EMS Celebrations - National Public Safety Telecommunications Week

This week, we honor the unseen heroes who serve as the crucial first point of contact in emergencies—our emergency dispatchers.

Emergency dispatchers play a vital role in ensuring the safety and well-being of our communities. They are the calm voice in the chaos, the steady presence in moments of panic, and the link between those in need and the help they require. 

Whether it’s a medical emergency, a fire, or a crime in progress, dispatchers are the ones who gather critical information, coordinate with first responders, and provide life-saving instructions—all while remaining composed under pressure.

These dedicated professionals work tirelessly behind the scenes, often without recognition, yet their impact is felt every day. Their quick thinking, compassion, and professionalism help save lives and keep our neighborhoods safe.

To all emergency dispatchers: thank you for your unwavering commitment, your strength in stressful situations, and your vital service to our communities. You are truly the lifeline in times of crisis, and we are deeply grateful for everything you do.

Happy National Public Safety Telecommunications Week!

EMS Hepatic Emergencies - Adults v Pediatric Jaundice

When EMS Providers encounter jaundice in patients, understanding the differences between adult and pediatric cases is essential for accurate assessment and intervention.

1. Etiology of Jaundice:

Adults: Jaundice in adults is often associated with liver disease, such as hepatitis, cirrhosis, or obstruction due to gallstones or tumors. 

Hemolysis (excessive breakdown of red blood cells) or pancreatic issues can also contribute to jaundice.

Pediatrics: In newborns and infants, jaundice is commonly due to physiological immaturity of the liver, resulting in an inability to process bilirubin efficiently. 

This condition is often benign and termed physiologic jaundice. Pathological causes in children can include hemolytic disease, infections, or biliary atresia.

2. Prevalence and Presentation:

Adults: Jaundice in adults is usually less common and more indicative of a potentially severe underlying condition. 

It may present with other signs of systemic illness, such as fever, weight loss, or abdominal pain.

Pediatrics: Jaundice is quite common in neonates, particularly in the first week of life. It may be noticeable in the eyes (scleral icterus) or skin. 

In older children, it is less common and may point to a serious issue.

3. Assessment Differences:

Adults: EMS providers should look for signs of liver dysfunction, such as changes in mental status (e.g., confusion or altered consciousness), abdominal distention, and a history of alcohol use or liver disease. 

Asking about dark urine or pale stools can also help identify underlying liver or biliary issues.

Pediatrics: In infants, checking for jaundice involves examining the skin under natural light. Special attention should be given to whether the jaundice is spreading from the face downward, which indicates increasing bilirubin levels. 

Noting feeding difficulties, lethargy, or poor weight gain is crucial in assessing severity.

4. Immediate Concerns:

Adults: Jaundice in adults often requires further evaluation for signs of liver failure, coagulopathy (e.g., easy bruising or bleeding), or potential sepsis in cases where infection is suspected.

Pediatrics: For neonates, a high bilirubin level (severe hyperbilirubinemia) can be a medical emergency, as it can lead to kernicterus, a type of brain damage. 

Any signs of jaundice persisting beyond two weeks or coupled with symptoms like high-pitched crying or arching of the back should prompt urgent attention.

5. Management Focus:

Adults: Management is often supportive, with emphasis on addressing the underlying condition. Transporting the patient to a facility equipped to diagnose liver issues is key.

Pediatrics: For neonatal jaundice, EMS Providers should ensure the baby is kept warm and hydrated. 

Transport to a pediatric-capable facility is crucial if severe jaundice or any concerning symptoms are noted.

Understanding these distinctions helps EMS Providers make informed decisions and prioritize care when faced with a jaundiced patient, ensuring they tailor their approach according to the patient's age and likely causes.

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

EMS Hepatic Emergencies - Scleral Icterus v Jaundice

For EMS providers, understanding the nuances of scleral icterus and jaundice is essential for accurate assessment and early intervention.

1. Scleral Icterus

Definition: Yellowing of the sclera (whites of the eyes) without concurrent skin yellowing.

Clinical Significance: Often the first visible sign of elevated bilirubin levels and an early indicator of liver dysfunction or hemolysis.

Implications: Identifying scleral icterus can suggest underlying conditions such as hepatitis, cirrhosis, or hemolytic anemia. 

Early detection can prompt the EMS Provider to prioritize further evaluation and expedite transport to the appropriate care facility.

2. Jaundice

Definition: Yellowing of both the skin and the whites of the eyes due to high levels of bilirubin in the blood.

Progression: Jaundice usually follows scleral icterus if the underlying cause continues or worsens.

Causes:

Pre-Hepatic: Conditions causing excessive breakdown of red blood cells (e.g., hemolysis).

Hepatic: Liver conditions impairing bilirubin processing (e.g., hepatitis, cirrhosis).

