Thursday, February 29, 2024

EMS Discussion - Use of Lights & Sirens


EMS Providers should be aware of the ongoing discussion surrounding the use of lights and sirens during emergency calls. There is a growing concern about the risks associated with their use, such as an increased likelihood of accidents and harm to patients.

EMS Providers should stay updated on local and national guidelines regarding when to use lights and sirens to ensure the safety of both themselves and the public.

Those operating emergency vehicles must consider alarming statistics showing that ambulance crashes significantly impact clinicians, patients, and the public, with the risk of a crash increasing by over 50% when lights and sirens are activated.

It is crucial for EMS Leaders to implement well-researched guidelines supporting the restricted use of lights and sirens to enhance the safety of all individuals involved in emergency responses.

In an outstanding demonstration of collaboration on provider, patient, and community safety, 13 national and international associations have partnered on the release of a Joint Statement on Lights and Siren Vehicle Operations in Emergency Medical Services (EMS) Responses (NAEMT, 2022).

The statement articulates principles guiding the use of lights and sirens during emergency vehicle responses to medical calls and initiatives to decrease their use safely. EMS vehicle operations using lights and sirens pose significant risks to both providers and the public. Therefore, their use should be limited to situations where time saved is expected to be clinically important to a patient’s outcome (Merill, 2022).

Communication centers should utilize structured call triage and categorization to identify subsets of calls based on the response resources needed and medical urgency. Physician oversight is crucial in developing response configurations and modes for these protocols.

Agency Leadership should monitor the rates of lights and sirens use, appropriateness, compliance, and outcomes related to their use. Municipal Leaders should be aware of the increased crash risks, and quality care metrics should drive contract agreements.

States and provinces should monitor and report on emergency vehicle crashes to better understand the risks associated with lights and sirens use.

Collaboration between EMS and Fire Agency Leaders is essential in understanding public perceptions and improving education about the risks associated with lights and sirens to create safer expectations.

According to a recent presentation by NEMSQA, 87% of EMS responses were made with the use of lights & sirens, while transports nationally used them 51% of the time. The time savings averaged 102-216 seconds during a response and between 42-228 seconds for transports (from multiple recent studies); yet life-saving interventions are being done in only 6.9% of responses (according to an ESO study of 7.5M records).

At the same time, our odds of being involved in an accident increase by 53% in responses and 184% during transports (not to mention accidents in our wake that do not involve an EMS unit). Furthermore, litigations that involve ambulance incidents are 86% when using L&S.

The data presented highlights concerning statistics surrounding the use of lights and sirens in EMS responses and transports. While time savings are evident, life-saving interventions are performed in only a small percentage of responses.

The increased risk of accidents during both responses and transports underscores the need for a shift towards safer practices. Litigations involving ambulance incidents predominantly occur when lights and sirens are used.

It is crucial to view the use of lights and sirens as a clinical treatment and to follow the guidance to "use only as needed" to ensure the safety of patients, the community, and EMS providers. Prioritizing safe ambulance operations is vital for everyone's well-being and to ensure a safe return home after each shift.

Further Reading:

Merrill, L. (2022) 14 Groups Issue Joint Statement on EMS Use Of lights, Sirens https://www.ems1.com/ambulance-safety/articles/14-groups-issue-joint-statement-on-ems-use-of-lights-sirens-AAfswfKx2gaog3dy/ Accessed February 28, 2024

National Association of Emergency Medical Technicians (2022) Joint Statement on Lights & Siren Vehicle Operations on Emergency Medical Services (EMS) Responses https://naemt.org/docs/default-source/advocacy-documents/positions/joint-statement-on-red-light-and-siren-operations-with-logos---final.pdf?sfvrsn=e586e893_4 Accessed February 28, 2024

National EMS Quality Alliance (2024) Improving Safety in EMS: Reducing the Use of Lights and Siren https://nemsqa.memberclicks.net/assets/LSChangePackage/Improving%20Safety%20in%20EMS%20Reducing%20the%20Use%20of%20Lights%20and%20Siren.pdf Accessed February 28, 2024

Zavadsky, M. (2023) Culture Shift: Reducing Lights and Siren Vehicle Operation https://www.ems1.com/safe-transport-point-b/articles/culture-shift-reducing-lights-and-siren-vehicle-operation-XDonsygscixIghQT/ Accessed February 28, 2024

Tuesday, February 27, 2024

EMS Patient Assessment - Referred Pain (2)


Referred pain is a phenomenon where pain is perceived at a location different from the actual site of the underlying problem or injury. This occurs because the same nerve pathways that carry pain signals from one area of the body can overlap or converge with the nerve pathways from another area. 

As a result, when pain signals are generated in one region, they can be misinterpreted by the brain as originating from a different area that shares nerve connections.

Referred pain can be confusing because it can lead to the misdiagnosis of the source of pain.

Cardiac Referred Pain: One of the classic examples of referred pain is related to the heart. When the heart muscle (myocardium) is deprived of oxygen and nutrients, such as during a heart attack, the brain often interprets this pain as originating in the left side of the chest, left arm, or even the jaw.

