Wednesday, May 29, 2024

EMS Pharmacology - IV Solutions Part Two


EMS Providers must understand the different properties, uses, and potential complications associated with isotonic, hypertonic, and hypotonic solutions to provide optimal care in various clinical scenarios. 

Here’s a breakdown with examples, advantages, and disadvantages for each type of solution:

Isotonic Solutions

An isotonic solution has the same concentration of solutes (e.g sodium) as blood plasma, preventing significant fluid shifts between compartments. 

It stays in the bloodstream, increasing intravascular volume. 

Examples:

  • Normal Saline (0.9% Sodium Chloride)
  • Lactated Ringer’s Solution (LR)
  • D5W (5% Dextrose in Water) - initially isotonic, but becomes hypotonic once dextrose is metabolized.

Advantages:

  • Volume Expansion: Effective for increasing intravascular volume without causing significant fluid shifts between compartments.
  • Versatility: Can be used in a wide range of conditions including dehydration, shock, and blood loss.
  • Compatibility: Generally well-tolerated and compatible with most medications and other IV fluids.

Disadvantages:

  • Risk of Fluid Overload: Can cause or exacerbate conditions like pulmonary edema or heart failure in patients with compromised cardiac function.
  • Electrolyte Imbalances: Long-term use can lead to imbalances, particularly with Normal Saline, which may cause hyperchloremic acidosis.

Hypertonic Solutions

A hypertonic solution has a higher concentration of solutes (e.g., sodium) than blood plasma, causing water to move out of cells into the bloodstream. 

This helps increase intravascular volume and reduce swelling. 

Examples:

  • 3% Sodium Chloride
  • D5NS (5% Dextrose in Normal Saline)
  • D10W (10% Dextrose in Water)

Advantages:

  • Rapid Volume Expansion: Quickly draws fluid into the intravascular space from the interstitial and intracellular compartments, useful in cases of severe hyponatremia or cerebral edema.
  • Elevating Blood Pressure: Helps increase blood pressure more rapidly in hypovolemic patients.

Disadvantages:

  • Cellular Dehydration: Can cause cells to shrink due to osmotic fluid shifts, potentially leading to dehydration at the cellular level.
  • Vascular Irritation: High osmolarity solutions can irritate veins, potentially causing phlebitis or damage to blood vessels.
  • Risk of Hypernatremia: Overuse can lead to elevated sodium levels and associated complications.

Hypotonic Solutions

A hypotonic solution has a lower concentration of solutes (e.g., sodium) than blood plasma, causing water to move into cells. 

This helps hydrate cells and lower serum sodium levels.

Examples:

  • 0.45% Sodium Chloride (Half Normal Saline)
  • 0.33% Sodium Chloride
  • D5W (after metabolism of dextrose)

Advantages:

  • Hydration of Cells: Helps hydrate cells and correct intracellular dehydration, useful in conditions such as diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).
  • Reduction of Serum Osmolality: Lowers serum osmolality, aiding in the correction of hypernatremia.

Disadvantages:

  • Risk of Hyponatremia: Excessive administration can dilute plasma sodium levels, leading to hyponatremia.
  • Cerebral Edema: In susceptible individuals, hypotonic solutions can exacerbate cerebral edema by increasing intracranial pressure.
  • Not for Volume Expansion: Ineffective for patients needing rapid intravascular volume expansion as the fluid quickly shifts into cells and interstitial spaces.

Key Considerations for EMS Providers

  • Isotonic Solutions:

    • When to Use: Ideal for general fluid resuscitation, dehydration, shock, and blood loss. For example, a trauma patient with significant blood loss may benefit from Normal Saline or Lactated Ringer’s.
    • When to Avoid: Caution in patients with renal or heart failure to prevent fluid overload.

  • Hypertonic Solutions:

    • When to Use: Useful in treating severe hyponatremia or cerebral edema. For example, a patient with a traumatic brain injury and signs of increased intracranial pressure may benefit from 3% Sodium Chloride.
    • When to Avoid: Avoid in patients with dehydration or conditions where cellular dehydration would be detrimental.

  • Hypotonic Solutions:

    • When to Use: Effective for treating hypernatremia or cellular dehydration. For example, a patient in DKA with elevated blood glucose and dehydration may be treated with Half Normal Saline.
    • When to Avoid: Not suitable for patients needing rapid intravascular volume expansion, and should be used cautiously in patients with potential for cerebral edema.

