Search

Point-of-care laboratory testing (POCT) is associated with a reduced time to testing results and critical decision making within emergency departments. POCT is an essential clinical assessment tool because laboratory data are used to support timely critical decisions regarding acute medical conditions onditions ; however, there is currently limited research to support the use of POCT in the critical care transport environment. Few studies have evaluated the changes in patient care that occur after POCT during critical care transport. This study aims to contribute to the limited data available correlating prehospital POCT and changes in patient care.After institutional review board approval, a retrospective review of patients transported by a critical care transport team between October 1, 2013 and September 31, 2015 was completed. During the study period, 11,454 patients were transported, and 632 (5.51%) received POCT testing.Patient care changes were noted in 244 (38.6%) patient tests. The most frequent patient care alterations were ventilator settings (10.9%), electrolyte changes (10.4%), and unit bed upgrades (7.1%). POCT most frequently altered care for patients with post-cardiac arrest syndrome (64.7%), sepsis/septic shock (61.8%), diabetic ketoacidosis (54.5%), or pneumonia (49.3%).Patient care alterations occurred in 38.6% of patients undergoing POCT. Patient care was most frequently changed when patients were diagnosed with post-arrest, sepsis/septic shock, diabetic ketoacidosis, and pneumonia.

Objective Rapid sequence intubation (RSI) is often required in managing critically ill patients in the prehospital setting. Although etomidate is a commonly used induction agent for RSI, ketamine has gained new interest in prehospital management with reported neutral hemodynamic effects. Limited data exist to support ketamine as an alternative to etomidate, particularly in the prehospital setting. The purpose of this study was to evaluate hemodynamic changes after the administration of ketamine versus etomidate in prehospital RSI. Methods This retrospective study evaluated adult patients undergoing prehospital RSI over 13 months within a regional emergency transport medicine service. Hypotension was defined as a 20% decrease in systolic blood pressure (SBP) within 15 minutes of receiving ketamine or etomidate. Hemodynamic data were collected 15 minutes before and 15 minutes after administration or until additional sedative medications were given. Data were analyzed using SPSS software (Version 21; IBM Corp, Armonk, NY), with P Results One hundred thirteen patients met the inclusion criteria (ketamine, n = 33; etomidate, n = 80), with the primary reasons for intubation being respiratory failure and trauma. There was no difference between the incidence of patients who experienced a 20% decrease in SBP (16% etomidate vs. 18% ketamine, P = .79). There were no significant differences in SBP pre- to postadministration between ketamine and etomidate. Conclusion No hemodynamic differences occurred between patients who received ketamine versus etomidate for prehospital RSI. Neither drug was associated with an increased need for additional sedatives, and neither drug was associated with an increased first-pass intubation success rate. Larger, prospective, powered studies are required to identify patients who may benefit from either ketamine or etomidate.

Evidence-based medicine will continually change the paradigm in which emergency medicine is practiced. Fifteen years ago tourniquets were a last resort and often considered a guaranteed way to lose a limb; today they are a gold standard in hemorrhage control. Believing in, and having practiced, medicine we later learn to be false doesn't make someone a bad provider, nor does it make them wrong. It simply means emergency medicine and EMS will continue to develop as a profession, and our body of evidence will continue to grow as we learn more about prehospital care. As we prepare to retire MAST, backboards and lidocaine, and realize the golden hour as a concept rather than a definitive 60 minutes, it's important to keep a critical eye out for the next intervention that truly will help patients during their prehospital care.

Managing the airway does not mean intubation, it means managing the airway. Allowing a patient to breathe on their own with appropriate positioning, bag-valve ventilation and blind insertion devices are all airway management options. The surgical cricothyrotomy is a rare and life-saving procedure when managing patients who are in a "can't intubate, can't ventilate" situation. These patients will die without aggressive and rapid intervention. While not all surgical cricothyrotomies provide a definitive airway, the needle cricothyrotomy is an ineffective means for ventilation and its use is discouraged. Understand the techniques used in your program and that are within your scope of practice as an EMS provider. Provide your patient the best opportunity for survival by knowing your program's surgical airway procedure thoroughly, and practice it regularly.

Aortic dissections and aneurysms are seen with low frequency and have high risk for deterioration during prehospital care. It is essential to include both dissections and aneurysms in your differential diagnoses whenever evaluating patients with chest or abdominal complaints. Often a good history is the best indication of one of these grave vascular emergencies. Consider thoracic aortic dissection in your differential diagnosis for any patient who complains of chest pain and aortic aneurysm in patients who have any sort of abdominal discomfort or syncope with an unknown etiology. When either is suspected transport rapidly to a facility with cardiothoracic and vascular surgery capability, and provide care that prepares you to manage the patient quickly should a rupture occur.