- Levine's Sign: Named after Dr. Samuel Levine, this sign is related to cardiac referred pain. It's a characteristic clutching of the chest seen in patients experiencing angina or a heart attack.

Gallbladder Referred Pain: Gallbladder issues, like gallstones or cholecystitis, can cause referred pain to the right shoulder or between the shoulder blades. This is because the same nerves that supply the gallbladder also connect to these areas.

- Murphy's Sign: Named after Dr. John Benjamin Murphy, this sign is used to diagnose gallbladder-related pain. It involves the patient experiencing increased pain or discomfort when the doctor palpates the area beneath the ribcage on the right side during deep inspiration.

Spleen Referred Pain: Referred pain from the spleen typically presents as discomfort in the left upper abdominal quadrant, just beneath the ribcage. Conditions that can cause spleen-related referred pain include splenomegaly and conditions that lead to trauma or rupture of the spleen.

- Kehr's Sign: Named after Dr. Hans Kehr, this sign relates to pain in the left shoulder that can occur due to irritation of the diaphragm, often resulting from conditions like a ruptured spleen or other sources of abdominal bleeding. In such cases, Kehr's Sign is used to describe both the referred pain and its association with spleen-related issues.

Appendicitis: Inflammation of the appendix can often cause pain around the navel or the upper abdomen before it eventually migrates to the right lower quadrant, which is the classic location for appendicitis pain.

- McBurney's Point: Named after Dr. Charles McBurney, this is a location used to diagnose appendicitis, which corresponds to the location of the base of the appendix.

Kidney Stone Pain: Pain caused by kidney stones can be felt not only in the lower back and side, where the kidneys are located but also radiate down to the groin area or the abdomen.

- Costovertebral Angle (CVA) Tenderness: While not named after a specific individual, this is an important sign to check for when evaluating kidney-related pain, such as kidney stones. Tenderness in the CVA, located on the back, just below the ribcage, is indicative of renal issues.

Diaphragm Referred Pain: Irritation of the diaphragm muscle can cause pain in the shoulder, especially the left shoulder. This is because it shares nerve connections with the shoulder area.

Liver Referred Pain: Liver inflammation or congestion can lead to referred pain in the right shoulder or upper back due to the shared nerve pathways.

Understanding referred pain is important for healthcare professionals as it can sometimes make diagnosing the underlying condition more challenging. It's crucial to consider referred pain in the diagnostic process to identify and treat the actual source of the problem accurately.

Sunday, February 25, 2024

EMS Patient Assessment - Referred Pain (1)


EMS Providers should have a comprehensive understanding of referred pain to effectively assess and manage patients in the field. 

Here are key points they should know:

Definition and Mechanism: A phenomenon where pain is felt in an area of the body that is different from the actual source of the pain. It occurs due to the convergence of nerve pathways, where signals from one area of the body are interpreted as originating from another area that shares nerve connections.

Common Examples: EMS providers should be familiar with common examples of referred pain, such as cardiac referred pain (e.g., chest pain radiating to the left arm or jaw during a heart attack), gallbladder referred pain (e.g., pain in the right shoulder or between the shoulder blades with gallstones or cholecystitis), and spleen referred pain (e.g., left shoulder pain with spleen-related issues).

Recognition: Recognizing patterns of referred pain can aid EMS providers in diagnosing the underlying cause of a patient's symptoms. Understanding the characteristic locations of referred pain associated with specific conditions can help differentiate between different potential diagnoses.

Clinical Signs: Some conditions have specific clinical signs associated with referred pain, such as Levine's Sign for cardiac referred pain (clutching of the chest) or Murphy's Sign for gallbladder-related pain (increased pain during palpation beneath the ribcage on the right side).

Diagnostic Considerations: Referred pain can complicate the diagnostic process by masking the true source of the pain. EMS Providers should be aware of this possibility and consider a broad range of differential diagnoses when assessing patients presenting with symptoms of referred pain.

Treatment Implications: Understanding referred pain can influence the treatment approach for patients. EMS Providers should consider the underlying cause of the pain when administering interventions and be prepared to manage the primary condition contributing to the referred pain.

Communication: Effective communication with receiving facilities is crucial when transferring patients with suspected referred pain. Providing a clear and accurate description of the patient's symptoms, including any associated referred pain, can help guide further evaluation and treatment at the receiving facility.

By being knowledgeable about referred pain and its clinical implications, EMS Providers can enhance their ability to assess, manage, and provide appropriate care for patients experiencing this phenomenon in the prehospital setting.

Friday, February 23, 2024

EMS Gastrointestinal Emergencies - Particular Patient Presentations


In the realm of emergency medical service provision, encountering gastrointestinal emergencies is not uncommon. From gastrointestinal bleeding to acute appendicitis, EMS Providers must be prepared to assess, manage, and provide timely intervention for these critical conditions. Understanding the signs, symptoms, and underlying causes of such emergencies is essential for swift and effective patient care.

Here are some examples of gastrointestinal emergencies an EMT might encounter:

Gastrointestinal Bleeding:

Signs and Symptoms: Hematemesis (vomiting blood), Melena (black, tarry stools), Hematochezia (bright red or maroon-colored stools), weakness, lightheadedness, and abdominal pain.

