Rapid Transport Trauma
When it comes to trauma, we can not treat or fix the cause, only the symptoms. Our greatest benefit to the patient is getting the patient to the right hospital, as fast as possible, and as prepared as possible. We can accomplish this by notifying the hospital to have their teams ready, to relieve the patient's pain, prepare the patient for treatment by removing clothes, doing a full body examination, establishing IVs, controlling bleeding, and splinting any injuries or applying dressing.
The old rule is the Golden Hour. From the time the patient is injured, to 911 being notified, to getting dispatched, arriving on scene, examining scene and MOI, triaging multiple patients, loading the patient, dealing with HPD, obtaining vitals, administering interventions, notifying telemetry, transporting to the right hospital, being triaged/evaluated and stabilized in the ER, getting x-rays/ultrasounds/CT, and then being transported to surgery and prepped - that hour can go by fast.
There are a lot of items in that list that we can not control, but one that we can is time on scene. Any delay on scene can be detrimental to our patient
Does this need stitches?
We often get asked if a patient's injury requires stitches, and if they need to go to the hospital now, or can wait and get stitches at their doctor tomorrow. As a paramedic, I had no idea how to answer those questions until I asked a few ER Physicians and this is what I learned.
Wounds are stitched or stapled to speed healing, close the wound, prevent an infection from entering, and for cosmetic reasons to reduce scarring.
Most wounds that need closure need to be treated in 6-8 hours, with a few exceptions.
If the laceration is 1/4" deep or more, or longer than 1" wide, it may require stitches.
If the edges of the wound can not be gently pulled/pressed together to close the gap, it will require stitches.
If bleeding can not be controlled after 15 minutes, it will require stitches.
If the wound is over a joint, or to the face or hands, it may require stitches.
Injuries from a bite or puncture may be more likely require stitches and receive a tetanus shot or antibiotics.
From Dr. Kimmel:
I will add that I use the 12 hour cut off mark for lacs. Also, I try not to close punctures or bites unless I have to -- they are a nidus of infection. Remember if you see someone who was involved in an altercation, that wound on their outer hand is a fight bite until proven otherwise!
We often pronounce patients dead on arrival. Being a new paramedic, you need to be confident in that decision, because you are choosing not to act. So what overwhelming signs should you see to confirm that this patient can not be resuscitated? One of them is rigor mortis. I have wondered when hearing units on the radio classify their DOA as less than 12 hours, 12-24, or greater than 24 hours, how they made that determination. Here is some information for rigor mortis time frame and post mortem body temperatures.
We frequently see patients with chronic kidney disease or end stage renal disease that receive dialysis (there are over 300,000). We pick them up at the dialysis center or at their home. If can be for chest pain, shortness of breath, nausea/vomiting/abdominal pain, hyper or hypotension, a bleeding fistula, or a cardiac arrest.
Patients receive dialysis when their kidney function falls below 15%. Without a transplant, their life expectancy on dialysis is 5-10 years. Your kidneys normally work around the clock 24 hours a day, and when they fail, the hemodialysis machine takes their place, doing their job 3 days a week for 3-4 hours at a time. That alone will lead to complications. Who decided that dialysis will be done 3 days a week? Why not 4, 5, 6
or 7? 3 days is basically the absolute minimum amount of dialysis that can be done to survive, and is the least inconvenient to the patient, so that is why it is the most common form. Studies have shown that getting dialysis 6 days a week for 2 hours at a time is a lot better (fewer complications), but that is more expensive (dialysis 3 times a week costs $75,000 - $100,000 a year). So if a patient misses one dialysis treatment - that is a big deal and causes a lot of problems.
A fistula is created by surgery, artificially joining an artery and a vein in the patient's arm, which allows the vein to get bigger and the walls harder, to allow repeated dialysis and needle stick access. It can take 3-6 months for a fistula to "mature" after surgery, to be safe for dialysis use. If your patient has a fistula that is bleeding at home, apply direct pressure to control it. If they are at the dialysis center, ask for a fistula clamp (pictured below) to control the bleeding, if bleeding is not controlled they will require surgery. Any obstruction to blood flow can lead to clotting and failure of the fistula, that is why we do not take blood pressures in the same arm.
Patients without working kidneys usually make little to no urine output. They retain this fluid and waste. They have a "dry weight" a normal weight before fluid build up. Most patients can have 2-3 litres of fluid pulled during dialysis, anything more causes complications, extracting too much fluid can lead to hypotension, syncope and abdominal pain and vomiting. You may hear of patient having 4 or 5 litres removed.
