EMS Celebrations - February is Heart Month!

As we celebrate American Heart Month, let us take a moment to acknowledge the critical role EMS plays in improving outcomes for cardiac emergencies.

From responding to myocardial infarctions to managing full cardiac arrests, prehospital providers are essential in delivering early, life-saving care. However, our work is far from over. The evolution of EMS has demonstrated that rapid response alone is not enough —our decisions and interventions directly influence patient survival and recovery rates.

Thanks to organizations like the American Heart Association and the American Red Cross, we have developed effective prehospital treatments and established the "Chain of Survival," which underscores the importance of early recognition, immediate CPR, rapid defibrillation, advanced care, and post-resuscitation support.

While EMS is a vital component of this system, transforming cardiac care requires a comprehensive, multidisciplinary approach.

By utilizing both basic and advanced cardiac life support, we can make a meaningful impact and improve patient outcomes.

Let us continue striving for advancements, refining our techniques, and enhancing our response to cardiac emergencies to save more lives.

Source: JEMS - Emergency Medical Services

Recommended CPR Training Providers: 

Bethesda, Wales, UK: Active First Aid

Littleton, Colorado, USA: Colorado Cardiac CPR

International: Crossing Latitudes 

EMS Environmental Emergencies - Lightning Related Incidents

Each year, lightning-related fatalities surpass those caused by tornadoes, hurricanes, and earthquakes combined, highlighting the frequency and severity of these incidents. 

However, lightning strike injuries are often an underestimated component of environmental emergencies that EMS Providers must be prepared to handle. 

Lightning strikes not only present unique mechanisms of trauma but can also lead to high morbidity and sudden fatalities. These incidents demand rapid, informed, and skillful response due to their sudden and unpredictable nature.

EMS Providers play a crucial role as the first line of care in such emergencies, especially given that lightning strikes often occur in remote or outdoor areas where specialized medical assistance is not immediately available. 

Recognizing lightning as the second most common storm-related cause of death - surpassed only by flash floods - emphasizes the need for comprehensive training and awareness.

Mechanisms of Lightning Injury

The mechanisms of injury (MOI) are multifaceted, ranging from direct strikes to complex indirect effects like ground current and blast injuries. 

These factors make understanding the nature of lightning-related incidents vital for effective prehospital management and prevention of complications.

EMS providers must understand the primary mechanisms of injury associated with lightning strikes to properly assess and manage patients:

Direct Hit: Occurs when a person is directly struck by lightning, most often in open spaces such as fields or meadows.

Splash Lightning: Lightning can strike an object and "splash" or jump to another nearby object or person, following the path of least resistance.

Ground Current: The most frequent cause of injury, where lightning hits the ground nearby, and the electrical current radiates outward. If someone is within this radius, the current can pass through or over the body.

Blast Injury: The rapid expansion of air from a lightning strike can create an explosive force, causing secondary trauma.

Contact Injury: Occurs when a person is touching an object that conducts electricity, such as a wire fence or a corded phone.

Signs and Symptoms of Lightning Injury

Lightning strikes can present with a range of symptoms, including:

Cardiac / Respiratory Arrest: Immediate life-threatening emergencies.

Neurological Impacts: Loss of consciousness, seizures, paralysis, and balance issues.

Burns: Typically minor due to the "flashover" effect where current passes over the body.

Sensory Disturbances: Temporary blindness or deafness.

Trauma: Injuries resulting from being thrown by the force of a strike.

Key Treatment Principles

Scene Safety: Ensure the scene is safe, as lightning can strike the same area more than once.

Basic Life Support (BLS): Be prepared for prolonged rescue breathing and CPR as needed.

Comprehensive Examination: Conduct a thorough assessment of the patient and treat injuries accordingly.

Continuous Monitoring: Keep a close watch for any changes in the patient's condition.

Evacuation: Transport any individual struck by lightning for further evaluation and care.

Prevention Tips for Lightening Safety

EMS Providers should be aware of preventive strategies to minimize lightning injuries:

Seek Shelter: In urban areas, take refuge in buildings (avoid small sheds) or vehicles. The motto “When thunder roars, go indoors” underscores the urgency.

In outdoor areas, select locations surrounded by a uniform stand of trees or low, rolling terrain.

Understand Risk Areas: Recognize that while some outdoor locations are safer than others, no place outside is completely safe during a lightning storm.