Examples: Peptic ulcers, Esophageal varices, Gastritis, Diverticulosis, colorectal cancer.

Appendicitis:

Signs and Symptoms: Right lower quadrant abdominal pain, nausea, vomiting, low-grade fever, rebound tenderness.

Example: Inflamed or infected appendix.

Gastroenteritis:

Signs and Symptoms: Diarrhea, vomiting, abdominal cramps, fever, dehydration.

Example: Viral or bacterial infection of the gastrointestinal tract.

Bowel Obstruction:

Signs and Symptoms: Abdominal pain and distension, nausea, vomiting (may be feculent), constipation, inability to pass gas.

Example: Blockage of the intestines, often due to adhesions, hernias, or tumors.

Pancreatitis:

Signs and Symptoms: Severe abdominal pain radiating to the back, nausea, vomiting, abdominal tenderness.

Example: Inflammation, often due to gallstones or excessive alcohol consumption.

Cholecystitis:

Signs and Symptoms: Right upper quadrant pain, nausea, vomiting, fever, tenderness.

Example: Inflammation of the gallbladder, often due to gallstones.

Diverticulitis:

Signs and Symptoms: Left lower quadrant abdominal pain, fever, nausea, change in bowel habits.

Example: Infection or inflammation of small pouches (diverticula) in the colon.

Gastrointestinal Perforation:

Signs and Symptoms: Sudden, severe abdominal pain, rigid abdomen, guarding, rebound tenderness.

Example: A hole or tear in the gastrointestinal tract, often due to trauma or ulceration.

Gastrointestinal (GI) emergencies pose significant challenges for EMS Providers in the field and can vary widely in terms of severity and presentation. Whether managing cases of GI bleeding or identifying and responding to appendicitis, quick and accurate assessment is essential for ensuring positive patient outcomes.

EMS Providers should follow local assessment protocols and communicate effectively with the receiving facility to ensure the best possible care for the patient. Additionally, maintaining good infection control practices and ensuring proper hygiene is essential when dealing with gastrointestinal emergencies, as many are infectious in nature.

By familiarizing themselves with the signs, symptoms, and potential causes of these emergencies, EMS providers can better navigate these critical situations and provide timely and effective care to those in need.

Wednesday, February 21, 2024

EMS Gastrointestinal Emergencies - Patient Assessment


EMS Providers should be prepared to recognize and respond to gastrointestinal (GI) emergencies, as they are relatively common and can range from mild to life-threatening. Here are some key points and examples of gastrointestinal emergencies that EMTs need to be aware of:

1. Signs and Symptoms: Be familiar with the common signs and symptoms of gastrointestinal emergencies, which may include abdominal pain, nausea, vomiting, diarrhea, constipation, blood in vomit or stool, and abdominal distension.

2. Dehydration: Many GI conditions can lead to dehydration due to fluid loss from vomiting or diarrhea. EMTs should be skilled in assessing a patient's hydration status by checking vital signs (e.g., blood pressure, pulse, skin condition) and mucous membrane moisture.

3. Abdominal Pain Assessment: Learn how to perform a thorough abdominal pain assessment, which includes identifying the location, intensity, and radiation of pain, as well as any aggravating or alleviating factors.

    -  Visceral pain originates from internal organs and is often described as a diffuse, deep, and aching sensation.

    -  Parietal pain originates from the parietal peritoneum and is typically sharp, well-localized, and easier to identify.

4. Gastrointestinal Bleeding: Understand the signs of gastrointestinal bleeding, such as hematemesis (vomiting blood), melena (black, tarry stools), and hematochezia (bright red blood in stool). Be prepared to manage bleeding and provide appropriate interventions.

5. Infection Control: Gastrointestinal emergencies can often be related to infectious causes. EMTs should practice strict infection control measures to prevent the spread of infection, including wearing appropriate personal protective equipment (PPE).

6. Medication Allergies: Ask about medication allergies or intolerances, as patients with gastrointestinal conditions may be taking medications or have allergies to specific drugs.

7. Abdominal Trauma: Consider the possibility of trauma, especially in cases of severe abdominal pain. Assess for signs of external trauma and be prepared to manage accordingly.

8. Patient History: Obtain a detailed patient history, including any pre-existing gastrointestinal conditions, previous surgeries, and current medications.

9. Vital Signs: Monitor vital signs regularly, paying close attention to changes in blood pressure, heart rate, and respiratory rate. These can indicate the severity of the condition.

10. Transport and Communication: Determine the need for transport to a medical facility based on the severity of the condition. Communicate effectively with higher-level medical providers to provide a smooth transition of care.

11. Patient Comfort: Help alleviate discomfort and anxiety in patients with gastrointestinal emergencies. Position the patient comfortably and provide reassurance.

12. Documentation: Maintain accurate patient care documentation, including the patient's history, assessment findings, interventions performed, and the patient's response to treatment.

EMS Providers should perform a thorough patient assessment, obtain a medical history, and note any pre-existing gastrointestinal conditions. 

In cases of GI bleeding or severe abdominal pain, initiate prompt transport to a healthcare facility. Monitoring vital signs, assessing for signs of shock, and providing appropriate interventions such as intravenous fluids can be life-saving.

