Comments (1)

By Bryan Fleck NREMT-P (Editor), August 16, 2010 1:15 pm

Dialysis centers and renal patients across the county activate EMS for a variety of concerning signs and symptoms either before, during or after dialyzing. The most common cases involve chest pain and dyspnea, however the etiology of these symptoms often involves hyperkalemia. Elevated levels of K+ can cause lethal arrhythmias and the management of these patients occasionally may require going above and beyond ACLS treatment of chest pain.

With any patient who presents with chest pain, managing airway, breathing, and circulation are obviously paramount and morphine/fentanyl, oxygen, nitroglycerin, aspirin (M.O.N.A), and early 12 lead ECGs are the first line treatment indications. If a 12 lead shows tall and peaked T waves, what does this mean for us in the back of an ambulance? This abnormal ECG indicates hyperkalemia, a true medical emergency, and our goal is to enhance the cellular uptake of potassium while stabilizing the myocardial cell membrane. Emergent dialysis is the definitive treatment, but we can help the patient with a few medications carried on Marion County ambulances.

Sample Case: You are dispatched to a residence for chest pain. Upon arrival you find a 45 year old black male who just returned from a long weekend trip out of town. His past medical history includes: atherosclerosis, acute renal failure and requires dialysis 3 times a week. The patient states he missed his last dialysis appointment 3 days ago and now complains of substernal chest pain 8/10, radiating to both arms and neck. The onset was gradual and while he was at rest. This sounds like a classic cardiac case right? Upon further exam his vitals are 110/58, heart rate of 42, and a respiratory rate of 14. His 12 lead ECG shows sinus bradycardia with no ST segment elevation, however you note markedly peaked T waves that are taller than the QRS complex. He is lethargic and diaphoretic. After first line cardiac treatments, he shows no signs of improvement and his pain is not relieved by nitro. His vitals remain unchanged. What are the options here? We need to treat his heart rate, but atropine is not an option as it’s an anticholinergic and increases oxygen demand on the heart. Since he is complaining of chest pain, we would not want to possibly increase cardiac ischemia. Transcutaneous pacing could be an option, however, his blood pressure is fine and his GCS is 15.

It’s now time to get creative with what we have on hand to treat this patient until he can be dialyzed. Under the current Marion County protocols, we have 3 medications that can be useful in this case in addition to our frontline ACS drugs. These medications are standing orders for a dialysis patient with wide complex rhythms associated with hypotension or refractory v-fib, but this patient doesn’t meet that criteria and we don’t want him to meet this criteria! If we can prevent a lethal arrhythmia, lets give that a go. It’s time to get on the radio and request orders for 1 gram of calcium chloride (slow IVP, to help shift the K+ intracellularly and stabilize the myocardial cell membrane), 100 mEq of sodium bicarbonate IV (if lung sounds are clear), and 5 mg albuterol treatments for the duration of the transport (the bicarb and albuterol will help cellular uptake of K+). Please note: DO NOT push calcium and bicarb through the same line.

In summary, get a good complete history on every patient and use this to your advantage. If they are a dialysis patient, start thinking a few steps ahead and give them every advantage for a favorable outcome. Always know the alternative uses for the medications we carry. The alternate uses may not be in the protocols, but we can always call for orders. The complex hyperkalemic patient can go south very quickly, so anticipate, react, and use your head.

Please let me know about your hyperkalemia cases, your treatments, and the patient’s outcomes.

References:
Bledsoe, B. E. (2007) Essentials of Paramedic Care

Verive, M. J. (2010). Hyperkalemia: Treatment & Medication. eMedicine. Retrieved from http://emedicine.medscape.com/article/907543-treatment

Indianapolis Metropolitan Area EMS Protocols 2010 Version

Comments (2)

By Bryan Fleck NREMT-P (Editor), July 16, 2010 9:43 am

I would like to hear everyone’s thoughts, concerns and any other related comments on the consolidation issue.

Links:
Mayor Ballard’s Press Release 7/15/10

The article about the estimated cost savings, courtesy of WISH TV

The original news story from Wednesday, courtesy of WISH-TV

Stay positive about this change as it will reshape our industry for the better; however, never let politics, politicians, or the uncertainty of our shirt logos dictate our patient care in the field. We are professionals, and our behavior over the coming months and years will set an example for the next generation of prehospital providers. Strive for consistent and exceptional patient care everyday, and we will have more influence from the street level all the way to the top.

