ems llsa review 2018€¦ · • mechanism a/w most unstable spinal injury: fall > 20 feet (10%...

EMS LLSA Review2018

Jeff Jarvis, MD, EMT-P, FAEMS @DrJeffJarvis

Taylor Ratcliff, MD, EMT-P, FAEMS @DrRatEMTP

“We make eating your

veggies less painful”

#TxNAEMSP19

Safety and Appropriateness of Tourniquets in 105 Civilians

Scerbo MH, Mumm JP, Gates K et al. Safety and

Appropriateness of Tourniquets in 105 Civilians. Prehosp

Emerg Care. 2016; 20: 712-722.

JLJ

Scerbo MH, Mumm JP, Gates K et al. Safety and Appropriateness of Tourniquets

in 105 Civilians. Prehosp Emerg Care. 2016; 20: 712-722.\\

• Trauma leading cause of death < 46• Majority of preventable deaths from hemorrhage• >1/3 from extremity bleeds• No clear civilian guidelines on TQ use (at time)



What is the most common cause of preventable deaths in civilian trauma patients?

A) Aortic tearB) Chest injuriesC) External hemorrhageD) Head injury



• Single center chart review (EMS & Trauma Registry)• Oct ‘08 to May ‘13• All patients with EMS or ED TQ applied• Categorized as ”Indicated” or “Not Indicated”• Described patients• Complications: Potential and Adjudicated



105 Total Patients

• Indicated

• 94 (90%)

• 48% Removed in ED

• Penetrating > Blunt

• Not Indicated

• 11 (10%)

• 100% removed in ED

• Blunt > Penetrating

• No complications due to TQ use

• Radial a. most common source (12%)

• Brachial and Femoral a. (10%)



In a tactical situation, a 35-year-old man sustains a through-and-through gunshot wound to his thigh. Both wounds are bleeding and his thigh is swelling. VS are 90/60, P120, R 24. What is the most appropriate next step?

A. Apply a hemostatic dressingB. Apply a tourniquetC. Evacuate to cold zoneD. IV fluid bolus

Clemency BM, Bart JA, Malhotra, Klun, Campanella,

Lindstrom. Prehospital Emergency Care 2016; 20:266-272

Patients Immobilized with a Long Spine Board Rarely Have Unstable Thoracolumbar Injuries.

TRat

Clemency BM, Bart JA, Malhotra, Klun, Campanella, Lindstrom. Prehospital

Emergency Care 2016; 20:266-272

• Goal: To determine the prevalence of unstable thoracolumbar spine injuries among patients receiving prehospital spine immobilization.

• 4 year retrospective study from Western New York.• Data reviewed for imaging at receiving ED and presence of

unstable TCL injury• Defined as “unstable” if operative repair was performed.• 5423/5593 transports linked to ED record.• Mechanism in 97.4% of patients was blunt injury.



• 4,475 (82.5%) of patients had imaging at the ED.

• Acute finding (fracture, dislocation, etc.) in 233 (4.3%).

• Surgical intervention needed in 29 patients (0.5%).

• Mechanism a/w most unstable spinal injury: fall > 20 feet

(10% who fell from this height needed surgical stabilization).

• Zero patients with ground level fall had unstable spinal injury.



According to Clemency et al., what mechanism of injury resulted in the highest frequency of unstable spinal injuries?

A) Fall greater than 20 feetB) Gunshot woundC) High speed vehicle crashD) Pedestrian struck by vehicle



A 76 year—old woman fell from a standing position at the nursing home. She suffered a forearm skin tear and a forehead contusion and laceration. Peripheral motor exam is grossly normal. Which of the following justifies an EMS decision to transport her without using a long spine board.

A) Being secured to a stretcher immobilizes the same as a spine boardB) Low incidence of unstable thoracolumbar injury after a same level fallC) Spine injury is not likely without loss of consciousnessD) There is no neurologic abnormality



Brown JB, Rosengart MR, Forsythe RM et al. Journal of

Trauma and Acute Care Surgery. 2016; 81: 93-100.

Not all prehospital time is equal.JLJ

• Goal: Assess association b/w time intervals & mortality in injured adults.