Monday, February 19, 2024

EMS Equipment - Traction Splints Addendum


For open femur fractures, it is essential to follow the principles of advanced trauma life support (ATLS) and local trauma management protocols.

These protocols typically recommend initial hemorrhage control, wound care, and expedited transport to a trauma center for definitive care.

According to the organization, International Trauma Life Support (ITLS), they advocate for the use of traction devices for open midshaft femur fractures.

ITLS reports the use of a traction device for open midshaft femur fractures can help reduce the risk of neurovascular injuries and alleviate patient pain. It highlights the importance of considering the patient's extrication and transportation needs when selecting a traction device.

In situations where the patient will be transported by air, the ITLS update suggests that a HARE traction splint may be preferred over a Sager traction splint. This is likely due to the design and ease of application of the HARE traction splint, which may be better suited for air transport scenarios.

It's important to note that guidelines and recommendations can vary across different organizations and regions. Therefore, it's crucial to consider the specific guidelines and protocols established by your local EMS authority or trauma organization when managing open midshaft femur fractures.

Bibliography

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Davis, D. D., Ginglen, J. G., Kwon, Y. H., & Kahwaji, C. I. (2023) EMS Traction Splint. StatPearls. https://pubmed.ncbi.nlm.nih.gov/29939619/ Accessed February 19, 2023

International Trauma Life Support (2011) Utilization of Traction Splints with Open Femur Fracture. https://www.itrauma.org/.../UtilizationofTractionSplintsw... Accessed November 14, 2023

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

The Bone School (ND) Femoral Shaft Fractures. http://www.boneschool.com/lower-limb/hip/femur-fractures/femoral-shaft-fractures Accessed February 19, 2024


Saturday, February 17, 2024

EMS Equipment - Traction Splints


Traction splints are devices used in prehospital settings to provide stabilization and immobilization for certain types of fractures, specifically femur fractures.

Their purpose is to help alleviate pain, reduce bleeding, and prevent further damage to surrounding tissues.

Some common brands of traction splints include the HARE traction splint, Sager traction splint, and Thomas traction splint.

These brands have variations in design and application method, but they all serve a similar purpose.

Recommendations for using traction splints typically include cases where there is a suspected or confirmed mid-shaft femur fracture.

The use of traction splints can help align the fractured bone ends and provide relief by reducing muscle spasm and restoring limb length.

Femur fractures are serious injuries that we often encounter in the field.

Recognizing Femur Fractures: Look for signs like severe pain, swelling, deformity (leg may appear shorter or rotated), inability to move the leg, and sometimes, bruising.

High-Impact Injuries: Remember, the femur is the strongest bone in the body. A fracture usually results from high-impact trauma, like motor vehicle accidents or significant falls.

Check for Complications: Be vigilant for potential complications such as bleeding (femoral artery damage), fat embolism, or shock, especially in high-impact traumas.

Immobilization is Key: Stabilize the leg with a traction splint if indicated. Proper immobilization reduces pain, bleeding, and the risk of further injury.

Monitor Vitals: Keep a close eye on the patient’s vital signs. Femur fractures can cause significant pain and shock, which may lead to changes in pulse, blood pressure, and respiratory rate.

Transportation Considerations: Handle with care during transport. Smooth movements and careful handling can prevent further injury and pain.

Communication with Hospital: Inform the receiving facility about the nature of the injury, your interventions, and the patient's response to treatment.

However, there are certain contraindications and situations where traction splints should not be used.

These include:

Proximal or Distal Femur Fractures: Traction splints are designed for mid-shaft femur fractures and may not be effective or appropriate for fractures closer to the hip or knee joint.

Pediatric Patients: Traction splints are generally not recommended for pediatric patients due to differences in bone anatomy and the risk of causing additional injury.

Inability to Apply Properly: If the EMS provider is unable to properly apply or use the traction splint, it should not be used. In such cases, alternative methods of immobilization will need to be considered.

Therefore, it is important to note that the decision to use a traction splint should be based on the specific circumstances of the patient and the availability of appropriate resources.

EMS providers should consider factors such as the mechanism of injury, the location and type of femur fracture, and the patient's overall condition.

It's always advisable for EMS providers to adhere to local protocols and guidelines, as they may vary depending on the region and specific healthcare system.

These protocols are typically established based on current evidence, best practices, and expert consensus to ensure optimal patient care.

Thursday, February 15, 2024

EMS Patient Monitoring - Capnography 4


Understanding the capnography waveform is essential. A consistent waveform indicates proper ventilation, while irregularities may signal airway or respiratory issues.

Considerations:

Equipment Calibration: Regular calibration of capnography equipment is essential to maintain accuracy in CO2 measurements.

Interference with Nasal Cannula: Nasal cannulas may result in lower ETCO2 readings due to air dilution. Consider using an alternative sampling method if necessary.

Low Perfusion States: In low perfusion states, such as during cardiac arrest, capnography may be less reliable in reflecting true ETCO2 levels.

Temperature Compensation: Capnography measurements are temperature-dependent. Providers should be aware of the need for temperature compensation to ensure accurate readings.

