Laryngospasm and Hypoxia after Ketamine

Posted by Patrick Lickiss on Feb 22, 2012 in General, Research, Treatment | 0 comments

There has been some talk recently about wanting to include ketamine in the pharmacopea for EMS providers. An interesting case study was published recently looking at a potential complication of providing ketamine for sedation:

Laryngospasm and Hypoxia after Intramuscular Administration of Ketamine to a Patient in Excited Delirium.
Prehosp Emerg Care. 2012 Jan 17;

Authors: Burnett AM, Watters BJ, Barringer KW, Griffith KR, Frascone RJ

ABSTRACT: An advanced life support emergency medical services (EMS) unit was dispatched with law enforcement to a report of a male patient with a possible overdose and psychiatric emergency. Police restrained the patient and cleared EMS into the scene. The patient was identified as having excited delirium, and ketamine was administered intramuscularly. Sedation was achieved and the patient was transported to the closest hospital. While in the emergency department, the patient developed laryngospasm and hypoxia. The airway obstruction was overcome with bag-valve-mask ventilation. Several minutes later, a second episode of laryngospasm occurred, which again responded to positive-pressure ventilation. At this point the airway was secured with an endotracheal tube. The patient was uneventfully extubated several hours later. This is the first report of laryngospam and hypoxia associated with prehospital administration of intramuscular ketamine to a patient with excited delirium.

Now I don’t know a whole lot about the pharmacodynamic of ketamine, is this something we need to worry about?  Is this an expected side effect in a portion of the population?  Is this simply an abbarency?  Has your system looked at alternate sedatives like ketamine? Let me know!

Adequacy of Pain Management in Children with Long Bone Fractures

Posted by Patrick Lickiss on Feb 15, 2012 in General, Research, Treatment | 6 comments

Continuing last week’s theme of trauma related research, today’s study is from the journal Pediatric Emergency Care and looks at emergency room management of pain in pediatric patients suffering from isolated long bone fractures. The researchers underwent a retrospective study to determine if patients ages 0-15 years were given adequate dosing based on standard, inadequate dosing or no pain medication at all when they presented with single long-bone fracture.

Here’s the abstract:

Pediatr Emerg Care. 2012 Jan 20. [Epub ahead of print]

Analgesic Administration in the Emergency Department for Children Requiring Hospitalization for Long-Bone Fracture.

Dong L, Donaldson A, Metzger R, Keenan H.

From the *Intensive Medicine Clincal Program, Intermountain Healthcare; †Department of Pediatrics, University of Utah; ‡Division of Pediatric Surgery, University of Utah School of Medicine, Primary Children’s Medical Center; and §Department of Pediatrics, University of Utah, Salt Lake City, UT.

OBJECTIVES: The objective of the study was to describe analgesia utilization before and during the emergency department (ED) visit and assess factors associated with analgesia use in pediatric patients with isolated long-bone fractures.

METHODS: This retrospective cohort study of patients aged 0 to 15 years with a diagnosis of an isolated long-bone fracture was conducted at a single, level I pediatric trauma center. Patients included were treated in the ED within 12 hours of injury and subsequently admitted to the hospital from January 2005 through August 2007. Pain medication received within the first hour after ED arrival was categorized based on prespecified standard doses as follows: adequate, inadequate, and no pain medication received. Cumulative logistic regression analysis assessed factors associated with analgesia use.

RESULTS: There were 773 patients with isolated long-bone fracture included in the analysis. Overall, 10% of patients received adequate pain medicine; 31% received inadequate medicine; and 59% received no pain medicine within 1 hour of ED arrival. In multivariable analysis, children with younger age, longer time from injury to ED arrival, closed fractures, and upper-extremity fractures were less likely to receive adequate pain medicine during the ED visit. Of those transported by emergency medical services directly from the scene to the ED, 9 (10%) of 88 were given pain medication during transport.

CONCLUSIONS: Pain management in pediatric patients following a traumatic injury has been recognized as an important component of care. This study suggests that alleviation of pain after traumatic injury requires further attention in both the prehospital and ED settings, especially among the youngest children.