The purpose of notifying a hospital of your incoming emergency is so they can be prepared to treat the patient immediately upon arrival and with all their resources available. The hospital's resources are constantly in use, so we need to give them as much of an advance notice as we can, but we also need to give them a good enough reason to be ready for us. Next time you are at the hospital, ask them what criteria must be met to activate the stroke team, the trauma team, the cardiologist, or respiratory. If that information is not given to the hospital in a radio report, they will not activate the team until we arrive and they can triage them, which is a delay in that patient's care. It is difficult as a medic to manage a medical emergency and talk on the radio at the same time. The goal is for the radio reports to be as short as possible, but also as effective as possible.Here are some sheets to practice your radio reports. Depending on your emergency, every radio report should be different, just like your assessments in the field. When EMTs and Paramedics in the field communicate well with Telemetry, and Telemetry communicates well with the hospital, it results in the best possible care for our patient, which is always our goal.
Houston Center For Sobriety, also known as the Sobering Center or Houston Recovery Center.
Houston has a specialized facility, located downtown near Minute Maid Park, that opened its doors to law enforcement 3 years ago. Their goal is to divert inebriates from jail or hospitals, to help with the clients recovery and save the city's resources. Since then they have helped over 17,500 people and they now take walk-ins.
We can not transport our patients to the Sobriety Center, but we can have HPD transport them there. If you have an intoxicated patient, who can not get home, does not want to go to jail, and does not need medical treatment at a hospital, you can request HPD to transport them to the Sobriety Center. A few exclusions:
No major head injuries or active bleeding head injuries
No blood alcohol > 0.4
No systolic blood pressure < 85
They must be able to speak and are alert enough to make it through the interview and check in phase
They must not be combative, no patients on bath salts or PCP, they do a breathalyzer and urinalysis and vitals on check in.
There is a 6 hour max time limit for the clients to sober up, and they are free to leave at any time before that. They have beds to sleep in, access to showers and have free clothes donated by the Star of Hope if they need a change of clothes. They also get crackers and water and over the counter medication. There is a room for women that has 16 beds, and a room for men with 84 beds. So far the most they have had at one time is 24 men. They also have two private rooms for transgender clients or VIP people who do not want to share a room or be seen. All their information is confidential, as they call it, "this is a nightmare that never happened", no one will know that they stayed in the Sobriety Center. When it is time to leave, they must arrange their own transportation - have someone pick them up or take a taxi or public transportation. If they are interested in entering rehab, the Recovery Center will put them in touch and transport them to appropriate services.
Patients complaining of syncope, near syncope, dizziness, and weakness should all be checked for orthostatic hypotension. When someone stands up, gravity causes blood to pool in their legs and this leads to a decrease in blood pressure because less blood returns to the heart. Baroreceptors pick up on this, tell the heart to speed up, and vasoconstriction increases blood pressure. When this natural process does not happen, something is wrong. Orthostatic hypotension can be caused by dehydration, heart problems, medication, infection, thyroid, anemia, blood loss, diabetes, and old age. 40% of patients over 70 will test positive for orthostatic hypotension, but we can not assume that is normal for them.
I am guilty of responding to patients that had a syncopal episode, are laying supine on the ground, either request or agree to go to the hospital, and I pick them up, place them on the stretcher and do not make them stand up or perform a full set of vitals in sitting and standing positions. If a patient is REFUSING transport, it is important to obtain all these vitals so they can truly make an informed refusal. If your patient passed out and thinks they are fine and don't need to go to the hospital, sometimes standing them up and having them become dizzy is all the convincing they need to agree to go. Assuming that your patient is ambulatory and not disabled, a good rule to follow is that a patient should not sign a refusal while lying in bed. Get them to sit up, and stand up, and then sign their refusal if that is their informed decision.
A very difficult patient to do an assessment on is an elderly nursing home patient that fell. Often times there are no witnesses to the event, and you have to rely on the patient who most likely had a syncopal episode or concussion to accurately remember the events. It may be difficult to understand any deviation from their baseline if they have any chronic cognitive impairment, and there may not be anyone on staff that knows the patient well enough to understand their behavior. There is a good chance they are on anti-coagulants that increase the risk of bleeding, and they may be on sleep medication that leads to rolling out of bed, or beta blockers that lead to syncopal episodes upon standing.
It is easy to believe that the majority of these patients who have difficulty walking without assistance, probably just slipped or tripped and fell and most likely did not hit their head. But as these studies show, the patient does not even need to have direct traumatic impact to the head to cause intracranial bleeding. And most likely due to their age, cognitive history, multiple medications, there is a good chance they had a cardiac event and then injured themselves with the fall. Many of these patient encounters that end in a refusal of transport, end up going to the hospital later and getting admitted.