Limitations:

Airway Anomalies: Some airway anomalies or pathologies may affect capnography readings. Providers should be cautious in interpreting results in such cases.

Equipment Malfunction: Malfunctions in the capnography equipment can lead to inaccurate readings. Regular maintenance and checks are necessary.

Rebreathing: Rebreathing or partial rebreathing masks can result in elevated ETCO2 levels, affecting the accuracy of monitoring.

Sampling Rate: Inadequate sampling rates may result in delayed detection of changes in ETCO2 levels. Ensure the capnography device has an appropriate sampling rate.

Pulmonary Embolism: In cases of massive pulmonary emboli, capnography may show a decrease in ETCO2 due to reduced perfusion to the lungs.

EMS providers should undergo proper training to interpret capnography data accurately and be aware of the limitations and special considerations in various clinical scenarios.

Regular education and updates on capnography technology are crucial to providing optimal patient care.

Further Reading:

Capnography: Principles and Practice by Michael K. Copeland

Capnography, King of the ABC’s: A Systematic Approach for Paramedics" by Troy Valente

Paramedic Care: Principles & Practice: by Bryan E. Bledsoe, Robert S. Porter, and Richard A. Cherry


Tuesday, February 13, 2024

EMS Patient Monitoring - Capnography 3


ETCO2 monitoring is a valuable tool for EMS Providers as it provides real-time information about a patient's respiratory status and overall physiological condition. Here's how ETCO2 is useful for EMS providers:
Ventilation Assessment: ETCO2 levels reflect the adequacy of ventilation. Monitoring ETCO2 helps EMS providers assess whether a patient is effectively eliminating CO2 through ventilation.
Confirmation of Airway Placement: ETCO2 is commonly used to confirm proper placement of an endotracheal tube or other advanced airway devices. A sudden increase in ETCO2 during intubation indicates successful placement within the trachea, whereas low or absent readings may suggest esophageal or misplaced airway.
Circulatory Status Indicator: Changes in ETCO2 levels can provide insight into the patient's circulatory status. A sudden decrease in ETCO2 may indicate reduced cardiac output, potentially signaling cardiac arrest or severe shock.
Monitoring During CPR: ETCO2 monitoring is crucial during cardiopulmonary resuscitation (CPR). A sudden increase in ETCO2 levels during CPR may indicate return of spontaneous circulation (ROSC), while persistently low levels may suggest poor perfusion and the need for intervention.
Detection of Respiratory Distress or Failure: ETCO2 is a sensitive indicator of respiratory distress or failure. A sudden decrease in ETCO2 may signal respiratory compromise, allowing providers to intervene promptly.
Prognostic Tool: Persistent low ETCO2 levels during CPR are associated with a poorer prognosis. Monitoring ETCO2 trends can help providers make informed decisions about the effectiveness of resuscitative efforts.
Guidance During Procedural Sedation: EMS providers can use ETCO2 monitoring to ensure adequate ventilation during procedural sedation. This is particularly important when administering sedatives or analgesics that may depress respiratory function.
Trauma Assessment: In trauma patients, ETCO2 monitoring can aid in identifying respiratory distress due to thoracic injuries or other traumatic conditions.
Early Detection of Respiratory Complications: Monitoring ETCO2 allows for the early detection of respiratory complications, such as hypoventilation or respiratory depression, enabling timely intervention.
Further Reading:
Capnography: Principles and Practice by Michael K. Copeland
Capnography, King of the ABC’s: A Systematic Approach for Paramedics" by Troy Valente

Paramedic Care: Principles & Practice" by Bryan E. Bledsoe, Robert S. Porter, and Richard A. Cherry 

Sunday, February 11, 2024

EMS Patient Monitoring - Capnography 2


The choice of monitoring device depends on factors such as the patient's condition, the level of invasiveness required, and the specific clinical scenario.

Mainstream and sidestream capnography are the most commonly used methods for continuous ETCO2 monitoring.

The devices used to measure end-tidal CO2 (ETCO2) typically include:

Capnometers: These are basic devices that measure and display the numerical value of ETCO2. They are commonly used in various medical settings.

Capnographs: More advanced devices that not only display the numerical value of ETCO2 but also provide a continuous graphical representation known as the capnogram.

The capnogram displays the CO2 concentration over time, showing inhalation, exhalation, and the phase where little or no CO2 is present (representing the end-tidal point).

Mainstream Capnography: With mainstream capnography, the sensor is placed directly in the patient's airway, usually at the end of an endotracheal tube or an adapter connected to a ventilation device.

This type of capnography provides immediate and accurate measurements but may add dead space to the breathing circuit.

Sidestream Capnography: With sidestream capnography, a sampling tube diverts a small portion of the patient's exhaled air to a separate sensor away from the patient.

This method is less invasive and reduces the dead space in the breathing circuit. It is commonly used in non-intubated patients and during procedural sedation.

Colorimetric Devices: These devices provide a color change based on the CO2 concentration. They are often used as a quick and cost-effective method for verifying endotracheal tube placement but may not provide continuous monitoring.

Portable Capnography Devices: There are compact and portable capnography devices designed for prehospital and emergency use by EMS providers. These devices are lightweight, battery-operated, and provide essential monitoring capabilities in various environments.

