Category: EMS
Keywords: cardiac arrest, chemical restraint, ketamine, agitation, delirium (PubMed Search)
Posted: 8/30/2023 by Ben Lawner, MS, DO
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Patient restraint is a high risk, high liability encounter for all levels of emergency medical practitioners. Often, acutely agitated patients benefit from de-escalation. This can be difficult to achieve in a resource limited setting. McDowell et al (2023) performed a comprehensive review of patient restraint encounters. Their work describes risk factors linked to adverse outcomes. Specifically, highly agitated patients who are physically and chemically restrained can experience clinical deterioration. The review also highlighted risks to EMS clinicians as well such as: needle stick, physical inury, and downstream litigation.
Bottom line:
Patient restraint represents a high risk encounter.
McDowall J, Makkink AW, Jarman K. Physical restraint within the prehospital Emergency Medical Care Environment: A scoping review. Afr J Emerg Med. 2023 Sep;13(3):157-165. doi: 10.1016/j.afjem.2023.03.006. Epub 2023 Jun 9. PMID: 37334175; PMCID: PMC10276259.
Category: EMS
Keywords: Hands only CPR, bystander CPR, directions (PubMed Search)
Posted: 8/16/2023 by Jenny Guyther, MD
(Updated: 10/29/2024)
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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.
Missel et al. Barriers to the Initiation of Telecommunicator-CPR during 911 Out-of-Hospital Cardiac Arrest Calls: A Qualitative Study. 2023. Prehospital Emergency Care.
Category: EMS
Keywords: Cardiac arrest, resuscitation, emergency medical services (PubMed Search)
Posted: 8/2/2023 by Ben Lawner, MS, DO
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There is room for improvement with respect to rates of meaningful neurological survival in patients experiencing out of hospital cardiac arrest. Post resuscitation blood pressure goals remain a matter of debate. Though a MAP of >65 mm Hg is often cited as "desirable" in the post cardiac arrest setting, some experts have advocated for a higher MAP goal to increase cerebral perfusion pressure and improve outcomes.
This study was a retrospective review and meta-analysis that examined post cardiac arrest patients with MAP goals < 70 mm Hg and > 70 mm Hg. Over 1000 patients were included in the final meta-analysis. The primary outcome was pooled mortality. Secondary outcomes included neurologically meaningful survival, dysrhythmia, and acute kidney injury. The study detected no statistically significant difference in survival. Neurological outcomes were also similar between the two groups of resuscitated patients with out of hospital cardiac arrest. However, the study revealed statistically significant decreases in ICU length of stay and mechanical ventilation time.
As with any retrospective review, there are important limitations to consider. Among them: Few RCTs were included and all of them were conducted in European countries. Generalizability may be limited given the differences in emergency medical services systems and resuscitation protocols.
Study authors recommend tailoring resuscitation goals to the individual patient since arrest physiology, comorbidities, and other factors influence a patient's post cardiac arrest course.
Bottom line:
There is insufficient evidence to recommend arbitrary MAP goals in patients resuscitated from out of hospital cardiac arrest.
Lim SL, Low CJW, Ling RR, Sultana R, Yang V, Ong MEH, Chia YW, Sharma VK, Ramanathan K. Blood Pressure Targets for Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. J Clin Med. 2023 Jul 5;12(13):4497. doi: 10.3390/jcm12134497. PMID: 37445530; PMCID: PMC10342823.
Category: EMS
Keywords: handoff, communication, adverse outcomes (PubMed Search)
Posted: 7/19/2023 by Jenny Guyther, MD
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Sumner BD, Grimsley EA, Cochrane NH, et al. Videographic Assessment of the Quality of EMS to ED Handoff Communication During Pediatric Resuscitations. Prehosp Emerg Care. 2019;23(1):15-21. doi:10.1080/10903127.2018.
Category: EMS
Keywords: ambulance, crash, response, fatality, collision (PubMed Search)
Posted: 6/22/2023 by Jenny Guyther, MD
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Prehosp Emerg Care. 2023;27(4):455-464. doi:10.1080/10903127.2022.