Post-Hepatic: Obstructions in bile flow (e.g., gallstones, tumors).

Symptoms & Associated Signs: Patients may also have dark urine, pale stools, fatigue, abdominal pain, and pruritus (itching).

Key Points for EMS Providers:

Assessment: Use adequate lighting when checking for scleral icterus or jaundice. Assess the patient’s history for recent liver disease, alcohol use, or risk factors for hemolysis.

Documentation: Record any visible signs and associated symptoms such as abdominal pain, confusion, or changes in consciousness, which could indicate worsening liver function or biliary obstruction.

Critical Situations: Rapidly progressive jaundice with symptoms such as altered mental status or significant abdominal pain may indicate acute liver failure or biliary sepsis, requiring urgent care.

Communication: Inform receiving facilities of the findings, which can be crucial for directing lab tests (e.g., liver function tests) and determining appropriate interventions.

Understanding these conditions allows EMS Providers to recognize early signs of potentially serious illnesses and ensure timely and effective patient management. 

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

EMS Airway Management - RSI v DSI

EMS providers should understand the key differences between Delayed Sequence Intubation (DSI) and Rapid Sequence Intubation (RSI) to determine the most appropriate approach for managing a patient's airway in critical situations.

Here are some things to know:

1. PURPOSE AND INDICATIONS

Rapid Sequence Intubation (RSI):

Purpose:

• RSI is designed to secure the airway quickly and efficiently by inducing unconsciousness and paralysis in a matter of seconds, allowing for immediate intubation.

Indications:

• RSI is used in situations where a patient requires immediate airway control, such as in cases of severe respiratory failure, trauma, or cardiac arrest, and where the patient is unable or unlikely to tolerate laryngoscopy without pharmacologic assistance.

Delayed Sequence Intubation (DSI):

Purpose:

• DSI is a modified version of RSI that allows for the controlled induction of unconsciousness in a patient who needs preoxygenation but is either combative, anxious, or unable to tolerate preoxygenation.
• The key difference is that DSI provides a window for preoxygenation after sedation but before paralysis.

Indications:

• DSI is particularly useful in patients with conditions like severe hypoxia, agitation, or anxiety, where cooperative preoxygenation is necessary but not possible without sedation.
• It’s often employed in cases where hypoxemia needs to be optimized before intubation.

2. SEQUENCE OF STEPS

RSI Steps:

• Preoxygenation: The patient is preoxygenated, typically with a non-rebreather mask or BVM.
• Induction and Paralysis: Sedative and paralytic agents are administered almost simultaneously to rapidly induce unconsciousness and paralysis.
• Intubation: The patient is immediately intubated once paralysis sets in, typically within seconds to a minute of drug administration.

DSI Steps:

• Sedation: The patient is sedated first, usually with a dissociative agent like ketamine, allowing them to tolerate preoxygenation without agitation.
• Preoxygenation: After sedation, the patient is preoxygenated in a more controlled manner, improving oxygen reserves before proceeding to intubation.
• Paralysis and Intubation: Once adequate preoxygenation is achieved, a paralytic is administered, and the patient is then intubated as in RSI.

3. KEY DIFFERENCES IN APPROACH

Sedation Timing:

• RSI: Sedation and paralysis occur almost simultaneously, leaving little time for any further patient preparation or intervention.
• DSI: Sedation is performed first, allowing the patient to be more effectively preoxygenated while still breathing spontaneously.

Oxygenation Focus:

• RSI: The priority is rapid intubation, often under the assumption that the patient has been adequately preoxygenated beforehand.
• DSI: The focus is on improving oxygenation in patients who are at risk of severe hypoxia before intubation, using the sedation phase to achieve better preoxygenation.

Patient Condition:

• RSI: Best suited for patients who can be adequately preoxygenated before the induction of anesthesia and paralysis.
• DSI: Ideal for patients who are agitated, hypoxic, or otherwise unable to cooperate with preoxygenation due to altered mental status, respiratory distress, or other factors.

4. ADVANTAGES AND DISADVANTAGES

Rapid Sequence Intubation:

Advantages:

• Quick and efficient airway control.
• Reduces the risk of aspiration and airway trauma.

Disadvantages:

• In patients who are not adequately preoxygenated, the risk of hypoxia during the apneic period is higher.
• May be challenging in patients who are difficult to preoxygenate or who have an unstable airway.

Delayed Sequence Intubation :

Advantages:

• Allows for better preoxygenation in high-risk patients.
• Reduces the risk of hypoxia during intubation by optimizing oxygen levels before paralysis.

Disadvantages:

• Takes longer than RSI, which may not be suitable in situations requiring immediate airway control.
• Requires careful monitoring to ensure that the patient remains adequately sedated without losing airway reflexes prematurely.