Further Reading:

Capnography: Principles and Practice by Michael K. Copeland

Capnography, King of the ABC’s: A Systematic Approach for Paramedics" by Troy Valente

Infinium (ND) What is a Capnograph https://infiniummedical.com/what-is-capnography/ Accessed January 16, 2024

Paramedic Care: Principles & Practice" by Bryan E. Bledsoe, Robert S. Porter, and Richard A. Cherry


Friday, February 09, 2024

EMS Patient Monitoring - Capnography 1


Widely embraced across diverse medical settings, including the exigencies of emergency medical services, the precision of intensive care units, the intricacies of operating rooms, and the nuanced demands of procedural sedation, capnography emerges as a multifaceted sentinel for healthcare providers.

Capnography is an indispensable asset within the realm of prehospital and emergency medical care, serving as a dynamic window into a patient's physiological landscape. This monitoring technique engages in the continuous, real-time measurement and graphical representation of carbon dioxide (CO2) concentration, specifically known as end-tidal CO2 (ETCO2), within a patient's exhaled breath.

By offering an unbroken stream of insights into both respiratory and circulatory dynamics, capnography provides a comprehensive understanding of a patient's evolving physiological status.

End-Tidal CO2 (ETCO2), the focal point of capnography, unveils the partial pressure or concentration of carbon dioxide at the culmination of each exhaled breath. This metric, expressed in millimeters of mercury (mmHg) or as a percentage, furnishes EMS providers with real-time, actionable information regarding a patient's respiratory well-being.

As a consequence, ETCO2 monitoring emerges as a linchpin in the delivery of timely and informed interventions, ensuring the optimization of patient care in critical and time-sensitive situations.

The word ‘capnography’ has its roots in Greek. The term is derived from the Greek word ‘kapnos’ meaning ‘smoke’, and the suffix ‘-graphy’, which refers to the process of recording. The name reflects its focus on the measuring of carbon dioxide which, historically, has been associated with the term ‘smoke’ due to its visible presence in combustion processes

Further Reading:

Capnography: Principles and Practice by Michael K. Copeland

Capnography, King of the ABC’s: A Systematic Approach for Paramedics" by Troy Valente

Paramedic Care: Principles & Practice" by Bryan E. Bledsoe, Robert S. Porter, and Richard A. Cherry


Wednesday, February 07, 2024

EMS Trauma Emergencies - Amnesia


EMS Providers should have a solid understanding of the causes and types of amnesia to effectively assess and manage patients presenting with memory disturbances. Here's what they need to know:

Causes of Amnesia

Head Trauma: Traumatic brain injury (TBI) is a common cause of amnesia, especially retrograde amnesia (RA), where memory loss occurs for events preceding the injury.

Stroke: Lack of blood flow to the brain can lead to transient global amnesia (TGA), characterized by sudden onset memory loss.

Seizures: Particularly prolonged or severe seizures can cause memory impairment.

Neurodegenerative Diseases: Alzheimer's disease, dementia, and other conditions can lead to progressive memory loss.

Psychological Trauma: Emotional shock or severe stress can result in dissociative amnesia, where memories are blocked due to psychological distress.

Drug or Alcohol Abuse: Substance abuse can lead to blackouts or memory gaps.

Infections: Encephalitis, meningitis, and other brain infections can impair memory function.

Brain Tumors: Tumors can affect memory centers in the brain, leading to amnesia.

Metabolic Disorders: Conditions like vitamin B12 deficiency or thyroid disorders can cause memory impairment.

Medications: Certain medications, such as benzodiazepines, can cause memory problems as side effects.

Types of Amnesia

Retrograde Amnesia (RA):

Definition: Memory loss for events that occurred before the onset of amnesia.

Causes: Typically associated with head trauma, brain injury, or neurological conditions.

Example: A patient may not remember events leading up to a car accident due to retrograde amnesia.

Anterograde Amnesia (AA):

Definition: Inability to form new memories after the onset of amnesia.

Causes: Often seen in cases of head trauma, stroke, or neurodegenerative diseases affecting the hippocampus.

Example: A patient may repeatedly ask the same question or fail to recall recent conversations due to anterograde amnesia.

Differential Diagnosis

Differentiating Retrograde vs. Anterograde Amnesia: Assessing the patient's ability to recall events before and after the onset of symptoms helps distinguish between the two types.

History and Physical Examination: Detailed history-taking, including information from family members or witnesses, and a thorough physical examination can help identify potential causes of amnesia.

Neuroimaging: CT scans or MRI scans may be necessary to detect structural abnormalities in the brain, such as tumors or lesions.

Laboratory Tests: Blood tests can help rule out metabolic causes of amnesia, such as vitamin deficiencies or infections.

Management

Stabilization: Ensure the patient's vital signs are stable and address any immediate life-threatening issues.

Supportive Care: Provide reassurance and support to the patient and their family members.

Referral: Depending on the underlying cause, patients may require further evaluation and management by neurologists, psychiatrists, or other specialists.

By understanding the causes and types of amnesia, EMS providers can effectively assess and manage patients experiencing memory disturbances, providing appropriate care and ensuring the best possible outcomes.