Comments (0)

By Bryan Fleck NREMT-P (Editor), July 12, 2010 5:38 pm

As we know, lack of fact leads to rumor and speculation. There are many rumors circulating among the Indianapolis EMS community about the future of our profession i.e. a third service, Wishard running all EMS, various fire departments not willing to consolidate their EMS divisions. Please weigh in on any facts that you may have on this highly important issue. We have a voice, and we need to use it.

Comments (0)

By Bryan Fleck NREMT-P (Editor), June 2, 2010 7:21 pm

This story is still developing; however, an EMS helicopter has crashed in Texas. Our sincere condolences go out to all family and friends involved. Here is the link to the story

Comments (0)

By Bryan Fleck NREMT-P (Editor), May 8, 2010 1:07 pm

See the flyer below about a free class offered during EMS week at Methodist:

MTH 12 Lead Class

Accurate EKG interpretation is paramount in the field of EMS. Register for this class and refresh key skills or learn new techniques.

Comments (0)

By Bryan Fleck NREMT-P (Editor), April 26, 2010 9:04 am

This brief Powerpoint presentation is a quick summary of the field activation component of the level one heart attack program at Methodist.

Click the following file to view:
Methodist Level One Heart Attack Program EMS Activation Statistics April 2010

I would like to thank Holly Cook R.N. for the information.

Comments (0)

By Bryan Fleck NREMT-P (Editor), April 14, 2010 9:43 am

Click here to read a story from WRTV about an Indiana University student’s suicide by inhalation of hydrogen sulfide. The student left a note on his dorm room door that simply read “H2S.” Click here to learn more about the chemical properties of hydrogen sulfide.

The incidence of this new method of suicide is increasing and poses a serious risk to first responders, EMS, and fire personnel. An alert was recently issued by the regional FBI office regarding this hazard.

As always, be aware of your surroundings and use caution on all your runs. Scene safety is not something that can be effectively taught by reading a book. Preceptors need to teach this skill to their students on the street, and senior medics must convey the subtleties of scene safety to those with less experience. Many clues that may reveal a potentially unsafe scene or patient can be observed before entering a situation. Do not rely on dispatch information as your only source of information when making a judgment call about a precarious scene. Don’t ignore a “gut” feeling. You get this feeling for a reason and although it may not be explained or justified, it is not worth tuning out.

I read an article recently about how firefighters are trained to find and activate the emergency button on their radio simply by touch and without looking at the radio. Practice this skill (obviously, without actually setting it off) and remember that you must press the button and hold it for 4 seconds for the signal to be transmitted to MECA. This may seem easy and not worth practicing, however; under dire circumstances you don’t want to take the time to fumble around and figure this out for the first time

Never take your safety for granted.

Please comment on this topic and let me know about your close calls so that others may learn from the experience.

Comments (1)

By Bryan Fleck NREMT-P (Editor), April 9, 2010 11:57 am

Dr. Miramonti asked me to post an abstract of this study that was published in the March 2010 issue of The Annals of Emergency Medicine. It is an interesting study that evaluates the importance of the golden hour of trauma. This is not an indication of a system wide priority change, or intended to adjust current trauma responses- it’s merely a discussion topic. Let me know what you think.

Study objective:
The first hour after the onset of out-of-hospital traumatic injury is referred to as the “golden hour,” yet the relationship between time and outcome remains unclear. We evaluate the association between emergency medical services (EMS) intervals and mortality among trauma patients with field-based physiologic abnormality.
Methods: This was a secondary analysis of an out-of-hospital, prospective cohort registry of adult (aged ????15 years) trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was inhospital mortality. We evaluated EMS intervals (activation, response, on-scene, transport, and total time) with logistic regression and 2-step instrumental variable models, adjusted for field-based confounders.

Results:
There were 3,656 trauma patients available for analysis, of whom 806 (22.0%) died. In multivariable analyses, there was no significant association between time and mortality for any EMS interval: activation (odds ratio [OR] 1.00; 95% confidence interval [CI] 0.95 to 1.05), response (OR 1.00; 95% CI 9.97 to 1.04), on-scene (OR 1.00; 95% CI 0.99 to 1.01), transport (OR 1.00; 95% CI 0.98 to 1.01), or total EMS time (OR 1.00; 95% CI 0.99 to 1.01). Subgroup and instrumental variable analyses did not qualitatively change these findings.

Conclusion: In this North American sample, there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.

Editor’s Capsule Summary:
What is already known on this topic
The “golden hour” concept in trauma is pervasive despite little evidence to support it.
What question this study addressed
Is there an association between various emergency medical services (EMS) intervals and inhospital mortality in seriously injured adults?
What this study adds to our knowledge
In 3,656 injured patients with substantial perturbations of vital signs or mental status, transported by 146 EMS agencies to 51 trauma centers across North America, no association was found among any EMS interval and mortality.
How this might change clinical practice
This study suggests that in our current out-of- hospital and emergency care system time may be less crucial than once thought. Routine lights-and-sirens transport for trauma patients, with its inherent risks, may not be warranted.