• Pennsylvania Trauma Registry EMS scene transports• Included all pts with total prehosp time (TPT) > 20m• Prolonged interval = interval => 50% TPT• Modeled in-hosp mortality ~ prolonged intervals

• Controlling for typical predictors of mortality

Brown JB, Rosengart MR, Forsythe RM et al. Journal of Trauma and Acute Care

Surgery. 2016; 81: 93-100.

164,471 patients

Only prolonged scene time a/w mortality in patients with:HypotensionPenetrating injuryFlail chest.

aOR 1.21 (1.02 - 1.44), p < .03


Surgery. 2016; 81: 93-100.

In trauma patients with a total prehospital time > 20 minutes, prolongation of which prehospital time interval leads to increased mortality?

A) Response timeB) Scene timeC) Total timeD) Transport time


Surgery. 2016; 81: 93-100.

In the study by Brown et al., prolonged relative scene time was a/w increased mortality, even after adjusting for intubation and extrication, in patients with which of the following conditions?

A) GCS < 14B) Pelvic fractureC) Penetrating traumaD) Pneumothorax


Surgery. 2016; 81: 93-100.

Improving early identification of the high-risk elderly trauma patient by emergency medical services.

Newgard CD, Holmes JF, Haukoos JS, Bulger EM, et al. International Journal

of Care of the Injured 47 (2016) 19-25.

TRat

• Goal: To identify high-risk injured older adults according to prognosis associated with different injury types.

• Identify alternate field triage guidelines to improve detection of these patients.

• Adults > 65yo transported to an acute care facility.

• Sample patients from rural and urban areas transported to all levels of hospitals.

• Abbreviated injury scale used to create 5 categories of “serious injury” (i.e. ISS > 16, TBI, chest injury, etc.)



• 33298 patients transported by EMS:

• 80% injured by falls• 1507 (4.5%) ISS > 16; • 1599 (4.8%) w/TBI; • 1135 (3.4%) chest injury; • 521 (1.6%) A/P injury; • 9732 (29.2%) serious extremity injury.



• Take away…

• Addition of injury type predictors, GCS and V/S parameters to predict “high risk” patients may result in improved sensitivity and decreased specificity of injury.

• Decreased specificity can result in over-triage as well as significantly increased costs associated with trauma care.

• The leading factor determining where these patients are transported is family preference.





According to Newgard et al., which of the following results from the use of alternative trauma triage guidelines for the elderly?

A) Decrease in over-triage of the elderlyB) Decreased sensitivity for injury identificationC) Decreased specificity for injury identification.D) Increase in under-triage of the elderly.



According to Newgard et al., what is the most common determinant of hospital destination for elderly trauma patients?

A) Hospital proximityB) On-line medical directionC) Patient/Family choiceD) Trauma destination protocol

An observational study of shift length, crew familiarity, and occupational injury and illness in EMS workers

Weaver MD, Patterson PD, Fabio A, Moore CG, Freiberg MS, Songer TJ. Occup

Environ Med. 2015; 72: 798-804.

JLJ

• EMS is at higher risk of injury than others• Goal: association b/w shift length and injury/illness• Retrospective, multi-center study• 14 agencies, 37 stations – administrative data• OSHA reporting

• Model: OSHA injury/illness ~ shift length


Environ Med. 2015; 72: 798-804.

950 OSHA reports from 677 employees


Environ Med. 2015; 72: 798-804.

Location of

Injury

Rate

Scene 454 (51.7%)

Ambulance

during

transport

256 (29.2%)

Receiving

facility

135 (15.4%)

EMS Station 33 (3.8%)

Total 878 (100%)

Nature of

Injury

Rate

Sprain/Strain 558 (79.2%)

Contusions &/or

Abrasions

84 (11.9%)

Concussions 21 (3.0%)

Needle Stick 15 (2.1%)

Lifting/Moving 345 (48.9%)

Neck/back 321 (45.5%)



Where does an EMS provider have the highest likelihood of experiencing an injury while on the job?

A) During transportB) In headquartersC) On sceneD) Receiving hospital

Increasing shift length had greatest a/winjury/illness

Newgard CD, Holmes JF, Haukoos JS,

Bulger EM, et al. International Journal




What factor in shift work scheduling has the greatest association with occupational injuries in EMS providers?