Further Reading

Alexander, M. & Belle, R (2012) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). New Jersey: Pearson.

Bledsoe, B. E., Cherry, R. A. & Porter, R. S. (2023) Paramedic Care: Principles and Practice Volume 1 (6th Ed). New Jersey: Pearson.

Brown, C. A., III., & Walls, R. M. (2023) The Walls Manual of Emergency Airway Management (6th Ed). Pennsylvania: Lippincott Williams & Wilkins.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). New Jersey. Pearson Education.

Monday, February 05, 2024

EMS Trauma Emergencies - Le Fort Fractures


EMS Providers should be familiar with Le Fort fractures as they are severe injuries to the facial bones that require immediate attention.

There are three main types of Le Fort fractures, each affecting different parts of the face. Here's what EMS providers should know about them:

Le Fort I Fracture (Horizontal Maxillary Fracture):

This fracture involves a horizontal separation of the maxilla (upper jaw) from the rest of the face.

Mechanism of injury often involves a blow to the front of the face, such as a dashboard impact in a motor vehicle accident.

Signs and symptoms may include:

- Pain and tenderness in the upper jaw region.

- Mobility or instability of the teeth.

- Numbness or tingling in the upper lip or gums.

Complications can include airway compromise due to displacement of the maxilla.

Le Fort II Fracture (Pyramidal Fracture):

This fracture involves separation of the central portion of the face from the skull, including the nasal bones, ethmoid bone, and maxilla.

Mechanism of injury often involves a high-energy impact to the middle third of the face, such as a direct blow to the nose or cheekbones.

Signs and symptoms may include:

- Swelling and deformity of the mid-face.

- Crepitus (grinding sensation) upon palpation.

- Periorbital ecchymosis (bruising around the eyes).

- CSF (cerebrospinal fluid) rhinorrhea or otorrhea, if there is associated skull base fracture.

Complications can include orbital and ocular injuries, as well as CSF leakage which may lead to increased risk of meningitis.

Le Fort III Fracture (Transverse Fracture):

This fracture involves separation of the entire facial skeleton from the skull, including the zygomatic arches, orbits, and nasal bones.

Mechanism of injury often involves a severe, high-velocity impact to the face, such as a fall from height or a significant blunt force trauma.

Signs and symptoms may include:

- Gross facial deformity with flattening of the mid-face.

- Bilateral periorbital ecchymosis (raccoon eyes).

- Subconjunctival hemorrhage.

- Epistaxis (nosebleed).

Complications can include severe facial disfigurement, orbital compartment syndrome, and optic nerve injuries leading to visual impairment or blindness.

The concept of Le Fort fractures was developed by a French surgeon named RenĂ© Le Fort. RenĂ© Le Fort conducted extensive anatomical studies on the human skull in the early 20th century. 

In 1901, he published his findings on patterns of fractures involving the mid-face region, which came to be known as Le Fort fractures. His work laid the foundation for understanding and classifying these severe injuries to the facial bones.

For EMS providers, prompt recognition and stabilization of patients with Le Fort fractures are crucial. Management typically involves securing the airway, controlling bleeding, and providing pain management while transporting the patient to an appropriate medical facility for further evaluation and treatment by a maxillofacial surgeon or a trauma specialist. 

Additionally, EMS providers should be vigilant for associated injuries, particularly to the cervical spine and head, given the mechanism of injury typically associated with these fractures.

Further Reading:

Alexander, M. & Belle, R (2012) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). New Jersey: Pearson. 

Bledsoe, B. E., Cherry, R. A. & Porter, R. S. (2023) Paramedic Care: Principles and Practice Volume 1 (6th Ed). New Jersey: Pearson. 

Brown, C. A., III., & Walls, R. M. (2023) The Walls Manual of Emergency Airway Management (6th Ed). Pennsylvania: Lippincott Williams & Wilkins. 

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). New Jersey. Pearson Education. 

Saturday, February 03, 2024

EMS Mnemonics - SALAD


For EMS providers, understanding the SALAD mnemonic in the context of airway management is crucial for effectively dealing with contaminated airways, particularly in emergency situations.

The SALAD (Suction-Assisted Laryngoscopy and Airway Decontamination) technique was developed by Dr. James DuCanto. Dr. DuCanto is an anesthesiologist and the Director of the Simulation Center at Aurora St. Luke's Medical Center in Milwaukee, Wisconsin. He is known for his contributions to airway management and the development of innovative techniques, including SALAD.

The SALAD technique is designed to address challenges in managing the airways of patients who are actively vomiting or have a risk of airway contamination. It involves the proactive use of suction to clear the upper airway before and during laryngoscopy, with the goal of optimizing visualization and reducing the risk of aspiration during emergency airway management. The technique often involves the use of the Ducanto catheter, a rigid suction catheter specifically designed for emergency airway situations.

Here's what EMS providers need to know about SALAD:

SALAD Mnemonic:

S - Suction-Assisted: The SALAD technique involves suction-assisted airway management. It emphasizes the proactive use of suction to clear the upper airway of contaminants such as blood, vomit, or other secretions.

