UMEM Educational Pearls - By Jenny Guyther

Category: EMS

Title: What can we learn from suicide related cardiac arrests?

Keywords: Suicide, EMS, prevention, causes (PubMed Search)

Posted: 3/20/2024 by Jenny Guyther, MD (Updated: 4/13/2024)
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7,365 suicide related cardiac arrests were included in this study that included a several year study period in Queensland Australia.  Cardiac arrests where resuscitation was attempted by EMS and where circumstances were concerning for suicide were included.  ROSC rates were 28.6% with survival at 30 days being only 8%.  30-day survival for medical cardiac arrests in this jurisdiction was 16.4%.  Overdose and poisoning had the best survival rate (19.9%), while hanging and chemical asphyxia were the worst (7.3 and 1.1% respectively).

Bottom line: Survival rates for suicide related out of hospital cardiac arrest were worse compared to other causes of medical arrest.  Suicide prevention should become a focus with emphasis on early identification and treatment of people at high risk of suicide.  While EMS is well trained on the management of cardiac arrest, training should also emphasize suicide risk assessment and identification.

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The gold standard for confirming ETT position is a chest xray, but this can often be delayed while the patient is stabilized. Many physicians will estimate ETT insertion depth to be 3x the ETT size, but this is based on selection of the correct tube.  There are several other published formulas, including the PALS guidelines [age in years/2 + 12] which applies to children older than one year.  In 1982, there was an article published that cited the formulas of [Height (cm) x 0.1 +5] or [Weight(kg)/5 + 12].

This was a retrospective study where the ideal position of cuffed ETT (from the front teeth) was determined by looking at post intubation xrays of 167 patients between 28 days and 18 years.  The individual optimal ETT insertion depth was plotted against age, weight and height for all children.  This study showed that there is not a fully linear relationship between age, height or weight which is a flaw of all of these formulas.  Calculations using the patients’ weight performed the worst.  Age based and height formulas performed the best.

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Category: EMS

Title: Should there be a different set of vital sign "norms" for EMS?

Keywords: vital signs, age, pediatric, prehospital intervention (PubMed Search)

Posted: 2/21/2024 by Jenny Guyther, MD (Updated: 4/13/2024)
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Vital signs in children can be difficult to remember since they vary with age.  Using a standardized card or app (such as PALS) can help EMS clinicians remember the values.  Most pediatric vital sign reference ranges were derived from samples of healthy children in the outpatient setting (ie PALS).  This study attempted to validate a range of pediatric vital signs that were more accurate in predicting the need for prehospital interventions compared to the standard PALS vital sign ranges. The thought was that by using EMS data, these vital sign ranges could better alert EMS to patients in need of acute intervention.

The authors used a large EMS database to determine the vital signs for the patients age and correlated that to prehospital interventions (including IV, medication, EKG, advanced airway management, ect).  They used the <10% and >90% for the age values (termed "extreme" vitals signs) as a cut off to be considered abnormal.  Using the EMS derived values, 17.8% of the encounters with an extreme vital sign received medication.  If the PALS abnormal vital sign range was used, only 15.2% of those patients were given medications.  Overall, encounters with an extreme vital sign had a higher proportion of any intervention being performed compared to other vital sign criteria (i.e. only 33.7% with PALS).

These extreme vital signs also had a greater accuracy in predicting mortality.

Bottom line: While vital signs are based on physiology that does not change based on location, using a seperate criteria for the EMS population, can improve discrimination between sick and sicker patients and hopefully allow EMS to recognize and intervene on sicker patients sooner.

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Category: Pediatrics

Title: What is BACM?

Keywords: myositis, acute kidney injury, problems walking, calf pain (PubMed Search)

Posted: 2/14/2024 by Jenny Guyther, MD (Emailed: 2/16/2024) (Updated: 2/16/2024)
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BACM stands for benign acute childhood myositis which is typically a benign, viral induced self limiting illness.  This was a retrospective study looking at 65 patients in Italy to further characterize the characteristics of the disease.