Summary

  • Isotonic Solutions are versatile and suitable for most situations requiring volume expansion.
  • Hypertonic Solutions are potent and used in specific scenarios like severe hyponatremia or cerebral edema.
  • Hypotonic Solutions are effective for cellular hydration but must be used cautiously to avoid complications like hyponatremia and cerebral edema.

EMS Providers should choose the appropriate type of IV solution based on the patient’s clinical condition, understanding the benefits and risks associated with each to ensure safe and effective patient care.

Further Reading:

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

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

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

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

Monday, May 27, 2024

EMS Pharmacology - IV Solutions Part One


EMS Providers must have a clear understanding of the different types of IV solutions, including crystalloids, colloids, and blood products, and their appropriate uses to ensure effective patient care in various medical scenarios. 

Here is an overview:

Crystalloid Solutions

Types:

  • Normal Saline (0.9% Sodium Chloride): Isotonic solution commonly used for fluid resuscitation.
  • Lactated Ringer’s Solution: Isotonic solution containing electrolytes, often used for trauma and burn patients.
  • D5W (5% Dextrose in Water): Hypotonic solution, initially isotonic but becomes hypotonic once dextrose is metabolized.

Uses:

  • Fluid Resuscitation: Effective for increasing intravascular volume in hypovolemia and dehydration.
  • Electrolyte Replacement: Suitable for maintaining or correcting electrolyte imbalances.
  • General Hydration: Used in various clinical situations requiring rehydration.

When Not to Use:

  • Pulmonary Edema: Excessive fluid administration can worsen pulmonary congestion.
  • Severe Hypoalbuminemia: Crystalloids do not replace lost proteins.

Colloid Solutions

Types:

  • Albumin: Natural protein solution, often used for volume expansion in hypoalbuminemia.
  • Hetastarch (HES): Synthetic starch solution used for volume expansion.
  • Dextran: Synthetic polysaccharide used for volume expansion.

Uses:

  • Hypovolemic Shock: Effective for rapid volume expansion due to their ability to remain in the intravascular space longer.
  • Burns and Trauma: Can be used when crystalloids alone are insufficient to maintain hemodynamic stability.

When Not to Use:

  • Coagulopathy: Some colloids can interfere with coagulation.
  • Renal Failure: Certain colloids can exacerbate renal dysfunction.
  • Allergic Reactions: Risk of anaphylaxis with synthetic colloids.

Blood Products

Types:

  • Packed Red Blood Cells (PRBCs): Used to increase oxygen-carrying capacity in anemia or hemorrhage.
  • Fresh Frozen Plasma (FFP): Contains clotting factors, used in coagulopathies.
  • Platelets: Used for thrombocytopenia or platelet function disorders.
  • Cryoprecipitate: Rich in fibrinogen, used in specific bleeding disorders.

Uses:

  • Severe Hemorrhage: To restore oxygen-carrying capacity and hemostasis.
  • Anemia: When hemoglobin levels are critically low and causing symptoms.
  • Coagulopathies: When there is a need to replace clotting factors or platelets.

When Not to Use:

  • Volume Expansion Alone: Blood products should not be used solely for volume expansion; crystalloids or colloids are more appropriate.
  • Allergic Reactions: Risk of transfusion reactions or infections.

Key Considerations for EMS Providers

  • Patient Assessment: Thorough assessment of the patient’s condition, including vital signs, history, and clinical presentation, is crucial to determine the appropriate IV solution.
  • Guidelines and Protocols: Adherence to local EMS protocols and guidelines is essential. These protocols are often based on evidence-based practices and can provide clear indications for the use of specific IV solutions.
  • Monitoring: Continuous monitoring of the patient’s response to the IV therapy is critical. Look for signs of improvement or deterioration, and be prepared to adjust the treatment plan accordingly.
  • Dosage and Administration: Knowledge of the correct dosages and administration rates for each type of IV solution is necessary to avoid complications such as fluid overload or electrolyte imbalances.
  • Communication: Effective communication with receiving hospital staff about the IV solutions administered and the patient's response to treatment is important for continuity of care.