Monitor Weather: Be aware of local weather patterns and avoid exposure to known risk zones during storms.

Avoid High-Risk Locations:

• Elevated areas such as peaks, ridges, and hills
• Isolated tall objects (e.g., single trees)
• Open fields or meadows
• Large bodies of water and shorelines
• Shallow cave entrances or overhangs
• Previously struck areas
• Long conductors like wire fences, pipes, or wet ropes

Insulate and Disperse: When moving to a safer location is impractical:

Insulate yourself from ground current by crouching in the lightning position (heels together, minimizing contact with the ground).

Encourage group members to spread out to minimize the risk of multiple casualties.

In Conclusion

EMS Providers should be equipped with the knowledge to recognize the broad spectrum of signs and symptoms that can accompany lightning injuries, from cardiac arrest and neurological damage to less apparent conditions like temporary blindness or minor burns. 

The potential for cardiac and respiratory arrest underscores the necessity of timely and proficient Basic Life Support (BLS). Additionally, ensuring scene safety is paramount, as lightning can strike the same location more than once, posing a continued threat to both the patient and the responder.

Given the unpredictable nature of storms, EMS teams must be adept at prevention, risk assessment, and patient education to minimize exposure and injury rates. 

By understanding these principles and preventive measures, EMS Providers can effectively manage and mitigate the risks associated with lightning injuries during environmental 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

Gookin, J. (2011) Backcountry Lightning Risk Management. NOLS. Accessed October 24, 2024

Grayson, S. & Gandy, W. (2011) Environmental Emergencies. EMS World Online. Accessed November 8, 2024.

Limmer, D., O'Keefe, M. F., & Dickinson, E. T. (2020) Emergency Care (13th Ed) - Chapter 31: Environmental Emergencies. Accessed November 8, 2024

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

Oglesbee, S. (2014) Considerations When Assessing & Treating Patients with Lightning Injuries. Journal of Emergency Medical Services. Accessed October 26, 2024

Osmosis (ND) Environmental Emergencies. Elsevier. Accessed October 8, 2024

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

Schimelpfenig, T. (2021) NOLS Wilderness Medicine (7th Ed). Mechanicsburg, Pennsylvania: Stackpole Books

EMS Anatomy & Physiology - Mammalian Diving Response Syndrome

EMS Providers should be familiar with the Mammalian Diving Response Syndrome as it is a physiological reflex that can have critical implications during emergency scenarios, especially those involving drowning, cold-water immersion, or apnea. 

Here are some key points to know:

Definition:

The Mammalian Diving Response Syncdrome is a reflex primarily triggered by submersion in cold water or holding one’s breath. 

It is characterized by specific physiological changes that help conserve oxygen and protect vital organs during hypoxia. 

This response is more pronounced in children and is part of an evolutionary adaptation found in many mammals.

Physiological Mechanisms:

The diving response involves three primary components:

- Bradycardia: The heart rate slows down significantly to reduce oxygen consumption by non-essential tissues.

- Peripheral Vasoconstriction: Blood vessels in the extremities constrict, redirecting blood flow to vital organs like the brain and heart.

- Blood Shift (during deep dives): In humans, blood is directed away from the lungs and limbs to maintain pressure and prevent lung collapse during deep dives.

Triggers:

Submersion of the face in water, especially cold water.

Holding breath (apnea).

Psychological stress, such as fear or panic.

Clinical Implications for EMS: 

Understanding the diving response is crucial because it affects how a patient may present and how to manage their condition:

- Bradycardia Management: EMS providers might encounter significantly reduced heart rates in drowning or near-drowning victims.

Bradycardia could be misinterpreted as a sign of severe hypoxia, but it’s a protective mechanism rather than a sign of complete cardiac failure.

Avoid aggressive measures to increase heart rate unless the patient shows other signs of instability.

- Respiratory Considerations: The diving response may cause prolonged breath-holding, so patients might appear apneic or have delayed hypoxic symptoms.

Observe for hypoxia carefully and administer oxygen as indicated.

- Pediatric Considerations: The diving response is more prominent in children, which is why some drowning victims can survive prolonged submersion with relatively less neurological damage.

Cold water can extend the safe resuscitation window in pediatric patients.

- Cardiac Arrest in Cold Water: During cold water submersion, the body’s metabolic rate decreases significantly, which can potentially improve resuscitation outcomes even after prolonged submersion.