A few interesting items jump out  when reviewing this study.  First, only 10% of patients were treated with adequate amounts of analgesia.  Second, 59% of patients received no pain management within the first hour of arriving.  Just to review, that’s 59% of patient 15 years and younger with long bone fractures receiving no pain medication whatsoever.  Finally, only 10% of patients arriving via EMS were given any pain medication at all.  There was no analysis performed on the adequacy of EMS dosing.  To review, that means that EMS did not give pain medication to 90% of pediatric patient with long bone fractures.  In short, this is unacceptable.

The researchers looked at root cause and found the expected variables: younger age, upper extremity fractures and closed fractures resulted in lower quantities of pain medication.  The EMS-related finding, however, is what upsets me the most about this paper.  If my son breaks an arm or a leg, the paramedics had better intend on giving him pain medication.  Same with the ED staff.

So what about you?  Do you treat pediatric patients as aggressively for pain as you do adults?  What about your co-workers?  What are some of the things that keep you from treating pediatrics aggressively?  Let me know in the comments.

Are Prehospital Trauma Triage Criteria Effective?

Posted by Patrick Lickiss on Feb 8, 2012 in Assessment, General, Research, Treatment | 0 comments

Chances are, the system you work in has a list of trauma criteria. Patients meeting such criteria are transported to specific trauma hospitals where advanced services are available. Some systems present their trauma criteria as guidelines while others are set in stone. Some systems mandate that certain criteria be activated while others are left to the discretion of the paramedics. The real question is: do these criteria even work?

Before answering that question, we need to decide what makes up an effective trauma triage system. In my opinion, an effective trauma system doesn’t miss severe life-threatening injuries and exhibits a minimum level of over-triage.
Why not just activate every trauma patient regardless of severity? A more thorough assessment is better right?

Yes and no. Well, actually no. Thorough assessment is good, unnecessary assessment isn’t.  Think about what happens when you bring in a trauma patient. Depending on the hospital there are up to 15 or so people in the room or immediately on stand-by. This includes physicians, nurses, lab technicians, radiology technicians, respiratory therapists, social workers (my favorite!) and many more. When dedicated to your patient, at least initially, they are unavailable to respond to another patient.

Now think about what happens to your patient: labs, x-rays, CT scans and countless other diagnostics. Each time a vein is punctured, there is a risk of infection. Every x-ray and CT scan involves exposing your patient to radiation which has additive effects over time.  In the end, a trauma system should be judged both on catching serious injuries and not activating patients unnecessarily.

Imagine my pleasure at reading the following excerpt from an Australian study published last year in Injury:

Injury. 2011 Sep;42(9):889-95. Epub 2010 Apr 28.

Differentiation of confirmed major trauma patients and potential major trauma patients using pre-hospital trauma triage criteria.

Cox S, Smith K, Currell A, Harriss L, Barger B, Cameron P.

Strategy & Planning Department, Ambulance Victoria, Australia. Shelley.Cox@ambulance.vic.gov.au

BACKGROUND: There is a paucity of literature comparing trauma patients who meet pre-hospital trauma triage guidelines (‘potential major trauma’) with trauma patients who are identified as ‘confirmed major trauma patients’ at hospital discharge. This type of epidemiological surveillance is critical to continuous performance monitoring of mature trauma care systems. The current study aimed to determine if the current trauma triage criteria resulted in under/over-triage and whether the triage criteria were being adhered to.

METHODS: For a 12-month time period there were 45,332 adult (≥16 years of age) trauma patients transported by ambulance to hospitals in metropolitan Melbourne. This retrospective study analysed data from 1166 patients identified at hospital discharge as ‘confirmed major trauma patients’ and 16,479 patients captured by the current pre-hospital trauma triage criteria, who did not go on to meet the definition of confirmed major trauma. These patients comprise the ‘potential major trauma’ group. Non-major trauma patients (N=27,687) were excluded from the study. Pre-hospital data was sourced from the Victorian Ambulance Clinical Information System (VACIS) and hospital data was sourced from the Victorian State Trauma Registry (VSTR). Statistical analyses compared the characteristics of confirmed major trauma and potential major trauma patients according to the current trauma triage criteria.