5. CLINICAL CONSIDERATIONS

Patient Selection:

• RSI: Preferred in situations where time is of the essence, and the patient is at immediate risk of airway compromise.
• DSI: Considered in cases where there is enough time to optimize the patient’s oxygenation before paralysis, especially in patients who are at high risk for desaturation or in those who are uncooperative.

Skill and Experience:

• Both RSI and DSI require advanced airway management skills. EMS providers must be adept at assessing the patient’s condition and deciding which approach is most appropriate.

CONCLUSION

Understanding the differences between DSI and RSI allows EMS providers to tailor their approach to the specific needs of the patient. While RSI is the standard for rapid airway control, DSI provides an important alternative for patients who need improved oxygenation before intubation.

The choice between the two depends on the patient's condition, the urgency of the situation, and the provider's assessment of the most effective strategy for ensuring a successful intubation.

Further Reading:

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

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

Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins

Fatolitis, N. (2022) Keys To Success For Airway Management. EMS Airway. https://emsairway.com/.../keys-to-success-for-airway.../... Accessed July 26, 2024

Laramie Fire Department (2024) Adult RSI Protocol. City of Laramie. https://www.cityoflaramie.org/DocumentCenter/View/29299/RSI-1-Adult-RSI-PROTOCOL? Accessed August 13, 2024

NAEMT (2023) PHTLS: Prehospital Trauma Life Support (10th Ed). Burlington, Massachusetts: Jones & Bartlett Learning.

Nickson, C. (2024) Delayed Sequence Intubation (DSI). Life In The Fast Lane. https://litfl.com/delayed-sequence-intubation-dsi/ Accessed August 13, 2024

Nickson, C. (2024) Rapid Sequence Intubation (RSI). Life In The Fast Lane. https://litfl.com/rapid-sequence-intubation-rsi/ Accessed July 26, 2024

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

EMS Medical Emergencies - Alcohol Poisoning & Withdrawal

EMS Providers play a crucial role in assessing and managing individuals who may be experiencing alcohol poisoning or withdrawal. 

Here are some key things that EMS providers need to know about these conditions:

Alcohol Poisoning:

1. Recognizing the Signs: EMS providers should be able to recognize the signs and symptoms of alcohol poisoning, which can include confusion, vomiting, seizures, slow or irregular breathing, hypothermia, and unconsciousness.

2. Assessment: Perform a thorough assessment of the patient's vital signs, including heart rate, blood pressure, and respiratory rate. Pay close attention to any signs of respiratory distress or decreased consciousness.

3. Airway Management: Ensure that the patient's airway is clear and open. If there is a risk of airway obstruction due to vomiting, position the patient on their side (recovery position) to prevent aspiration.

4. Breathing: Monitor the patient's breathing closely. Administer supplemental oxygen if necessary and be prepared to assist with artificial ventilation if the patient's breathing becomes inadequate.

5. Circulation: Assess the patient's circulation, and be prepared to administer intravenous fluids if needed to treat dehydration and maintain blood pressure.

6. Transport: Patients with alcohol poisoning should be transported to the hospital for further evaluation and treatment. This is especially important if the patient's level of consciousness is severely impaired or if they have any other concerning symptoms.

Alcohol Withdrawal:

1. Recognition: EMS providers should be able to recognize the signs and symptoms of alcohol withdrawal, which can include anxiety, agitation, tremors, hallucinations, seizures, and potentially life-threatening conditions like delirium tremens (DT).

2. Assessment: Perform a comprehensive assessment of the patient's vital signs, including heart rate, blood pressure, and respiratory rate. Pay attention to signs of dehydration and electrolyte imbalances.

3. Seizure Management: Patients experiencing alcohol withdrawal may be at risk of seizures. Be prepared to manage seizures with appropriate medications and airway management if necessary.

4. Delirium Tremens (DT): Recognize the signs of DT, which is a severe form of alcohol withdrawal characterized by hallucinations, severe confusion, and cardiovascular instability. Patients with DT require intensive medical intervention and should be transported to the hospital immediately.

5. Psychiatric Assessment: Assess the patient's mental status and level of distress. Patients experiencing severe alcohol withdrawal may require psychiatric evaluation and treatment.

6. Transport: Patients experiencing alcohol withdrawal, especially those with severe symptoms, should be transported to a medical facility for evaluation and appropriate management.

7. Prevention: In cases of known alcohol dependence, consider providing information and resources for alcohol addiction treatment and rehabilitation.

It's important for EMS providers to stay up-to-date with the latest guidelines and protocols related to alcohol poisoning and withdrawal in their region, as these may vary. 

Additionally, effective communication with the receiving medical facility is crucial to ensure a seamless transition of care for the patient.

#EMS #MedicalEmergencies #AlcoholPoisoning #AirwayManagement 

#AlcoholWithdrawal #DeliriumTremens