In this study, the median patient age was 6 years with a male predominance.  The incidence of BACM peaked in winter with a second peak in the fall.  Patients presented with prodromal symptoms including fever, cough, coryza, sore throat and vomiting.  The exam showed difficulty walking and myalgias with reproducible calf tenderness and preserved reflexes.  Influenza B and A, COVID and other viral pathogens have been detected in these patients.

Lab work may show an elevated creatinine kinase, AST and potassium.  WBC and CRP may also be elevated.  The median CK value was 943 U/L and on average normalized within one week.  Other studies have shown median CK values in the 3300s. Treatment includes hydration to promote CK clearance and prevent complications including acute kidney injury related to rhabdomyolysis.  Recurrent myositis or CK values > 5000 U/L should have screening tests for muscular dystrophy and metabolic disorders.

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Category: Pediatrics

Title: Pediatric bounce backs

Keywords: Bouncebacks, high risk discharges, gastroenteritis, death (PubMed Search)

Posted: 1/19/2024 by Jenny Guyther, MD (Updated: 4/13/2024)
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Revisits back to the ED within 3 days of the initial visit represent a standard quality measure.  A critical ED revisit was defined as an ICU admission or death within 3 days of ED discharge.  This study looked at 16.3 million children who were discharged from various EDs over a 4 year period and found that 0.1% (18,704 patients) had a critical revisit and 0.00001% (180 patients) died.  

The most common diagnosis at the initial visit of those patients coming back with a critical revisit included: Upper respiratory infections, gastroenteritis/nausea/vomiting and asthma.

The most common critical revisit diagnosis were: asthma, pneumonia, cellulitis, bronchiolitis, upper respiratory infections, respiratory failure, seizure, gastroenteritis/nausea/vomiting, appendectomy and sickle cell crisis. Among the patients who died, 48.9% were younger than 4 years. Patients with complex medical problems and patients seen at a high volume center were more likely to have a critical ED visit.

Bottom line: These ED revisits may not have been related to missed diagnosis (with the exception of appendicitis), but rather due to the natural progression of certain disease processes.  Patients with these diagnoses may benefit from careful reassessment, targeted patient education, more specific return precautions and closer outpatient follow up.

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Category: EMS

Title: Can paramedics accurately risk stratify patients with acute chest pain?

Keywords: ACS, PE, risk stratification (PubMed Search)

Posted: 1/17/2024 by Jenny Guyther, MD (Updated: 4/13/2024)
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The 2nd most common reason for EMS activation is chest pain.  In this study, paramedics were asked to complete the HEAR (history, EKG, age, risk factor) score, EDACS (ED Assessment of chest pain score), the Revised Geneva Score and the PERC (Pulmonary embolism rule-out criteria) for all patients older than 21 who presented with chest pain.  The positive and negative likelihood ratios (LR) of the risk scores in relation to 30 day MACE and PE risk were calculated.

837 patients were included in this study with 687 patients having all 4 scores completed.   The combination of HEAR/PERC had the best negative LR (0.25) for ruling our MACE and PE at 30 days.   However, these scores, alone or in combination, were not sufficient to exclusively guide treatment or destination decisions.  Adding biomarkers (ie troponin or Ddimer to the prehospital setting) could improve the usefulness of these scores.

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Category: EMS

Title: Does EMS diversion impact the number of ambulances that arrive at a particular facility?

Keywords: EMS, red, yellow, divert, capacity (PubMed Search)

Posted: 12/20/2023 by Jenny Guyther, MD (Updated: 4/13/2024)
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US hospitals have traditionally been concerned that without an ambulance diversion protocol that they would be overrun with EMS arrivals.  EMS had been concerned that without diversion there would be extended wait times at the hospital.  This study looked at EMS arrivals one year (2021) before the elimination of diversion and compared the number to one year after diversion elimination (2022).  

This study of a single level 1 trauma center showed that there was NO difference between the number of EMS arrivals per day (84 vs 83, p = 0.08), time to room for ESI 2 patients, time to head CT in acute stroke patients OR ambulance turn around time (16 min vs 17 min, p = 0.15).