As a responder, you won't always see a Cushing's Triad of hypertension and bradycardia and irregular respirations or irregular pupils, and there are many instances of elderly patients being adamant about refusing to go to the hospital. But consider that not all slip and falls are really just a simple slip and fall, and try to convince the patient to get further evaluation at the hospital.
Deep Suction Bronchiolitis
Our protocols ask us to treat children under 2 with respiratory distress and wheezing different than everybody else. Instead of the asthma route and albuterol treatments, we are going the bronchiolitis route. We can administer nebulized Epi 3ml 1:1000. Also consider giving a fluid bolus of 20ml/kg because kids can get dehydrated easy from having an increased respiratory rate and heart rate, and they are probably not drinking enough fluid due to all the secretions in their airway. We can use the blue bulb suction to try and remove mucous, but the most effective treatment is deep suction, and this will really make a difference in their respiratory distress. Below is a video describing the suction technique.
Is Sinus Tach over 150 beats per minute SVT?
The confusion between sinus tach and SVT is because what we think of as SVT - is really AVNRT (Atrioventricular nodal reentrant tachycardia). Supraventricular Tachycardia is really a catch all term (like PEA) used to describe any tachycardia that originates above the ventricles. It is not a single dysrhythmia, but a group of them. That means that sinus tach, a-fib, a-flutter, junctional tachycardia, and AVNRT are ALL considered SVT. And we definitely don't treat all of those the same. So let's distinguish why we treat sinus tach and SVT (really AVNRT) differently.
Sinus tach is caused by external influences on the heart, such as exercise, pain/anxiety, fever/sepsis, anemia, hypotension, or blood loss. These are systemic conditions, entire body conditions, not cardiac conditions. Sinus tachycardia is a regular rhythm, although the rate may be slowed by vagal maneuvers. We do not want to cardiovert these patients. We do not need to give them adenosine. Most of them need a fluid bolus. Sinus tach will be distinguished by the presence of p-waves, but when the heart rate is 150-200 those p-waves are harder to see. A max heart rate is a general term used for healthy individuals, and that is 220 minus your age. So if you are 30, your max heart rate is 190.
SVT or AVNRT, is an electrical problem, a re-entry problem. An extra pathway lies near or in the AV node, which causes the electrical impulse to travel in a circle or loop and re-enter areas it already passed through. There are two seperate conduction pathways instead of one. SVT or AVNRT can begin and end suddenly for no reason, it can last seconds, minutes or days untreated. It is not a slow progression. So we need to interfere with medicine or cardioversion. Adenosine is the medication we use, and it works by temporarily blocking the AV node, and interrupting the impulses between the atria and ventricles. One study showed the 6mg dose of Adenosine works 62% of the time, and the 12mg dose works 90% of the time.
And why is Adenosine contraindicated in patients that have WPW Wolff-Parkinson White? Because administering Adenosine to these patients can cause them to go into V-Tach or V-Fib. This is because Adeonsine in WPW causes INCREASED conduction along the accessory pathway, and leads to increased ventricular response, which can degenerate into v-tach or v-fib.
In a pediatric cardiac arrest or a pediatric symptomatic bradycardia, we give EPI 1:10,000. This comes in a prefilled 10cc/1mg dose. The dose we give pediatrics is 0.01mg/kg which equals 0.1mL/kg. If you have a 7kg pediatric that needs Epi, you would administer 0.07mg or 0.7mL. That is hard to accurately measure and administer in the 10cc prefilled dose. You can get a 1cc syringe, attach the 18g orange needle top to it, poke it through the blue top on the prefilled Epi, and withdraw your correct dose.
Pediatric Cyanokit Dosage
Pediatric Cyanokit Doses [100mg/kg over 15 minutes]
In the back pharmacology reference section of our protocols, under Hydroxocobalamin, you will find a detailed table of pediatric weight in kilograms and the corresponding mg and mL for the Cyanokit. It is a nice chart but there is still more thought to put into delivering the medication. If someone handed me a Cyanokit and said you have a 30kg patient, I would not know what drip rate to start it at, it would take me quite some time to figure it out, and on scene with a smoke inhalation victim is the wrong time. There are two complications to delivering a smaller dose. The drop set is a 20drop set, not the typical 10 or 60 that we use, and when you mix the 200mL in the 5gram vial, there are no detailed markings to accurately show how much you have used.
The most important thing for your patient is to get the medication on board and not delay treatment for this math problem. I made another less detailed table of approximately how many drops a second to set your Cyanokit drip at to deliver the dose over 15 minutes. In the standard adult dose, we deliver 13mL a minute, and in a 20drop set that is 4 drops a second. You can start your drip at an approximation and once you get everything stable en route you can accurately figure out your dose.