Time-sensitive emergencies require early recognition and rapid transport to a facility properly equipped to manage the patient's needs. When managing STEMI, cardiac arrest, suspected stroke, trauma or a severe sepsis patient, use your resources smartly. Manage the patient using all of your capabilities on scene and know the destination best prepared to manage the patient upon ED arrival. When it makes sense to extend transport time to take a patient to a proper facility, it is OK to do so. Considering air medical transport for patients as ground transports exceed 30 minutes is reasonable as long as the flight team provides transport more rapidly or brings additional care that will improve patient outcomes.

Reducing back injuries requires a holistic approach and investment by all interested parties, from front-line staff to leadership and supporting agencies. As a provider, take the time to ensure you are lifting and moving equipment and patients in a manner that protects both the patient and you.

Point-of-care testing is a rapidly evolving yet complex field. As your POCT program grows, take the time to understand the regulations, as they are important to ensuring patient safety. The regualtions established CLIA are designed to ensure consistent and reliable laboratory results that can accurately impact patient care. When beginning your look into POCY, first identify what labs can directly impact your patient care, then look for a device that meets your needs.

Diabetes mellitus is on incredibly complex disease and impacts millions of Americans. The pancreas and insulin are both key to normal glucose metabolism and glucose control.Nearly any body stressor that alters a patient's metabolism can impair normal insulin function and trigger hyperglycemia. It is prudent to check blood sugar in all patients with suspected serious illness, whether or not they have diabetic histories. Hyperglycemia can affect any patient and is a predictor of increased mortality if not treated early. Diabetic ketoacidosis has a more rapid onset than a hyperosmolar hyperglycemic state and often presents with a comparatively lower blood sugar and the presence of acidosis. HHS does not present with profound acidosis and has a slower onset, yet more profound dehydration and a higher blood sugar. Do not underestimate the need for early prehospital intervention with hyperglycemia. Early and aggressive IV fluid administration can improve patient outcomes and speed recovery.

Burnout and PTSD are closely linked and often underreported in EMS. EMS classrooms do little or nothing to prepare providers for the inherent emotional stresses of emergency response and the "thick skin" culture of EMS may make many providers apprehensive about sharing their true feelings. Burnout is triggered by many of the same stresses that lead to the symptoms of PTSD and providers experiencing burnout that doesn't resolve within a few weeks may actually be experiencing PTSD. Be mindful of yourself and your fellow coworkers, particularly after a very traumatic response. And remember traumatic responses don't need to be as dramatic as Sept. 11, New Orleans after Hurricane Katrina or the Aurora, CO shootings to bother an EMS worker. In contrast, these are the calls where providers often receive the most attention. Instead, watch for the new father who just performed CPR on an infant the same age as his own, or the provider who just watched his or her friend die following a motor vehicle collision. Pay attention to yourself and colleagues, and be responsible and honest with yourself and others about when coping strategies are enough, and when they aren't. Finally, don't ever be afraid to seek help.

Roughly 2,000 U.S. children experience spinal column injuries annually. However, thousands more present to emergency departments with mechanisms of injury that could injure their spine. When children can follow commands and understand questions, performing a careful and accurate spine assessment may eliminate the need for unnecessary spine immobilization. When a spine injury is suspected, proper pediatric immobilization requires careful control of the spine's weight centers and proper padding to ensure the spine remains in a neutral position.

Obesity is a serious disease that poses many problems for EMS. Morbidly obese patients do not fit on standard EMS equipment and the need for the safe transport of obese patients is rising. In addition to posing many logistical dilemmas, obese patients are prone to many serious medical conditions that are likely to increase their exposure to EMS systems. Prepare yourself and your program for the management and transport of obese patients by designing a safe patient transport model and policy with protocols geared toward the obese patient.

Sarah and Michael were able to obtain their patient's blood pressure and heart rate while she was lying in bed as her blood pressure changed from 110/84 to 92/60 and her heart rate increased from 94 to 112 beats per minute. In speaking with her, they learned she was trying to break herself of long-standing alcoholism and had not had a drink in over a week. She had been taking aspirin for her "pains all over." They secured her to their cot in a position of comfort and Sarah established an IV, initiated a fluid bolus of normal saline and administered Zofran to control the patient's nausea and vomiting. In the emergency department, the patient was diagnosed with esophageal varices and was taken to the operating room for repair.

Musculoskeletal injuries are commonly treated by prehospital providers. The American College of Surgeons Committee on Trauma supports the early management of musculoskeletal injuries including analgesia, repositioning and splint application. Even when patients have multiple injuries, it is important to apply splints to reduce internal bleeding, pain and the potential for fatty embolisms. Strongly consider administering analgesia to any patient with a suspected musculoskeletal injury; the majority of these patients go on to receive analgesia in the hospital while their time in the ambulance is likely the most uncomfortable period of their care. When applying a splint, remember that effective splints are complete, compact and comfortable.

The administration of oxygen is safe and effective for patients who are in respiratory distress or who are hypoxic. Never feel that oxygen needs to be withheld. However, keep in mind that there are real consequences to the long-term utilization of high-flow oxygen. To help prevent potential complications from oxygen administration, reach for the nasal cannula before the non-rebreather mask, and apply just enough oxygen to maintain normal saturations.