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Urinary tract infection (UTI) is the leading cause of fever without a source in infants younger than 3 months.  This data was collected from patients who presented to the emergency department with fever without a source over a 16 year period.  Out of 2850 patients, 20.8% were diagnosed with a UTI, the majority of which grew E coli.  Of those patients who were diagnosed with UTI, these patients were more likely to have a history of renal/GU problems, have a fever of at least 39C (38% vs 29%) or poor feeding (13% vs 8.7%).  However, 48% had none of these risk factors.  Also 6.1% of patients with a febrile UTI had another invasive bacterial infection.  These patients were more likely to be < 1 month, be "irritable" per parents and have an elevated procalcitonin and CRP.  

Bottom line:  A lack of risk factors can not exclude a UTI in febrile infants < 3 months.  A diagnosis of UTI also does not definitively exclude an additional invasive bacterial infection in a subset of these children.

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Category: Pediatrics

Title: Does the timing of patient transfer impact mortality in the pediatric trauma patient?

Keywords: pediatric trauma, transport, time to destination (PubMed Search)

Posted: 11/17/2023 by Jenny Guyther, MD (Updated: 4/13/2024)
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Pediatric patients treated at pediatric specific trauma centers have improved mortality.  However, it is estimated that only 57% of patients live within 30 miles of a pediatric trauma center.  This means that many children will need to be stabilized at an adult trauma center or community hospital prior to transfer.  This study showed that > 25% of injured children were transferred to a pediatric trauma center following stabilization at another hospital.
 
The American College of Surgeons has previously recommended that the optimal interfacility transfer time for trauma patients is 60 minutes.
 
Data for this study was extracted from a database fed by over 800 trauma hospitals.  Every minute increase in the interfacility transfer time is associated with a 2% increase in risk adjusted odds of mortality among severely injured pediatric trauma patients.
 
Bottom line: When faced with a moderate to severely injured pediatric trauma patient, the availability and time to transport should be taken into account. If the time is > 60 minutes, then mode of transport and destination (if others are available), should be considered.

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Category: EMS

Title: EMS and the management of pediatric agitation

Keywords: mental health, excited delirium, agitation, sedation, ketamine (PubMed Search)

Posted: 11/15/2023 by Jenny Guyther, MD (Updated: 4/13/2024)
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This is a retrospective review of pediatric patients with mental health presentations to EMS in Australia.  For children 12 or older, EMS has standing orders for midazolam for mild to moderate agitation and ketamine for severe agitation.  Patients younger than 12 require medical consultation prior to administration.
14% of pediatric EMS calls in this study were for mental health problems.  In 8% of the 7816 pediatric mental health EMS encounters, patients received either midazolam (about 75%) or ketamine (25% of cases). 11% of patients who received midazolam had an adverse event while 37% in the ketamine group had an adverse event.  Adverse events included airway obstruction requiring jaw thrust, OPA or NPA placement, BVM or desaturations requiring oxygen. No serious adverse events occurred in either group.
Police accompanied EMS in 82% of these cases.  Patients who received medication management were more likely to have autism spectrum disorder, post traumatic stress disorder, intellectual disability, psychiatric disorder or history of substance abuse.
Bottom line: Pediatric mental health is a significant global problem where further research is needed.

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Category: Pediatrics

Title: Should an ED thoracotomy be performed in pediatrics?

Keywords: trauma arrest, ROSC, blunt, penetrating (PubMed Search)

Posted: 10/20/2023 by Jenny Guyther, MD (Updated: 4/13/2024)
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12 pediatric and adult surgeons with pediatric trauma expertise reviewed the literature to form a consensus statement on the indications for ED thoracotomy (EDT) on patients younger than 19 years.  Eleven studies were included for a total of 319 children who underwent EDT.  142 patients had penetrating trauma while 177 sustained blunt trauma.  Survival in the penetrating group was 13.4% and 2.3% in the blunt group.  Many of these patients were 15 and older.  Based on the review of the literature, the group made recommendations:
 
1) In pediatric patients with signs of life (SOL) who present pulseless in the setting of penetrating trauma, EDT was conditionally recommended.
2) In pediatric patients without SOL who present pulseless in the setting of penetrating thoracic trauma EDT was conditionally NOT recommended.  
3)  In pediatric patients with SOL who present pulseless in the setting of penetrating abdominopelvic trauma EDT was conditionally recommended.  
4) In pediatric patients without SOL who present pulseless in the setting of penetrating abdominopelvic trauma EDT was conditionally NOT recommended.  
5) In pediatric patients with SOL who present pulseless in the setting of blunt trauma EDT was conditionally recommended AFTER emergency adjuncts which include ultrasound and thoracostomies.  
6)  In pediatric patients without SOL who present pulseless in the setting of blunt trauma EDT was NOT recommended.  
 