Follow hypothermia protocols and prolonged resuscitation efforts in cases of drowning in cold water.

Treatment and Management:

- ABC Approach: Focus on Airway, Breathing, and Circulation.

Hypothermia Management: Consider hypothermia treatment protocols as the mammalian diving response is often accompanied by cold water immersion.

Consider ECLS/ECMO in severe cases: In cases of cardiac arrest with diving reflex activation, specialized centers might use Extracorporeal Life Support (ECLS) or Extracorporeal Membrane Oxygenation (ECMO).

Key Takeaways:

Do not confuse bradycardia with imminent cardiac arrest. It can be a protective adaptation.

Cold-water submersion can improve survival outcomes—keep in mind for prolonged resuscitation in cold environments.

Children are more likely to benefit from the diving response due to their physiology.

Understanding this reflex allows EMS providers to better assess, treat, and manage patients exposed to cold water or other scenarios that can induce the diving response.

Who Discovered The Mammalian Diving Response Syndrome?

The mammalian diving response was first described by Edmund Goodwyn in 1786. However, it was extensively studied and popularized by Paul Bert and later Johan E. Severin Nilsson in the late 19th and early 20th centuries.

Goodwyn, a British physician, observed physiological changes in animals and humans during submersion. His initial work laid the foundation for understanding the reflex, but it was Paul Bert who made significant contributions by studying the effects of breath-holding and diving on the heart rate and blood flow.

Johan E. Severin Nilsson, a Swedish physiologist, further refined the concept, investigating how immersion and apnea affected circulation and oxygen usage in various mammals. His research solidified the understanding of the mammalian diving reflex as a protective adaptation seen across multiple species, including humans.

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

Godek, D., & Freeman, A. M. (2022) Physiology, Diving Reflex. Treasure Island, Florida: StatPearls Publishing

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

Panneton, W. M. (2013) The Mammalian Diving Response: An Enigmatic Reflex To Preserve Life? Physiology 28(5): 284-97. Accessed October 6, 2024

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

EMS Pediatric Populations - Pediatric Emergencies

EMS providers should have knowledge and skills to effectively manage pediatric emergencies.

Here are some key points they should know:

1. Pediatric Assessment: Understanding the differences in anatomy, physiology, and vital signs between adults and children is crucial. Providers should be skilled in performing a thorough pediatric assessment, including assessing airway, breathing, circulation, disability, and exposure (ABCDE).

2. Airway Management: Pediatric airways are smaller and more easily obstructed than adult airways. Providers should be proficient in managing pediatric airway emergencies, including using appropriate airway adjuncts and techniques such as bag-mask ventilation and endotracheal intubation.

3. Respiratory Distress: Common respiratory emergencies in children include asthma, bronchiolitis, and croup. Providers should be familiar with respiratory assessment, oxygen therapy, and administering nebulized medications.

4. Cardiac Arrest and CPR: Pediatric cardiac arrest requires prompt recognition and intervention. Providers must be skilled in pediatric cardiopulmonary resuscitation (CPR), including chest compressions, ventilation, and the use of automated external defibrillators (AEDs).

5. Fever and Sepsis: Fever is a common presentation in pediatric patients. EMS providers should recognize signs of serious bacterial infections, sepsis, and know how to provide appropriate supportive care during transport.

6. Allergic Reactions: Anaphylaxis and severe allergic reactions can be life-threatening. Providers should be trained in recognizing and managing allergic emergencies, including the administration of epinephrine.

7. Trauma: Pediatric trauma may present differently than adult trauma. Providers should know how to assess and manage common pediatric injuries, including fractures, head injuries, and burns. They should also consider the psychological needs of the child and provide age-appropriate support.

8. Seizures: Seizures can occur in children due to various causes. Providers should be familiar with seizure recognition, seizure management, and appropriate administration of anti-seizure medications.

9. Dehydration: Children are more prone to dehydration due to their smaller fluid reserves. Providers should be able to assess and manage pediatric patients with suspected dehydration, including fluid resuscitation if necessary.

10. Communication and Psychological Support: Effective communication with both the child and their parents or caregivers is vital. Providers should use age-appropriate language, provide reassurance, and involve parents or caregivers in the decision-making process.

These are general considerations, and ongoing training and education in pediatric emergency care are essential for EMS providers to ensure optimal care for children in emergencies.