A) Consecutive shiftsB) Hours of recoveryC) Overnight shiftsD) Shift length

High-flow nasal cannula (HFNC) support in inter-hospital transport of critically ill children.

Schlapbach LJ, Schaefer J, Brady AM, Mayfield S, Schibler A, Intensive Care

Medicine 2014; 40: 592-599.

TRat

• Goal: Does the implementation of a high flow nasal cannula capability in pre-hospital pediatric transfer reduce intubation rates.

• Retrospective study of children < 2yo transported by Mater Children’s transport team in Queensland, Australia.

• Evaluation of decrease in need for invasive ventilation (intubation) after implementation of high flow nasal cannula (HFNC) treatment capability for respiratory distress.

• 793 children (331 pre-HFNC, 462 post-HFNC) retrieved with mean duration of 1.4 hour (205km) transport.


Medicine 2014; 40: 592-599.

• Pre-HFNC 13% of patients were intubated and 7% on NIV.

• Post-HFNC 7 % of patients were intubated and 33% transported on NIV>

HFNC associated with

“decreased invasive

airway rate”

Schlapbach LJ, Schaefer J, Brady AM,

Mayfield S, Schibler A, Intensive Care

Medicine 2014; 40: 592-599.

• Bottom line:

• Implementing HFNC in transport of critically ill infants decreases the invasive ventilation rate, i.e. intubation.

• Compared to intubation (IV), there is a lower rate of intrinsic risk including pneumothorax, dislodgement and obstruction of the ETT including the requirement for less sedation, neuromuscular paralysis and the chance for ventilator induced lung injury.


Medicine 2014; 40: 592-599.

During an interfacility transport, the pediatric transport team places an 11 month-old child with bronchiolitis and respiratory distress on 2 L/kg/min of oxygen by nasal cannula. What should the team anticipate during transport as a result of this therapy as compared to treatment with intubation?

a) Cardiac arrhythmiasb) Less sedation requirementc) Pneumothorax developmentd) Worsening hypoxia

A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke

Berkhemer OA, Fransen PS, Beumer D et al. N Engl J Med. 2015; 372: 11-20.

“Mr. Clean”

JLJ

• tPA available only < 4.5 hrs• “Issues”

• Intraarterial treatment may be option for LVO• Prospective, randomized controlled trial• 16 centers in Netherlands


Inclusion:Adults with proximal occlusion of anterior circulation < 6 hours of onsetNIH > 2Lesion confirmed with imagingTx initiated within 6 hours


• Intervention: intraarterial therapy (thrombolysis, retrieval, or both.. dealer’s choice) + usual care

• Control: usual care

• Primary Outcome:

• Functional Independence (mRS at 90 days)


Outcome Intervention

(233)

Control

(267)

Adjusted OR

(95%CI)

mRS @ 90 days

(functional

independence)

3 [2, 5] 4 [3,5] 1.67

(1.21 – 2.30)

mRS 0 – 2 32.6% 19.1% 2.05

(1.36 – 3.09)

No occlusion on

repeat imaging @ 24

hrs

75.4% 32.9% 6.27

(4.03 – 9.74)


Results

Intra-arterial treatment within six hours of proximal intracranial arterial occlusion of the anterior circulation leads to a clinically significant increase in what outcome at three months?

A) All cause mortalityB) Functional independenceC) Recanalization scoreD) Serious adverse events

Variability in the treatment of prehospital hypoglycemia: a structured review of EMS protocols in the United States.

Rostykus P, Kennel J, Adair K, Fillinger M, et al. Prehospital Emergency

Care 2016; 20:524-530

TRat


Care 2016; 20:524-530

• Goal: To examine the treatment variability for pre-hospital hypoglycemia within EMS protocols in the United States.

• Protocols on www.emsprotocols.org and 50 largest populated states included.

• Comparison of glucose level for treatment an modality, i.e. D50W vs. D10 and adjustments for pediatric/neonatal dosing.

• 185 sets of protocols reviewed.

http://www.emsprotocols.org/


Care 2016; 20:524-530

Findings:

• D50W prevails as most common modality

• Highly variable guidance for “hypoglycemia” (30-120mg/dL)

• Pediatric dosing most commonly 0.5mg/kg and few had neonatal dosing.