SOL included cardiac electrical activity, respiratory effort, pupillary response, pulses, blood pressure, or extremity movement.
 
Bottom line:  If the pediatric trauma patient presents pulseless, but with SOL, EDT can be considered.  However, evidence is still very limited, especially in children < 15 and these recommendations are conditional.

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Category: EMS

Title: Which type of BVM provides appropriate tidal volumes in the back of an ambulance?

Keywords: BVM, tidal volume, TV, ALS, BLS (PubMed Search)

Posted: 10/18/2023 by Jenny Guyther, MD (Updated: 4/13/2024)
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The typical bag valve mask ventilator (BVM) for adults has a reservoir volume between 1500-2000 mL depending on the manufacturer while the volume is between 500-1000 mL for a pediatric BVM.  When trying to obtain the recommended tidal volume of 6-8 mL/kg (500-600 mL for the typical adult), one thought was that a pediatric BVM could be used with adult patients so as to avoid iatrogenic barotrauma.  This has been studied on manakins using an oral pharyngeal airway, supraglottic airway and endotracheal tubes (ETT) and has been successful.  This study attempted to obtain the same results in the back of a moving ambulance.  Paramedics and EMTs, squeezing pediatric and adult BVMs with one hand, bagged adult manakins in the back of a moving ambulance (without lights and sirens).  The average tidal volume was recorded using various types of airways (i-gel, King airway and ETT).

Volumes delivered with the pediatric BVM were significantly lower than the tidal volumes with adult BVMs across all airway types suggesting that in the moving ambulance, using pediatric BVMs on an adult patient would not be appropriate.

The I-Gel and King airway provided similar tidal volumes which were not statistically different than volume delivered through the ETT.

EMTs consistently delivered 50% less tidal volumes compared to paramedics. The authors suggested that perhaps the additional training and pathophysiology knowledge that paramedics have could also be important with a skill that is considered basic. 

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Category: EMS

Title: What are the barriers for laypeople to be trained in CPR?

Keywords: cardiac arrest, CPR, bystander (PubMed Search)

Posted: 9/20/2023 by Jenny Guyther, MD (Updated: 4/13/2024)
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Prior studies have shown that CPR education is associated with a greater willingness to perform CPR.  This was a review of 23 studies to determine factors that enable and hinder a layperson from learning CPR.
 
Enabling factors included having witnessed someone collapse in the past, awareness of public AEDs, certain occupations and legal requirements for training (i.e. mandatory high school CPR training).
 
Married people were more likely to be trained than those that were not married and people with children younger than 3 years were less likely to take a BLS course.  
 
Barriers that were found to impact people taking CPR classes included lower socioeconomic status and education level, and advanced age and language barriers.  
 
Bottom line: CPR education sessions should target groups with these identified barriers.

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Category: Pediatrics

Title: Spontaneous Pneumomediastinum in Children: What should I do?

Keywords: Spontaneous Pneumomediastinum, asthma, crepitus, esophagram (PubMed Search)

Posted: 9/15/2023 by Jenny Guyther, MD
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Spontaneous pneumomediastinum (SPM) is air within the mediastinum in the absence of trauma.  This occurs more often in males and has 2 age peaks: children younger than 6 years as a result of lower respiratory tract infections and adolescents due to asthma exacerbations.  Typical symptoms include chest pain, subcutaneous emphysema and shortness of breath, but can also include neck pain, dysphagia, pneumopericardium, and pneumorrhachis (air in the spinal cord).   SPM has been seen in patients with a history of asthma, current influenza infection and hyperventilation with anxiety, but many have no known precipitating factor. 
The diagnosis of SPM is typically made on CXR.  The literature is mixed on the utility of CT scans, esophagrams, esophagoscopy and bronchoscopy.  This study looked at 179 pediatric patients who were diagnosed with SPM.  No patients were found to have an esophageal injury.  Also, CT scans did not provide additional information or change management based on what was seen on the chest xray.
The author's concluded that CT scans and esophagrams can be avoided unless there is a specific esophageal concern.  Management should be guided based on the patient's symptoms.

