture occurs with electrical capture + palpable and perfusing pulse Medications such as midazolam can be used for sedation if patient's BP improves and will tolerate Stable patients: Truly stable patients may just require monitoring and transport, however if having soft pressures, but not truly unstable, can trial meds: Atropine 5mg IV/IO trial  Dopamine 2-10 mcg/kg/min titrating to HR / SBP    Credits: Music: Scott Holmes Music Sound effect: zapsplat.com

EMS A to Z: Journal Club – Intranasal Midazolam for Pediatric Seizures Show Notes: From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn   Pediatric Seizures: According to the American Academy of Pediatrics, epilepsy affects up to 1% of children. It's location dependent, but pediatric EMS calls can make up about 13% of our calls, with 5 – 8 % of those being for seizures.  https://www.acep.org/how-we-serve/sections/quality-improvement--patient-safety/newsletters/february-2016/pediatric-seizure-management-in-the-out-of-hospital-environment/ Recognizing and rapidly treating pediatric seizures or status epilepticus can decrease the morbidity associated with this disease process. What are the best medication and route to treat pediatric seizure?   In our system and administrative guidelines, we are currently using IM midazolam as our first line medication. This decision was informed largely by the RAMPART What are the other therapeutic options out there?  IV, IM, IN, buccal midazolam IV or PR diazepam IV lorazepam What is the new study we're discussing today?  Whitfield D, Bosson N, Kaji AH, Gausche-Hill M. The Effectiveness of Intranasal Midazolam for the Treatment of Prehospital Pediatric Seizures: A Non-inferiority Study. Prehosp Emerg Care. 2021 Mar 29:1-9. doi: 10.1080/10903127.2021.1897197. Epub ahead of print. PMID: 33656973. Study details: This was a retrospective study looking at IN vs IM/IV midazolam and whether or not redosing of benzodiazepine was required in the prehospital setting. >2,000 patients with a median age of 6 years were evaluated in the study. 25% vs 14% of patients receiving IN vs IV/IM/IO midazolam required re-dosing. While it is tempting to say that IN midazolam just isn't as effective for seizure control as the other routes, we must consider that the dose used was only 0.1mg/kg for all routes, whereas in other studies evaluating IN midazolam, a 0.2mg/kg dose was used. Perhaps the dose was just too small. Additionally, the outcome measured wasn't a true patient centered outcome and we do not have follow up data on the patients' hospital courses, etc.

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. In this severely distressed patient, you also prepare to administer magnesium.   En route, she starts to improve slightly – or so you thought – as her respiratory rate had slowed, and her ETCO2 went up from the 20 it was initially to almost 40 now. But you look more closely, and you see that her mental status is declining and she's becoming less responsive now.   What other things are in your toolbox for severe asthma exacerbations? Is there another possible diagnosis to consider?  Other items to consider:  Epi CPAP Could this be anaphylaxis?   You administer IM epi at 0.01mg/kg and place the patient on CPAP with in-line nebs ongoing. She starts to improve, and her mental status returns to normal. The ED is super impressed with your treatment and your aggressive interventions helped save the patient from an intubation!   Remember, in critical asthma patients, the goal is to dilate the bronchioles as much as possible – while albuterol / ipratropium are the most commonly used and when nebulized have direct access to the pulmonary tissues, other therapies like magnesium and epi can also provide some bronchodilation and help in critical patients. We often administer steroids in the prehospital setting / ED, but their effect can take a few hours to set in, so while important, they won't act as quickly as our other therapies.     Case 3)  Dispatch: 30M involved in MCC. You arrive on scene to find a motorcycle on it's side after hitting the side of a truck trying to beat a red light turning left. The driver of the truck is ambulating around, but the motorcyclist is sitting on the ground clutching the right side of his chest. Fortunately, he was wearing a helmet and full protective gear. On your assessment, you note an intact airway, bilateral upper extremity pulses, but severely diminished breath sounds on the right. He is speaking in short sentences and complains only of the chest pain. While you're doing your secondary survey, getting him out of the protective gear, checking c-spine, etc. He abruptly loses consciousness.   What is your most likely differential diagnosis, and some others to consider?  Pneumothorax Hemothorax Pulmonary contusion Cardiac contusion Hemorrhagic shock  The patient has weak pulses, agonal breathing. You quickly needle decompress his right chest with a rush of air. Gradually his pulses become less thready, and his breathing improves. You expertly toss in bilateral 18-gauge IVs and transport him to the trauma center, where he is ultimately treated for his right sided pneumothorax with a chest tube. He has a few rib fractures, bumps and bruises, but recovers well, thanks to your quick recognition and treatment of his tension pneumothorax!   Remember, tension pneumothoraxes are fatal unless treated! The increased intrathoracic pressure essentially prevents blood return to the heart and prevents it from pumping. What's the difference between a simple and tension pneumothorax?  Hypotension Tracheal deviation JVD Cardiac arrest   

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  

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.   

EMS A to Z: Stroke Screening Scores Show Notes: From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn Follow your Stroke Administrative Guideline! If a stroke is suspected, first perform a Cincinnati Prehospital Screening Scale: If positive perform a VAN. VAN positive Greater than 4 hours of symptom onset: transport to Comprehensive Stroke Center (Banner UMC or TMC). Within 4 hours of symptom onset: transport to nearest Stroke Center (patient may still be tPA candidate). VAN negative Transport to the nearest Stroke Center. See this reference from CoreEM for performing a VAN screen. Don't forget to consider and evaluate for stroke mimics (like hypoglycemia).  

EMS A to Z: Narcan in Cardiac Arrest Show Notes: From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn Narcan is a competitive opiate receptor antagonist, meaning that it competes with opiate drugs (fentanyl, morphine, heroin) to bind to those receptors and essentially kicks them off. Narcan is indicated for respiratory depression thought to be caused by an opiate. Narcan doesn't help in cardiac arrest, because the problem – or cause of the arrest – is usually hypoxia, which requires ventilation to correct. The most important aspects of cardiac arrest care due to an opiate overdose are: good ventilations, good CPR, shocking shockable rhythms, and administering epinephrine early in non-shockable rhythms.

EMS A to Z: Introduction Show Notes: From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn Hello and welcome to EMS A to Z! This is a weekly podcast hosted by Dr. Rachel Munn, featuring Dr. Josh Gaither, the medical director of Tucson Fire, as well as Dr. Amber Rice, the medical director of Northwest Fire here in Tucson, AZ. Each week we'll release a 5 to 10 minute episode on a topic ranging from cardiac arrest to refusal of care. Our goal is to provide free, accessible, high yield education on common and potentially challenging cases encountered in the field. We'll feature guests from our local agencies to provide some boots on the ground perspective, as well as discuss interesting cases. Feel free to shoot us an email with questions that may arise from the episodes or with suggestions for topics you'd like to hear about (rmunn@email.arizona.edu)!   *Disclaimer – the opinions, recommendations, and guidelines discussed in this podcast belong to the individual medical directors and the University EMS Administrative Guidelines. They should not replace or substitute for following your own agency protocols and guidelines.