There’s an interesting video that has been making the rounds on the Internet that provides a first hand account of what it’s like to suffer from carbon monoxide poisoning. The backstory is that the driver (patient) is a recreational racer who is driving a mid-engine vehicle. His car has a carbon monoxide leak which is filling up the passenger compartment with the products of combustion (CO and soot among others). He has conveniently been videotaping his race. Over time, you can start to see his level of confusion increase and his coordination become delayed. He starts to exhibit rambling speech. Additionally, you can see the buildup of soot on the glass of his roof. Important to note is that for a large portion of time after he claims not to remember, he still appears conscious. Check out the video for yourself:
If you read through the comments on YouTube (something I try not to do often) you’ll see that there is a lot of criticism reserved for the response crew. While that may be a valid conversation to have I think it’s more important to focus on the driver’s presentation. Most recreational racing leagues use volunteers (some with little or no training) to work as safety staff. Many of these leagues also discourage doing damage to drivers’ vehicles (like breaking out a window). Cut them a little slack.
Have you ever run a CO poisoning call? How did the patient present? What was their outcome?
I’ve written before about the CDC Field Triage criteria. There has been a lot of talk since the guidelines were released about whether mechanism of injury is a worthy criteria to use when deciding about whether to trauma activate a patient or not. Though mechanism is questioned, the physiologic criteria are generally accepted as effective criteria. The question is: how effective are they? Is a patient meeting those criteria more likely to die and therefore may have a benefit from going to a trauma center? A study published in Prehospital Emergency Care looks to answer that question for traumatic brain injury (TBI) patients.
Let’s look at the abstract from PubMed:
Prehosp Emerg Care. 2012 May 1. [Epub ahead of print]
A Review of Traumatic Brain Injury Trauma Center Visits Meeting Physiologic Criteria from the American College of Surgeons Committee on Trauma/Centers for Disease Control and Prevention Field Triage Guidelines.
Pearson WS, Ovalle F Jr, Faul M, Sasser SM.
From the Division of Injury Response, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (WSP, FO, MF, SMS) , Atlanta , Georgia ; Vanderbilt University School of Medicine (FO) , Nashville , Tennessee ; and the Department of Emergency Medicine, Emory University (SMS) , Atlanta , Georgia .
Background. Traumatic brain injury (TBI) represents a serious subset of injuries among persons in the United States, and prehospital care of these injuries can mitigate both the morbidity and the mortality in patients who suffer from these injuries. Guidelines for triage of injured patients have been set forth by the American College of Surgeons Committee on Trauma (ACS-COT) in cooperation with the Centers for Disease Control and Prevention (CDC). These guidelines include physiologic criteria, such as the Glasgow Coma Scale (GCS) score, systolic blood pressure, and respiratory rate, which should be used in determining triage of an injured patient.
Objectives. This study examined the numbers of visits at level I and II trauma centers by patients with a diagnosed TBI to determine the prevalence of those meeting physiologic criteria from the ACS-COT/CDC guidelines and to determine the extent of mortality among this patient population.
Methods. The data for this study were taken from the 2007 National Trauma Data Bank (NTDB) National Sample Program (NSP). This data set is a nationally representative sample of visits to level I and II trauma centers across the United States and is funded by the American College of Surgeons. Estimates of demographic characteristics, physiologic measures, and death were made for this study population using both chi-square analyses and adjusted logistic regression modeling.
Results. The analyses demonstrated that although many people who sustain a TBI and were taken to a level I or II trauma center did not meet the physiologic criteria, those who did meet the physiologic criteria had significantly higher odds of death than those who did not meet the criteria. After controlling for age, gender, race, Injury Severity Score (ISS), and length of stay in the hospital, persons who had a GCS score ≤13 were 17 times more likely to die than TBI patients who had a higher GCS score (odds ratio [OR] 17.4; 95% confidence interval [CI] 10.7-28.3). Other physiologic criteria also demonstrated significant odds of death.
Conclusions. These findings support the validity of the ACS-COT/CDC physiologic criteria in this population and stress the importance of prehospital triage of patients with TBI in the hopes of reducing both the morbidity and the mortality resulting from this injury.
Well would look at that? Physiologic changes, particularly those measured by GCS are linked to increased mortality. I suppose we did know that, but think about the flip side. This means that a patient with a GCS of 14 or 15 is 17 times less likely to die than a patient with a GCS of 13 or less. Maybe we can consider a basic ED for those patients or transporting them without lights and sirens.
What do you think? Does your system use the CDC criteria? What do you do with patients that don’t meet physiologic or anatomic criteria but might meet mechanism criteria? Let me know in the comments.