Rostykus P, Kennel J, Adair K, Fillinger M, et al. Prehospital Emergency Care

2016; 20:524-530

Takeaways:

• Significant variation in protocols related to dextrose administration.

• Primary advantage of D10 over D50 is it can be used for all age groups

According to Rostykus et al., what is the primary advantage to the administration of 10% dextrose over 50% dextrose for the prehospital treatment of hypoglycemia?

A) Can be given IO or IVB) Can be used for all age groupsC) Easier to titrate to effectD) Faster resolution of hypoglycemia


2016; 20:524-530

• Still marked trend toward D50W administration despite risk for supraphysiologic glucose levels, infusion of hypertonic solutions at risk for tissue necrosis (“most common adverse event”) and challenges for pediatric administration.

• NASEMSO model EMS guidelines call for a blood glucose treatment level of < 60mg/dL.


2016; 20:524-530

What is the most common adverse effect aswociate with adminisyration of D50 compared to lower concentrations of dextrose?

A) Cerebral edemaB) Dosing errorsC) Osmotic diuresisD) Tissue necrosis


2016; 20:524-530

Survival rates in out-of-hospital cardiac arrest patients transported without prehospital return of spontaneous circulation: an observational cohort study

Drennan IR, Lin S, Sidalak DE, Morrison LJ. Resuscitation. 2014; 85: 1488-1493.

JLJ

• Medical Futility at 1% odds of survival• Universal ToR Guideline (2009)

• Specificity 100% (transporting survivors)• PPV 100% (death)• Reduce transport rate to 37% w/o missing survivors• All of following:

• Not witnessed by EMS• No ROSC on scene (NPV 99.6% survival to hospital dc)• No AED delivered

Goal: Determine survival rates w/o ROSC by: ToR vs Transport recommendation of Universal Rule


Inclusion: All adult patients w/ cardiac etiology OOHCA transported to hospital without prehospital ROSC

Analysis:Compared survival rates of those meeting and not meeting transport criteria of Universal rule.


Lack of

ROSC, by

itself, is

not a

sufficient

ToR

criteria

Drennan IR, Lin S, Sidalak DE, Morrison LJ. Resuscitation. 2014; 85: 1488-1493

A BLS crew arrives to find a 67 year-old man in cardiac arrest. The AED advises no shock. After several rounds of CPR, there is no pulse noted. According to the Universal Termination of Resuscitation Guidelines, what is the most appropriate next step in management?

A) Continue resuscitation for 20 minutesB) Continue until ALS arrivesC) Terminate resuscitationD) Transport to hospital

EMS responds to a patient in cardiac arrest whose arrest was witnessed by bystanders. His initial rhythm is VF and a total of 3 shocks are delivered. His rhythm deteriorates to asystole and EMS is unable to obtain ROSC after 35 mninutes on scene? According to the Universal Termination of Resusciation Guidelines, what should EMS do next?

A) Ascertain wishes of the next of kinB) Continue resuscitation and transportC) Continue resuscitation for 25 more minutes on sceneD) Discontinue resuscitation now

Police officers can safely and effectively administer intranasal naloxone.

Fisher R, O’Donnell D, Ray B, Rusyniak D. Prehospital Emergency Care, Nov/Dec

2016:20;675-680.

TRat

• Goal: To describe the indications and outcomes of LE naloxone administration including the incidence of cardiac arrest, deterioration and voluntary transport to the hospital.

• 900 officers in specific area trained on administration of 2mL vial of naloxone with MAD device.

• 126 naloxone administrations recorded on department capture form and corresponding ePCR


2016:20;675-680.

• Top indications were unconscious/unresponsive, slow breathing, turning blue and not breathing.

• 65.1% regained consciousness, 56.3% had improved breathing, 55.1% got 2nd dose by EMS

• 96.8% of patients agreed to be transported voluntarily to the hospital

Fisher R, O’Donnell D, Ray B, Rusyniak D.

Prehospital Emergency Care, Nov/Dec 2016:20;675-

680.