Summary

  • Crystalloids are generally the first choice for fluid resuscitation and hydration.
  • Colloids are used for more aggressive volume expansion but have more potential side effects.
  • Blood Products are reserved for situations requiring restoration of oxygen-carrying capacity and hemostasis.

EMS Providers should be well-versed in the indications, contraindications, and potential complications of each type of IV solution to make informed decisions in the field and provide the best possible care to their patients.

Further Reading:

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

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

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

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

Saturday, May 25, 2024

EMS Research - Chest Decompressions: The Driver of CPR Efficacy


The study aims was to optimize cardiopulmonary resuscitation (CPR) efficacy by investigating the relationship between key CPR metrics: compression rate, depth, and recoil velocity.

The goal was to model the impact of these variables on CPR effectiveness, particularly through their influence on end-tidal carbon dioxide (ETCO2), which is a marker of perfusion.

The study emphasizes the crucial role of chest recoil in CPR effectiveness. The findings suggest that CPR guidelines should prioritize maximum chest recoil to improve hemodynamics and increase the chances of survival during cardiac arrest.

The research advocates for an increased focus on chest recoil in CPR training and guidelines, potentially leading to improved outcomes in cardiac arrest scenarios by enhancing the quality of perfusion during resuscitation efforts.
Further Reading:
Chandran, K., AlgazeGonzalez, I.M., Wang, S., & Davis, D.P. (2024) Chest Decompressions - the Driver of CPR Efficacy: Exploring The Relationship Between Compression Rate, Depth, Recoil Velocity & End-Tidal CO2. Taylor & Francis Online Accessed May 25, 2024

Thursday, May 23, 2024

EMS Celebration - History of EMS Week


President Gerald Ford established the first National Emergency Medical Services Week in 1974, and since then it has been celebrated on the third week of May every year. 

The goal of EMS Week was to raise awareness and pay tribute to the crucial work EMS professional do, often times risking their own safety and well-being in the pursuit to provide care to others. 

As it has evolved, we now celebrate it with various events that honor the achievements of EMS professionals, highlight the importance of EMS in healthcare, and advocate for the challenges and issues faced by the EMS community.

For the full article follow the link below: 

https://emsweek.org/2024/03/21/history-of-ems-week/

Further Reading:

Woodyard, D.R. (2023) EMS in the United States: Fragmented Past, Future of Opportunity. Colorado: Donnie Woodyard

Tuesday, May 21, 2024

EMS Week - What is EMS today?


Is it what you see on TV or in movies? EMS started as an improvement to service to transport you to a hospital, with treatment and care along the way.

For the first time we brought care to you – but only in an emergency. It was an enormous step up from a stretcher in a hearse supplied by a funeral home (because they had the vehicles).

From the extremes of defibrillating a cardiac patient in a marathon to assisting a senior citizen with her or his prescriptions for cancer treatment or congestive heart failure: is EMS an emergency service, a health care service or a preventive medical service?

The answer to that depends on who you ask, as EMS still has several delivery models and philosophical approaches.

Are we a community service in the continuum of healthcare or just the angels of 3:00 AM? We are balancing the original-and-since-improved, yet cobbled-together, EMS system as an essential service with the changing needs of healthcare for our citizenry.

Further Reading:

Woodyard, D. R. (2023) EMS in the United States: Fragmented Past, Future of Opportunity. Colorado: Donnie Woodyard

Sunday, May 19, 2024

EMS Celebration - EMS Week 50th Anniversary


“EMS Week celebrates all EMS providers who diligently care for their patients and communities in times of crisis,” states NAEMT President Susan Bailey, MSEM, NRP.

'Honoring Our Past, Forging Our Future’ reflects on the proud history and contributions of EMS practitioners. We must remain focused on evolving, innovating, and ensuring EMS has the necessary support to respond to the public's call for help effectively.

This year, marking the 50th anniversary of National EMS Week, we pay tribute to those who paved the way, challenging norms and setting higher standards.

Simultaneously, we anticipate the future, leveraging their work to shape a path for the next generation of EMS professionals dedicated to community service.