Before you administer your medication, take two 10cc syringes and withdraw blood to be inserted in the two green and two grey tubes later to give to the hospital along with the letter from Dr Persse.
Following our protocol, to perform a nasotracheal intubation, your patient must be breathing, must not have injury to bones of the face, or evidence of a basilar skull fracture. Examine the nostrils and select the correct size tube, lubricate the end of the tube. REMOVE THE STYLET. Advance the tube and listen to breath sounds coming from the end of the tube. When breath sounds are the loudest and you see misting in tube, have your patient take a deep breath or time it with inhalation, and advance the tube past the vocal cords. The patient should not be able to speak, you should feel the patients breaths out the end of the tube, auscultate for lung sounds and absent over epigastric area, attach end tidal CO2. If you do not place it correctly on the first attempt, pull back slightly, reposition the patient and try again. Pulling the tube out all the way will cause further trauma to the nares and make additional attempts more difficult.
Dr. Gates "I like to curl the tube around my finger a couple time to give it an anterior bend before inserting it to give it a better chance of finding the trach vs going posterior into the goose."
Hyperkalemia is when your serum potassium concentration is greater than 5.5mEq/L (normal levels are 3.6-5.2). This can be caused by increased potassium intake, alcoholism, impaired renal potassium excretion, drug use, rhabdomyolysis, kidney diseases, diabetes, missed dialysis. Symptoms can present as muscle weakness, seizures, paralysis, nausea, chest pain. High levels of potassium can lead to v-fib and cardiac arrest.
We can administer 1 gram of Calcium Chloride IVP if our patient is bradycardic and has peaked t waves or suspected hyperkalemia. Call for orders for a second dose if needed, and for sodium Bicarb and albuterol (high doses of albuterol have been found to lower potassium levels by 0.6-1.0 mEq/L)
The humeral head is the preferred site for adults, and the proximal tibia is preferred for pediatrics. It has been my experience that if an EZ I/O is being utilized on an adult, it is because a patient has poor vascular access, most often due to size, and the I/O is inserted in the tibia due to easier landmark identification. We should never attempt humeral I/O insertion unless we have positive, confirmed identification of the greater tubercle and the intertubercular groove
12Lead EKG Placement
12lead EKG placement
Proper lead placement of V1 and V2 can make a difference in your patient's EKG reading. As you can see from the 3 sets of EKGs we ran below, placing V1 and V2 too high on the patient can lead to a false reading (the EKG strip on the top is the incorrect placement, the strip on the bottom is the correct placement). The leads are supposed to be placed at the 4th intercostal space. It is easy to place the leads too high, especially with female patients when trying to be modest or when what they are wearing leads to difficult lead placement access. Incorrect lead placement can often read 'septal infarct age undetermined'. If you have an abnormal reading that does not seem to fit the patient's chief complaint or past medical history, double check your lead placement and perform the EKG again.
Continuous cardiac monitoring
While it is not explicitly laid out in our protocols, if you are concerned enough to turn on your monitor and apply a 3lead or 12lead EKG, you should continue monitoring your patient during your entire interaction with them. Whether that is a transport to the hospital, sending them by BLS, or a refusal, we should continue to monitor them until they are no longer in our care. Our practice should not be turn on the monitor, 12lead, turn off. Transport to the hospital means monitoring until they are in the hospital bed, or getting an EKG by the hospital, or going to the lobby - we should not be taking patients off the monitor in the ambulance bay before we walk in to the hospital. We have brand new monitors with longer lasting batteries, we are no longer interrupted multiple times during the day to change batteries. Multiple EKGs is great documentation during a refusal - and most effective when they are more than a few minutes apart - one at our initial interaction, and one just prior to leaving the scene. It is very embarrassing and neglectful as a paramedic to have a patient that is stable in our care, then are removed from our monitor, and by the time our patient makes it through triage, they are put on the hospital monitor and are no longer stable - we have no explanation or justification for our actions. Bringing the monitor everywhere with us is not easy - try putting a patient in trendelenberg without having to then place the monitor on top of the patient - but finding a solution to that problem is easier than finding excuses to the ER physician on why the patient you brought in is not on a cardiac monitor.
Have you ever wondered how long it takes to give someone a litre fluid bolus with different sized IVs? The chart below explains the different flow rates for different size catheters. Breaking it down, here is the timing for 1000mL
14gauge: 4 minutes
16gauge: 5.5 minutes
18gauge: 11 minutes
20gauge: 16 minutes
22gauge: 27 minutes
24gauge: 50 minutes