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Category: Pediatrics

Title: Pediatric drowning what are the risk factors?

Keywords: Drowning, near drowning, CXR (PubMed Search)

Posted: 8/18/2023 by Jenny Guyther, MD (Updated: 4/13/2024)
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This was a retrospective study involving several hospitals in Italy.  135 patients who had drowned (the term used in the article) were included.  4.5% of patients died.  Most drowning occurred in July and August.  The most common comorbidity was epilepsy in about 10% of patients.  Several patients were also witnessed to have trauma and syncope.  Early resuscitation, either by bystanders or trained professionals, was paramount in survival. 

Children who are conscious at presentation and have mild or no respiratory distress have the best prognosis.  A well appearing child should be observed for 6-8 hours, given that 98% of children will present with symptoms within the first 7 hours.  A chest xray is not indicated in the asymptomatic patient.  Patients who are submerged greater than 25 minutes or without ROSC after 30 minutes have a poor prognosis.

Bottom line: Never swim alone and everyone should be trained in bystander CPR.



Category: EMS

Title: What are the barriers to 911 being able to direct hands only CPR instructions to callers?

Keywords: Hands only CPR, bystander CPR, directions (PubMed Search)

Posted: 8/16/2023 by Jenny Guyther, MD (Updated: 4/13/2024)
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Bystander CPR increases out-of-hospital CPR survival and direction by 911 telecommunicators increases the frequency of bystander CPR.  The majority of 911 centers use Medical Priority Dispatch System which walks 911 telecommunicators through a series of questions that give different instructions based on the caller's answers.  Studies have shown out-of-hospital cardiac arrests are only recognized between 79-92% of the time and telecommunicator instructions for CPR can take between 176-285 seconds.

This study reviewed recorded 911 calls of patients who were found to be in cardiac arrest. Calls where the caller was not with the patient and confirmed overdoses were some of the call types that were excluded.

Out of 65 reviewed calls, 28% were not recognized during the actual call.  When they were reviewed, 8/18 of the calls were deemed to be recognizable.  Themes that were noted were: incomplete or delayed recognition assessment (ie uncertainty in breathing), communication gaps (callers were confused with instructions or questions), caller emotional distress, delayed repositioning for chest compressions, non essential questions and assessments, and caller refusal/hesitation or inability to act.

Bottom line: In addition to bystander CPR training, education on the process and questions involved in calling 911 could be helpful in an emergency.  

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Category: Pediatrics

Title: Should blood cultures be drawn in a child with fever and lower extremity pain?

Keywords: fever, limp, bacteremia, osteomyelitis, septic joint (PubMed Search)

Posted: 7/21/2023 by Jenny Guyther, MD (Updated: 4/13/2024)
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This was a cross sectional review of 698 patients ages 1 year to 18 years who presented to a tertiary care center with fever of at least 38 degrees centigrade and non traumatic acute lower extremity pain. This hospital was located in the North East of the United States. Lower extremity pain was defined as an antalgic gait by report or on exam, inability or refusal to bear weight or reported bone or joint pain in the verbal patient within the past 14 days.
Blood cultures were available for review in 510 patients.  Blood cultures were positive in 70 of them (13.7%).  Pathogens included MSSA, MRSA, Strep pyogenes and Salmonella.  Significant predictors of bacteremia included an elevated CRP and localizing exam findings.  
8 blood culture contaminants were identified.  6/8 of these patients had other testing and treatment consistent with osteomyelitis.  
The final diagnosis of the patients with bacteremia included osteomyelitis, septic arthritis, pyomyositis and toxic shock syndrome.
 
 
Bottom line: The prevalence of bacteremia, even in Lyme endemic areas, in healthy children presenting to the ED with fever AND lower extremity pain is high enough to strongly consider obtaining a blood culture with other lab work during the initial evaluation. 