RESULTS: The leading causes of confirmed major trauma and potential major trauma were motor vehicle collisions (30.1% vs. 19.2%) and falls (30.0% vs. 48.7%). More than 80% of confirmed major trauma and 24.4% of potential major trauma patients were directly transported to a major trauma service. Overall, similar numbers of confirmed major trauma patients and potential major trauma patients had one or more aberrant vital signs (67.0% vs. 66.4%). Specific injuries meeting triage criteria were sustained by 69.2% of confirmed major trauma patients and 51.4% of potential major trauma patients, while 11.7% of confirmed major trauma patients and 4.6% of potential major trauma patients met the combined mechanism of injury criteria.

CONCLUSIONS: While the sensitivity of the current pre-hospital trauma triage criteria is high, if paramedics strictly followed the criteria there would be significant over-triage. Triage models using different mechanistic and physiologic criteria should be evaluated.

There are a few reasons I like this study, not the least of which is that the following ad campaign came out of Australia:

But I digress.  Basically, I think this study takes a pretty realistic look at what works and what doesn’t in their system.  According to the study authors, their triage criteria (and associated paramedic discretion) catch about 80% of confirmed traumas.  This is respectable sensitivity (ability to identify positive results).  The authors admit, however, that strict adherence to triage criteria would result in unacceptably high over-triage.

With no evidence to back this up, my gut reaction is that most trauma systems suffer from similar over triage, or at least the potential for over triage.

What about your system?  Have you done anything to reduce the amount of over triage for trauma patients?  Are the study authors totally off base?  Let me know in the comments.

Early Increase in Blood Glucose Predicts Poor Outcome

Posted by Patrick Lickiss on Feb 1, 2012 in General, Research, Treatment | 1 comment

In a study just electronically published in Diabetes Care, researchers explore the link, if any, between changes in blood glucose level following return of circulation in patients initially presenting in ventricular fibrillation and ultimate patient outcome.

Take a quick look at the abstract:

Early Increase in Blood Glucose in Patients Resuscitated From Out-of-Hospital Ventricular Fibrillation Predicts Poor Outcome.

Nurmi J, Boyd J, Anttalainen N, Westerbacka J, Kuisma M.

Helsinki Emergency Medical Services, Department of Anesthesia and Intensive Care, Helsinki University Central Hospital, Helsinki, Finland.

OBJECTIVE: To describe the trend of blood glucose immediately after successful resuscitation from out-of-hospital ventricular fibrillation.
RESEARCH DESIGN AND METHODS: Data from cardiac arrest registry supplemented with blood glucose data were analyzed in this population-based observational study. Between 2005 and 2009, a total of 170 adult patients survived to hospital admission after resuscitation from bystander-witnessed cardiac arrest of cardiac origin and ventricular fibrillation as an initial rhythm.
RESULTS: Sufficient data for analysis were available in 134 (79%) patients, of whom 87 (65% [95% CI 57-73]) survived to hospital discharge in Cerebral Performance Category 1 or 2. Blood glucose did not change significantly between prehospital (10.5 ± 4.1 mmol/L) and admission (10.0 ± 3.7 mmol/L) in survivors (P = 0.3483), whereas in nonsurvivors, blood glucose increased from 11.8 ± 4.6 to 13.8 ± 3.3 mmol/L (P = 0.0025).
CONCLUSIONS: Patients who are resuscitated from out-of-hospital ventricular fibrillation, but whose outcome is unfavorable are characterized by significant increase of blood glucose in the ultraacute postresuscitation phase.

WHAT’S IT ALL MEAN?
The first limitation of any study reporting observations from paramedic charts is that the data comes from paramedic charts.  We, as an industry, are notorious for estimating and rounding.  Is a systolic blood pressure 136 or 140?  Does it make a difference?  Sometimes it does, especially when comparing prehospital to in-patient values.  That being said, blood glucose is probably pretty reliably documented because it is easy to pull up the last value on many glucometers.

The second limitation is a frequency of glucometer calibration.  I know EMS systems which dictate that this be done daily and some which never calibrate.  That being said, this study did look for significant changes in blood glucose so my hope would be that they were able to overcome some of those variances.

The third limitation is that they rely on EMS performing a blood glucose on a post arrest patient.  Should this be done routinely?  Probably.  Is it?  Maybe, but who knows.  This limitation may have kept the study population artificially low.

There are a few things I like about this study.  First of all, they focus on V-fib presenting patients with witnessed cardiac arrest.  This is the population which appears to have the best shot at getting out of the hospital alive.