A - Laryngoscopy & Airway Decontamination: SALAD stands for Suction-Assisted Laryngoscopy and Airway Decontamination. The primary goal is to optimize visualization during laryngoscopy while simultaneously decontaminating the airway.

L - Laryngoscope Blade-Like Use of Suction Catheter: The rigid suction catheter is used in a manner similar to a laryngoscope blade. It is employed to compress the tongue, distract the lower mandible, and lift the base of the tongue off the posterior pharyngeal wall. This technique aids in the insertion of oral airways, supraglottic airways (SGAs), and laryngoscopes.

A - Aspiration Prevention: One of the main objectives of SALAD is to prevent massive aspiration during emergency airway management. Proactive suctioning is employed before basic and advanced life support maneuvers to reduce the potential for forcing aspiration of airway contaminants.

D - Ducanto Catheter Utilization: The SALAD technique often involves the use of the Ducanto catheter, a rigid suction catheter designed for emergency airway management. The catheter assists in clearing the upper airway and plays a role in creating space during the insertion of oral airways, SGAs, and laryngoscopes.

Key Points for EMS Providers:

Clinical Context: SALAD is particularly relevant in situations involving copious secretions, blood, or emesis, such as out-of-hospital cardiac arrest (OHCA) scenarios.

Operator Proficiency: EMS providers must be technically proficient in the SALAD technique to ensure effective airway management without compromising the view of the airway.

Proactive Suctioning: The proactive use of suction as the initial step in emergency airway management is emphasized. This helps prevent aspiration during face mask ventilation and ventilation through SGAs.

Wider Application: While initially focused on managing contaminated airways, the SALAD technique's proactive use of a rigid suction catheter suggests potential applications in various emergency airway management scenarios.

Training: EMS providers should receive proper training and education on the SALAD technique, including the correct utilization of the Ducanto catheter and the proactive use of suction during airway interventions.

Understanding and implementing the SALAD mnemonic can enhance the capabilities of EMS providers in managing challenging airway situations, ultimately contributing to better patient outcomes during emergencies.

Further Reading:

Root, C. Et Al.(2020) Suction Assisted Laryngoscopy and Airway Decontamination (SALAD): A Technique For Improved Emergency Airway Management. Resuscitation Plus. Science Direct.

https://www.sciencedirect.com/.../pii/S2666520420300059 Accessed January 10, 2024

Thursday, February 01, 2024

EMS Pharmacology - Common Medication (Rx) Forms


Medications come in various dosage forms, each designed to deliver the medication in a specific way.

Some of the most common Rx dosage forms include:

Tablets and Capsules: These are solid dosage forms that contain the active ingredient(s) along with other inactive ingredients. They are taken orally and come in various shapes, sizes, and colors.

Liquid Solutions and Suspensions: These are liquid dosage forms where the active ingredient(s) are dissolved (solution) or suspended (suspension) in a liquid medium. They are often measured with a dropper or a measuring cup and can be administered orally.

Topical Preparations: These dosage forms are applied externally to the skin or mucous membranes and include creams, ointments, gels, lotions, and patches. They deliver medication locally to the affected area.

Injectables: These are dosage forms that are administered via injection into the body, either subcutaneously (under the skin), intramuscularly (into the muscle), or intravenously (into the vein). They include solutions, suspensions, and emulsions.

Suppositories: These are solid dosage forms that are inserted into the rectum, vagina, or urethra, where they dissolve or melt to release the medication. They are often used when oral administration is not feasible or when rapid absorption is needed.

Nasal Sprays and Inhalers: These are dosage forms designed for administration through the nasal passage or inhalation into the lungs. They deliver medication directly to the respiratory tract and are commonly used for conditions such as asthma or allergies.

Eye Drops and Ear Drops: These are liquid dosage forms administered directly into the eyes or ears. They are used to treat various eye and ear conditions and deliver medication locally to these areas.

Powders for Reconstitution: Some medications are supplied as powders that need to be mixed with a liquid (such as water or saline) before administration. These are often used for oral solutions or suspensions.

The choice of dosage form depends on various factors including the route of administration, the intended site of action, patient preference, and the characteristics of the medication itself.

Tuesday, January 30, 2024

EMS Pharmacology - FDA Pregnancy Category



The FDA Pregnancy Category system classifies drugs according to their safety for use during pregnancy.

It is a system used by the U.S. Food and Drug Administration (FDA) to categorize the risk of fetal harm associated with the use of medications during pregnancy.

The categories are as follows:

Category A: Adequate and well-controlled studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters).

Category B: Animal reproduction studies have failed to demonstrate a risk to the fetus, but there are no adequate and well-controlled studies in pregnant women.

Category C: Animal reproduction studies have shown adverse effects on the fetus, and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

Category D: There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

Category X: Studies in animals or humans have demonstrated fetal abnormalities, and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.

It's worth noting that the FDA has moved away from this system in recent years, and labeling now includes more detailed information about the risks associated with drug use during pregnancy rather than simply assigning a category.

Further Reading:

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Pearson.

Guy, J. S. (2019) Pharmacology for the Prehospital Professional (2nd Ed) Jones & Bartlett Learning.