• Takeaways:

• Narcotic overdose is currently the leading cause of death in ages 25-64. Naloxone administration is a likely option to reduce the likelihood of death.

• The most common outcome of LE administration of naloxone is the patient regaining consciousness.

• EMS re-dosing of naloxone is likely and a presumed cause may be due to LE administered naloxone not having time for full effect yet.

• Cases where nothing happened, either patient was deceased, non-opiate overdose or required additional dose of naloxone.

According to Fisher et al., what is the most common patient response to law enforcement administration of naloxone?

A) Combative behaviorB) Profound vomitingC) Regained consciousnessD) Resumed breathing


2016:20;675-680.

What intervention would most likely improve the outcome from the leading cause of death in persons between 25 & 64 in the US?

A) Bystander CPRB) DefibrillationC) Hemorrhage controlD) Naloxone administration


2016:20;675-680.

Police administer IN naloxone to an unconscious man suspected of opioid overdose. EMS arrive 2 minutes later and find no change in his condition. What is the most likely explanation?

A) Improper administration by policeB) Naloxone effect has not yet occurredC) Presence of a concomitant intoxicantD) Subtherapeutic naloxone dose


2016:20;675-680.

Trial of Continuous or Interrupted Chest Compressions during CPR

Nichol G, Leroux B, Wang H et al. N Engl J Med. 2015

JLJ

• Decreased blood flow during CPR is a/wdecreased survival.

• Standard CPR has frequent pauses for ventilations.

• Continuous compression CPR should result in more blood flow and higher survival

• Goal: compare two approaches to CPR


• ROC multi-centered prospective trial• OOHCA in adults• Cluster randomized, cross-over• Exclusion: trauma, asphyxiation, bleeding• Intervention: Continuous vs Interrupted

Compressions• Outcome: Survival to hospital discharge



Cont.

(12,653)

Int.

(11,058)

Diff/p

Survival to

discharge

9.0% 9.7% -0.7

(-1.5 to 0.1)

p = .07

mRS 0-3

survival

7.0% 7.7% -.6

(-1.4 to 0.1)

p = .09

Compression

fraction

0.83 0.77 p < .001

# pause > 2

sec

3.8 +-

2.6

7.0 +- 4.3 p < .001

In the study by Nichol et al., what was the impact of continuous chest compressions on OOHCA as compared to interrupted chstcompressions?

A) Improved survival to dischargeB) No difference in survival to dischargeC) Increased hospital admission ratesD) No difference in hospital admission rates


2016:20;675-680.

In the ROC trial of continuous vs interrupted compressions, which of the following is an important limitation?

A) Both groups received positive pressure ventilationsB) Group cluster randomization method was usedC) Higher intubation rate in the interrupted groupD) Small difference in chest compression fraction between

groups


2016:20;675-680.

Prekker ME, Delgado F, Shin J et al. Ann Emerg Med. 2016

Pediatric Intubation by Paramedics in a Large Emergency Medical Services System: Process, Challenges, and Outcomes

JLJ


• Retrospective chart review, King County, WA• 2006 – 2012• Children < 13 with attempted ETI• 299 cases in 6.3 years ( 1 ETI n 2,198 responses)• 44% for cardiac arrest• FPS 66%, Overall Success 97%


Challenges

Bodily fluids

33%

Positioning 6%

Facial/spinal trauma

5%

Obesity <1%

Complications

Mainstream bronchus

intubation

16%

Aspiration PNA 15%

Recognized tube

dislodgement

5%

Significant

bradycardia

4%

According to the study by Prekker et al., what is the most frequent challenge faced by paramedics attempted pediatric intubation?

A) Body fluidsB) ObesityC) Patient positioningD) Suspected spinal trauma


2016:20;675-680.

According to the study by Prekker et al., what was the most frequent intubation complication among pediatric intubations by paramedics?

A) Decreased heart rateB) Endotracheal tube dislodgementC) Mainstem bronchus intubationD) Respiratory tract injury


2016:20;675-680.

Jeff Jarvis@DrJeffJarvis

Taylor Ratcliff@DrRatEMTP

ems llsa review 2018€¦ · • mechanism a/w most unstable spinal injury: fall > 20 feet (10%...

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