Second, they look only at patients who survived to hospital admission and their metric for “good outcome” is neurologically intact after discharge.  It’s high time that we focused more studies are what actually matters (getting patients out of the hospital alive and functioning) and ignoring what doesn’t (ROSC).

RESULTS
The researchers found that a significant increase in blood glucose from the prehospital setting to the in-patient one is linked to poor outcomes.  It should be noted that this is probably not a causal relationship.  Will this change prehospital care?  Probably not.  Thought if, as a Critical Care provider, you are transferring a post arrest patient and note an increase in blood glucose since the resuscitation in the field it might be wise to expect a re-arrest.

Does your system routinely check blood glucose on post arrest patients?  Do you know how to recall the last reading on your glucometer?  Let me know in the comments.

California Paramedic Regulations are Open for Public Comment

Posted by Patrick Lickiss on Sep 21, 2011 in Current Events, EMS 2.0, General, Treatment | 26 comments

Did you hear that?  That was the sound of my brain exploding.  Seriously.  If you’ve read this blog for any length of time, you’ll know that I’m a huge advocate for expanding the role, educational requirements and scope of practice of prehospital practitioners.  I may finally get my vindication.

The State of California is looking at revising their scope of practice to fall in line with the National Scope of Practice Model.  This can’t happen soon enough.  There are three main areas of focus:  additions to the paramedic scope, establishing a standard for Critical Care Transport Paramedics (CCT-P) and Advanced Prehospital Paramedics (APP) and revising minimum standards for controlled substances management.  Since narcotic control is a dissertation in itself, I’ll focus on the first two topics today.

BASIC PARAMEDIC SCOPE
Alameda County readers of this blog will note that many of the changes detailed below represent medications we already give and treatments we already perform.  It’s important to note that local medical directors ultimately control what happens in their system and that many counties have requested permission from the state to incorporate these treatments already.  Adding these to the state scope means that special permission won’t be necessary and that local medical directors can add these items to their protocols with ease.

Medications

• Amiodarone
• Dextrose 10%
• Diltiazem
• Fentanyl
• Ipratropium
• Lorazepam
• Magnesium Sulfate
• Ondansetron (Zofran)
• Potassium up to 40 meq

Procedures

• External pacing
• Perilaryngeal airways and pediatric endotracheal intubation
• CPAP/BiPAP
• Intraosseous Insertion
• Prehospital lab tests including capnography and carbon monoxide monitoring
• Naso and orogastric insertion and suctioning
• Intranasal medication administration

Not a bad list of additions if you ask me.  I’m glad to see a move towards fentanyl for pain management and I think that lorazepam is better suited for sedation than the midazolam most of us are using now.   Standardizing CPAP and IO usage is a great idea as well.  We’ve had excellent results here with both and I think those skills will serve other systems as well.

CCT-P/APP
Now this is what I’m really excited about.  Several counties in the Bay Area have implemented CCT-P programs but this opens that idea up to the rest of the state and expands to allow advanced ALS practitioners.  The state would standardize the training programs for both designations and allow local medical directors to authorize these levels of care without additional state approval.  Let’s start with the CCT-P scope:

• Set up, maintain and troubleshoot thoracic drainage system.
• Set up, maintenance and troubleshooting of a mechanical ventilator.
• Set up, maintenance and troubleshooting of fluid delivery pumps and devices.
• Administer medication infusions during interfacility transports including, Heparin, blood and blood products, Glycoprotein IIB/IIIA inhibitors, nitroglycerine, norepinephrine, TPN, and thrombolytics.

Not too shabby.  This allows systems to develop CCT-P level interfacility units with the ability to backup the 911 system, or to train a portion of their 911 responders to perform these transfers, depending on the volume of either type of call.  I’m actually an advocate for the second option.  By providing advanced training to interested 911 responders, you not only obtain the ability to utilize them for complex transfers (which likely have a higher reimbursement success rate than 911 calls) but you also win on the 911 side by having better trained providers caring for your emergent patients.  Everyone wins.