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Category: EMS

Title: ED handoff of pediatric patients by EMS

Keywords: handoff, communication, adverse outcomes (PubMed Search)

Posted: 7/19/2023 by Jenny Guyther, MD
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Ineffective handoff communications have been shown to occur in up to 80% of medical errors.  Previous studies have shown that up to 1/3 of pertinent information is lost during the handoff of trauma patients.  Interruptions, lack of listening and ED team preoccupation with their own patient assessment have been associated with adverse outcomes.
This study reviewed videotaped footage of pediatric critical care resuscitations and the handoff between the ED and EMS.  Inefficient communication occurred in 87% of handoffs, including 51% of cases with interruptions by staff, 40% with questions from the ED leader about information that had already been given and 65% requesting information that had not yet been communicated.
Bottom line: Allow for an uninterrupted hand off from EMS followed by closed loop communication and asking any additional questions.

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Burns are common pediatric injuries and usually represent preventable unintentional trauma.
Approximately 10% of children hospitalized with burns are victims of abuse. Thermal burns are the most common type of burn and can result from scalding injuries or contact with objects (irons, radiators, or cigarettes). Features of scald burns that are concerning for inflicted trauma include clear lines of demarcation, uniformity of burn depth and characteristic pattern. Abusive contact burns tend to have distinct margins (branding of the hot object), while accidental contact burns tend to have less distinctive edges
How Kids are Different than Adults: 
- Kids have thinner skin, so time to burn/energy required to cause a burn is less. 
- Kids have increased blood volume relative to their mass, so may need more volume resuscitation compared to adults. 
- Kids are more likely to become hypoglycemic so give glucose in mIVF in kids <20 kgs.
- Risk of airway compromise in kids following inhalation injury is higher due to their smaller airway openings 
Treatment:
- Initial treatment should follow ABCs of resuscitation
- Airway: Airway management should include assessment for presence of airway or inhalation injury, with early intubation if such an injury is suspected. Smoke inhalation may be associated with carbon monoxide toxicity; 100% humidified oxygen should be given if hypoxia or inhalation is suspected.
- Circulation: Parkland's formula
     - Fluid requirements = TBSA burned (%) x weight (kg) x4mL
     - Give ½ of total requirements in 1st 8 hours, then give 2nd half over the next 16 hours. 
     - REMEMBER KIDS HAVE BIG HEADS
          - Rule of 9's for adults: 9% for each arm, 18% for each leg, 9% for head, 18% for front torso, 18% for back torso
          - Rule of 9's for children" 9% for each arm, 14% for each leg, 18% for head, 18% for front torso, 18% for back torso. 
Options for pain management
- fentanyl IN
- morphine IV
- ketamine IV
 Burns you should consider admission
- >6% TBSA
- full thickness burns
- specialty areas: face, eyes, airway, genitalia, palmar crease, sole of foot
- concern for non-accidental injury
- caused by treadmill

 

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Category: EMS

Title: What are risk factors in ambulance crashes?

Keywords: ambulance, crash, response, fatality, collision (PubMed Search)

Posted: 6/22/2023 by Jenny Guyther, MD
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Between 2010 and 2020, there were 279 fatalities related to ambulance accidents.  In up to 50% of accidents, EMS is not at fault.  The use of lights and sirens and intersections have been previously shown to be the most common risk factor for accidents.  There is a national push for a more judicious use of lights and sirens.  
Most ambulance crashes are minor, but up to 1/3 of crashes can result in significant injury or significant damage to the vehicle.  This study attempted to relate driver demographics and aggressive driving behavior to ambulance crashes using a vehicle telematics system.  The agency in this study responded to about 130,000 calls per year and the incident rate of any crash was 2.1/100,000 miles and the incident rate of a serious crash was 0.63/100,000 miles.  Injuries occured in 8% of the 214 crashes over the 3 year study period.  One third of the cases resulted in significant vehicle damage.  Female sex and age 18-24 were found to be independently associated with a collision.
Bottom line: Transporting patients via ambulance, especially when lights and sirens are used, is not a risk free event.  Even if injuries do not occur, the impact of damage to the vehicle can significantly impact the EMS system.

 

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