Abstract Reference:
Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort
Craig D. Newgard, Robert H. Schmicker, Jerris R. Hedges, John P. Trickett, Daniel P. Davis, Eileen M. Bulger, Tom P. Aufderheide, Joseph P. Minei, J. Steven Hata, K. Dean Gubler, Todd B. Brown, Jean-Denis Yelle, Berit Bardarson, Graham Nichol

Annals of emergency medicine 1 March 2010 (volume 55 issue 3 Pages 235-246.e4 DOI: 10.1016/j.annemergmed.2009.07.024)

Comments (2)

By Bryan Fleck NREMT-P (Editor), April 7, 2010 1:44 am

See the file below regarding Methodist’s new tiered trauma response

MTH Trauma Tiered Response

Comments (3)

By Bryan Fleck NREMT-P (Editor), March 30, 2010 1:15 pm

The following excerpts are courtesy of Wishard Education and Marion County Protocols:

Remember that CPAP is a second line treatment for respiratory distress from COPD and/or pulmonary edema after the patient has failed pharmacological management as evidenced by: persistent dyspnea/hypoxemia, secondary to to pulmonary edema and/or COPD, and history consistent with heart failure, volume overload, or COPD exacerbation.

Continuous positive airway pressure (CPAP) is a non-invasive method to provide respiratory support to certain patients. CPAP has been shown to rapidly improve vital signs, gas exchange, the work of breathing, decrease the sense of dyspnea, and decrease the need for endotracheal intubation in patients who suffer from shortness of breath from congestive heart failure (CHF) and acute pulmonary edema.

CPAP has been successfully demonstrated as an effective adjunct in the management of pulmonary edema secondary to CHF. CPAP allows time for administered medications to work.

Goals of therapy with CPAP:
Increase the amount of inspired oxygen
Decrease the work of breathing
Decrease the need for intubation
Decrease the length of hospital stay
Decrease the mortality rate

Marion County Protocol:

Indications: Age greater than or equal to 18 years old, has the ability to maintain and protect an open airway, Systolic BP at or above 90 mm HG, pulse oximetry <92% on 100% oxygen, plus at least two of the following; severe onset of dyspnea, respiratory rate > 25/minute, accessory muscle use, dyspnea at rest, rales or wheezes.

Contraindications: respiratory or cardiac arrest, agonal respirations, suspected or confirmed pneumothorax or penetrating chest trauma, inability to maintain a patent airway, any impediment to proper mask placement or seal (facial trauma, stroke, facial anomalies, epistaxis), tracheostomy, persistent nausea and vomiting/upper GI bleeding, inability to comply with the device due to severe anxiety or altered mental status.

Procedure: Assure patent airway, place patient on EKG monitor and pulse oximetry; capnography if available, explain procedure to patient. CPAP DOES NOT REPLACE PHARMACOLOGY- initiate medications first if applicable: if suspected pulmonary edema and SBP > 90 mm Hg administer three 0.4 mg doses of NTG SL and repeat three 0.4 mg doses every 3 minutes if SBP remains at or above 90 mm Hg and the patient remains dyspneic (*Remember to avoid the use of NTG in the setting of Viagra, Levitra, Cialis, or other ED drug use.)

If reactive airway disease is suspected, give albuterol 5 mg though the circuit every 10 minutes if patient remains dyspneic.

If the second round of pharmacological therapy fails to resolve the patient’s dyspnea, and they remain hypoxemic (oxygen saturation <92% on 100% oxygen) then CPAP may be initiated.

Use of CPAP device:
*Ensure adequate oxygen supply to device, if needed, set manufacturers recommended airflow
*Place mask and hold in place as patient adjusts to ventilatory support
*Encourage patient to breath deeply
*Secure mask, check for air leaks and if recommended by manufacturer, increase liter flow as needed
*Contact receiving facility as early as possible to allow RT to prepare their equipment
*Monitor and document patient's vitals and pulse oximetry
*Do not use chemical restraint protocols for patients on CPAP
*If patient deteriorates, remove device and consider BVM ventilations or endotracheal intubation

How has CPAP changed your management and outcome of CHF and/or acute pulmonary edema patients on the street? What problems have you encountered? What advice would you offer those who have not used CPAP? Do you have any positive or negative feedback about this protocol change?