Activities:
Sunday, May 19: Health, Wellness & Resilience Day

Monday, May 20: EMS Education Day

Tuesday, May 21: EMS Safety Day

Wednesday, May 22: EMS for Children Day

Thursday, May 23: Save-A-Life Day (CPR & National Stop the Bleed Day)

Friday, May 24: EMS Recognition Day

Saturday, May 25: EMS Remembrance Day

Further Reading:

Woodyard, D.R. (2023) EMS in the United States: Fragmented Past, Future of Opportunity. Colorado: Donnie Woodyard

Friday, May 17, 2024

EMS Emergencies - Pediatric Patients


EMS providers need to be well-prepared to handle pediatric emergencies as they require specialized knowledge and skills due to the unique needs of children.

Here are some key points they should know:

  1. Respiratory Distress: Children commonly present with respiratory distress due to conditions such as asthma, bronchiolitis, or croup. EMS providers should be proficient in assessing respiratory status, administering oxygen, and managing airway obstructions.

  2. Febrile Seizures: Febrile seizures are common in young children and are often frightening for caregivers. EMS providers should know how to assess and manage febrile seizures, including ensuring adequate ventilation and preventing injury during the seizure.

  3. Trauma: Children are at risk for various types of trauma, including falls, burns, and motor vehicle accidents. EMS providers should be skilled in assessing and managing pediatric trauma, including immobilization techniques and pain management.

  4. Sepsis: Sepsis can be challenging to recognize in children, as symptoms may be nonspecific. EMS providers should be vigilant for signs of sepsis, such as fever, tachycardia, and altered mental status, and be prepared to initiate early treatment.

  5. Anaphylaxis: Allergic reactions, including anaphylaxis, can occur in children due to food allergies, insect stings, or medications. EMS providers should be trained in recognizing anaphylaxis and administering epinephrine as needed.

  6. Dehydration: Children are at increased risk for dehydration due to factors such as vomiting, diarrhea, or fever. EMS providers should be skilled in assessing hydration status and administering fluids as needed, especially in cases of severe dehydration.

  7. Seizures: Seizures can occur in children due to various causes, including epilepsy or febrile illnesses. EMS providers should know how to assess and manage seizures, including protecting the child from injury and administering appropriate medications if necessary.

  8. Poisoning: Accidental poisoning is a common pediatric emergency. EMS providers should be familiar with common toxins and their effects on children, as well as appropriate decontamination and treatment measures.

  9. Cardiac Arrest: While less common in children than in adults, cardiac arrest can still occur due to various causes, including congenital heart defects or respiratory failure. EMS providers should be proficient in pediatric CPR and advanced life support techniques.

  10. Communication & Family Support: Effective communication with caregivers is essential in pediatric emergencies. EMS providers should be skilled in providing clear and compassionate communication, as well as offering support to families during stressful situations.

By being knowledgeable about these common pediatric emergencies and having the necessary skills to assess and manage them effectively, EMS providers can play a crucial role in providing optimal care for children in emergency situations.

Further Reading:

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

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

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

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

Wednesday, May 15, 2024

EMS Emergencies - Geriatric Patients


EMS providers should be well-versed in managing common geriatric emergencies, as elderly patients often present with unique challenges due to age-related physiological changes and comorbidities. Here are some key points EMS providers should know:

  1. Recognition of Geriatric Syndromes: Understand common geriatric syndromes such as delirium, falls, urinary incontinence, and frailty. These may not present as typical medical emergencies but can significantly impact the overall health and well-being of older adults.

  2. Comprehensive Assessment: Perform a thorough assessment, considering the potential for atypical presentations of illness. Geriatric patients may not exhibit classic signs and symptoms of illness, so a high index of suspicion is crucial.

  3. Polypharmacy: Recognize the impact of polypharmacy on geriatric patients. Elderly individuals often take multiple medications, increasing the risk of drug interactions, adverse effects, and medication non-compliance.

  4. Dementia & Cognitive Impairment: Be prepared to manage patients with dementia or cognitive impairment. Communicate effectively, use clear and simple language, and involve family members or caregivers in the assessment and decision-making process.

  5. Mobility & Functional Status: Consider the patient's mobility and functional status when assessing and managing emergencies. Reduced mobility and functional limitations can affect the patient's ability to participate in care and may require adaptations in treatment approaches.

  6. Fall Prevention: Assess for fall risk factors and implement appropriate fall prevention strategies. Falls are a leading cause of morbidity and mortality in older adults and can result in serious injuries such as fractures, head trauma, and soft tissue injuries.