Image via Flickr
The “Golden Hour” is one of those topic in EMS which people feel very strongly about. Plenty of research exists on both sides of the issue and further studies are released all the time which tend to compound the issue rather than clarify it. The Golden Hour, to review, is the time interval said to be linked with survival of a traumatic injury and is measure from the time of injury until the patient receives surgical intervention. The idea, of course, is that getting a patient to surgery within an hour will improve outcomes. It is important to note, however, that there a certain subset of trauma patients who have fatal injuries regardless of time to intervention, sometimes it is just your day to go.
A study was released recently for Injury looking at what might be a grey area in the argument about the Golden Hour: severe head injury. Let’s take a look at the abstract:
Injury. 2012 Feb 13. [Epub ahead of print]
Redefining the golden hour for severe head injury in an urban setting: The effect of prehospital arrival times on patient outcomes.
Dinh MM, Bein K, Roncal S, Byrne CM, Petchell J, Brennan J.
Royal Prince Alfred Hospital, Trauma Office level 10, Missenden Road, Camperdown, NSW 2050, Australia.
BACKGROUND: In patients with severe head injuries, transportation to a trauma centre within the “golden hour” are important markers of trauma system effectiveness but evidence regarding impacts on patient outcomes is limited.
OBJECTIVE: To determine the effect of patient arrival within the golden hour on patient outcomes.
METHODS: A retrospective cohort of adult patients with severe head injuries (head AIS≥3) arriving within 24h of injury was identified using the trauma registry from 2000 to 2011. Survival analysis was used to determine the effect of patient arrival time on overall mortality. Study outcomes were in hospital mortality and survival to hospital discharge without requiring transfer for ongoing rehabilitation or nursing home care.
RESULTS: There was a significant association with mortality with each incremental minute of patient arrival (HR 1.002, 95%CI 1.001-1.004, p=0.001). There was however no survival benefit observed for patients arriving within 60min of injury time (HR 0.77, 95%CI 0.50-1.18, p=0.22) but an apparent benefit for those presenting within 2h of injury time (HR 0.31, 95%CI 0.15-0.66, p=0.002). Patient arrival within 60min of injury time was associated with increased odds of survival to hospital discharge without requiring ongoing rehabilitation (OR 1.78, 95%CI 1.14-2.79, p=0.01).
CONCLUSION: A survival benefit exists in patients arriving earlier to hospital after severe head injury but the benefit may extend beyond the golden hour. There was evidence of improved functional outcomes in patients arriving within 60min of injury time.
So what’s your take? First of all, let me say that I am pleased to see more researchers looking at patients who are surviving illness and injury AND retaining functionality. Simply surviving a head injury or cardiac arrest but being unable to function at all should not be considered a success of medicine. The patient who survived AND did not require ongoing rehabilitation were counted an analyzed.
Second, this is looking at an urban trauma system. Given the prevalence of research and teaching institutions in urban centers, this type of research tends to be focused there. I am in an urban system so this is useful for me, but it would be nice to see more research targeted at rural trauma patients.
Third, the results are fairly interesting. Patients appear to be more likely to survive if treated within the first two hours. They are more likely, however, to be discharged functionally intact if treated within the first 60 minutes. Sounds like the “Golden Hour” may work here. There was, though, no benefit associated with treatment before 60 minutes.
So what does this all mean? Clearly, severe head injury patients are time sensitive. For the purposes of this study, however, that only means that they are seen within one hour of their time of injury. There is no noted benefit to being seen before then. Perhaps these patients fall into the growing category of those who do not require “lights and sirens” transport. If these patients are maintaining an airway and vital signs, maybe we can forgo the risk of running code into the hospital? What do you think? Let me know in the comments.
You are dispatched Code 2 (no lights and sirens) to a report an elderly female who fell on the steps of the library. It rained recently and has been cold out. There have been several slip-and-falls responded to around the city this morning.
As you pull up on scene, you find that your patient is still leaning up against the steps and has been covered with a blanket by a bystander. The patient tracks you visually when you walk up and appears to be in obvious pain. Witnesses report that the patient was walking down the ice-covered steps and fell. Both the patient and bystanders state that she did not have a loss of consciousness nor did she strike her head.
As you begin to assess the patient, she reports that she only has pain to her right knee. She denies feeling dizzy or weak before the fall. She has a history of hypertension and is currently taking Atenolol. She reports an allergy to aspirin. Enlisting the help of bystanders, you move the patient to the gurney and into the ambulance out of the cold. You now have an opportunity to directly visualize her knee:
There is obvious deformity to the knee joint and swelling to the back of the knee. The patient has good circulation, sensory and motor distal to the injury site. She is in significant pain.
What are your potential differential diagnoses? What is your treatment? What hospital services do you anticipate that she will need? Anything else?
Image via MedScape
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!
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.