Now, on to the coup de gras…Advanced Prehospital Paramedics:

• Perform digital and nasotracheal intubation procedure.
• Surgical cricothyrotomy.
• Perform procedure for facilitated intubation using sedation and neuromuscular blockade.
• Set up, maintenance and troubleshooting of a mechanical ventilator.
• Administer medication including succinylcholine and etomidate.
• Administer OTC medications.
• Assess and refer patients, and assess and provide treatment without transport.

Now the likelihood is that I’ll be writing about this level of care for some time to come so let’s start with the big one:  ”Assess and refer patients, and assess and provide treatment without transport.”  Simply awesome.

One of the biggest roadblocks to APP programs is the inability to bill for services.  State and Federal insurance programs (and most privates) reimburse for transport only.  The addition of treat and release/treat and refer to the state scope is a huge step towards advocating for EMS reimbursement for those programs.  Making those programs sustainable means that they can be rolled out on a state-wide basis.  Now you see why I’m so excited about this and I hope you are too!

If you’re interested in reading the regulations in their entirety or making your voice hear during the public comment period, head over to the EMSA website. The period for public comment ends October 24th!

What are you looking forward to in the future of EMS?  Were any of those addressed in this scope update?  What are your next steps towards making your EMS dreams a reality?

Image via Flickr

Upcoming Randomized Trial of Assessment and Referral by Paramedics

Posted by Patrick Lickiss on Aug 17, 2011 in Assessment, EMS 2.0, General, Research, Treatment | 2 comments

By far, one of the possibilities for the future of EMS which excites me the most is generally characterized as “community paramedicine”.  The idea that paramedics will be placed in a position to treat and release and treat and refer in the field, diverting patients from the local emergency rooms is an exciting one to be sure.  The first step in rolling out a system like that, however, is determining whether or not paramedics can safely determine which patients don’t actually need an ambulance transport.  Published recently in BMC Emergency Medicine (PDF link) was the study protocol for just such an experiment in Perth, Western Australia ^[1].

INCLUSION/EXCLUSION CRITERIA
Patients will be considered for the trial if they are suffering from the following conditions:

• Isolated minor injury
• Simple infection
• Hardware problem (like issues with a urinary catheter)

The exclusion criteria are:

• Younger than 16
• Third trimester pregnancy
• Not in the patient’s residence
• Residence is unsafe
• GCS < 15
• SpO2 < 95% on room air
• Heart rate > 100
• Systolic BP < 100
• Pain requiring narcotics
• Patient unable to wait four hours for further treatment

STUDY DESIGN
For patients meeting the eligibility criteria, the paramedics will call in, provide enrollment information and be told if the patient is randomized into the control arm (transport by ambulance to the ED) or the intervention arm (referral to the in-home hospital service).  Within four hours, a home hospital service nurse or nurse practitioner will respond to the patient’s residence for evaluation and treatment.  The patient might be treated and then released from the service, enrolled into ongoing care or referred to the ED.  As a side note for US readers, check out the website for Silver Chain, the home hospital service.  This is an amazing concept.

OUTCOMES
The primary outcome focus of the researchers is the proportion of patients needing unplanned medical care within 48 hours of enrollment.  The secondary outcome focuses include a variety of clinical, operational and investigatory measures.  Additionally, cost benefit and patient satisfaction data will be collected and analyzed.

ESTIMATED OUTCOMES
With an annual transport volume of approximately 100,000, researchers estimate that they can enroll roughly 10% of their total patient base in the study.  With a goal of 940 patients in both the control and intervention arms, it is estimated that patient enrollment will be completed within a year.

DISCUSSION
As I mentioned earlier, this is a truly exciting possibility.  If paramedics can be shown to safely determine whether or not a patient can be treated at home, it opens the door to diverting at least a portion of patients from overwhelmed Emergency Departments.  As the researchers note, there have been mixed messages in the literature about the ability of paramedics to safely evaluate patients for non-transport.  This study seems well designed and isn’t biting off too much at once.  By focusing on one piece at a time, the researchers appear to be approaching this type of program the right way.  I’ll keep an eye out for the completed study and will let you know the results when it is published, likely next year.

CITED ARTICLES
[1]- Arendts G, et al.: “ParaMED Home: A protocol for a randomised controlled trial of paramedic assessment and referral to access medical care at home”. BMC Emergency Medicine 2011; 11:7.

Image via Flickr