  7. Cardiovascular Emergencies: Be vigilant for cardiovascular emergencies such as myocardial infarction, heart failure, and arrhythmias, which are common in the elderly population. Older adults may present with atypical symptoms, so consider a broad differential diagnosis.

  8. Respiratory Emergencies: Recognize respiratory emergencies such as pneumonia, exacerbations of chronic obstructive pulmonary disease (COPD), and pulmonary embolism. Aging-related changes in the respiratory system can predispose older adults to respiratory infections and other pulmonary conditions.

  9. Sepsis: Be aware of the increased susceptibility of geriatric patients to infections and sepsis. Early recognition and prompt initiation of treatment are crucial to improve outcomes in this population.

  10. End-of-Life Care: Provide compassionate end-of-life care when appropriate. Understand the patient's wishes regarding resuscitation and advanced directives, and involve palliative care services as needed to ensure optimal symptom management and support for both the patient and their family.

By incorporating these considerations into their practice, EMS providers can effectively assess, manage, and optimize outcomes for geriatric patients experiencing emergencies.

Further Reading:

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

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

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

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

Monday, May 13, 2024

EMS Equipment - Mechanical Chest Compression Devices

EMS providers should be familiar with the LUCAS (Lund University Cardiopulmonary Assist System) device and similar mechanical chest compression devices as they can significantly impact the management of patients in cardiac arrest. 

Here are some key points regarding both advantages and disadvantages:

Advantages:

Consistency: Mechanical chest compression devices like LUCAS can provide consistent and uninterrupted compressions, ensuring that the quality and depth of compressions are maintained throughout resuscitation efforts. This consistency is often challenging to achieve with manual compressions, especially during prolonged resuscitation attempts.

Reduced Fatigue: Manual chest compressions can quickly lead to provider fatigue, resulting in decreased effectiveness over time. Mechanical devices alleviate this issue by delivering continuous compressions without fatigue, ensuring that high-quality compressions are maintained for extended periods.

Standardization: Mechanical devices offer standardized compression rates and depths, reducing the variability that can occur with manual compressions performed by different providers. This standardization helps optimize perfusion during cardiac arrest and improves outcomes.

Safety: Mechanical devices reduce the risk of injury to EMS providers during transport and resuscitation efforts, particularly in challenging environments such as moving ambulances or confined spaces where manual compressions may be difficult to perform safely.

Multitasking: By automating chest compressions, EMS providers can focus on other critical aspects of patient care, such as airway management, medication administration, and team coordination, without compromising the quality of compressions.

Disadvantages:

Cost: Mechanical chest compression devices like LUCAS can be expensive to purchase and maintain, potentially limiting their availability in some EMS systems. The initial investment in these devices and ongoing maintenance costs should be considered when evaluating their implementation.

Training Requirements: Proper training is essential for EMS providers to effectively use mechanical chest compression devices. Training should include device operation, troubleshooting, and integration into resuscitation protocols to ensure optimal patient outcomes.

Device Limitations: Mechanical devices may not be suitable for all patients, particularly those with certain anatomical characteristics or injuries. EMS providers must be aware of the device's limitations and know when manual chest compressions may be more appropriate.

Interruptions: Although mechanical devices aim to provide continuous compressions, interruptions may still occur during battery changes, device malfunctions, or transfer between care providers or settings. EMS providers should be prepared to quickly address and minimize these interruptions to maintain effective resuscitation efforts.

Patient Considerations: Some patients may experience discomfort or injury from mechanical chest compressions, such as rib fractures or skin abrasions. EMS providers should assess each patient's condition and adjust device settings or techniques accordingly to minimize potential harm.

Overall, mechanical chest compression devices like LUCAS offer several advantages in the management of patients in cardiac arrest, including consistency, reduced provider fatigue, standardization, safety, and the ability to multitask. 

However, EMS providers must also be aware of the associated disadvantages, such as cost, training requirements, device limitations, interruptions, and patient considerations, to ensure appropriate and effective use in clinical practice.

Further Reading:

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

Frascone, R. J. (2014) The Risk Versus Benefit of LUCAS: Is It Worth It? Anesthesiology 120: 797–798

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

Vitali (2022) The Lucas Device Explained  https://www.vitalipartners.com/blog/2022/08/the-lucas-device-explained-chest-compression-system/ Accessed May 12, 2024