Advanced Directives, Tourniquets, Tasers & Prehospital ETI in Seattle

What current studies mean to EMS


Elizabeth Criss, NP, MED, MS, CEN, CCRN | From the June 2009 Issue | Wednesday, June 3, 2009

Effect of Advanced Directives

Mirarchi FL, Kalantzis S, Hunter D, et al: "TRIAD II: Do living wills have an impact on pre-hospital lifesaving care?"Journal of Emergency Medicine.36(2):105Ï115, 2009.

TRIAD, The Realistic Interpretation of Advanced Directives, is a multi-part study with the goal of increasing patient safety by interpreting and understanding living wills and do-not-resuscitate orders in the prehospital environment. The long-term goal is to make prehospital advanced directives easier to understand in a time of crisis.

This specific portion of the study evaluated the ability of EMTs and paramedics to evaluate and determine treatment for hypothetical cases based on an interpretation of a living will. The authors found that most of the respondents were unclear about initiating life-saving care for a patient with a treatable condition when presented with a living will.

Advanced directives are becoming very common; however, it seems prehospital providers aren_t given enough education about the role of advanced directives when the patient has a treatable medical condition. This is an enlightening study, and all EMS educators should read it and pass the information on to students.

Tourniquets & Pressure Points

Swan KG Jr., Wright DS, Barbagiovanni SS, et al: "Tourniquets revisited."Journal of Trauma. 66(3):672Ï675, 2009.

Tourniquets have been a part of trauma care for a long time. But we_ve also been taught that using pressure points is the preferred method to control bleeding. These authors set out to determine if tourniquets can be safely used below the elbow or knee, which tourniquet is the easiest to use, and if pressure points are an adequate way to control bleeding.

Tourniquets were placed in sequential order to the upper arm, lower arm, thigh and lower leg of simulated victims, and the subjects evaluated the location for pain. Adequate compression was determined by the absence of a pulse at the wrist or ankle for at least 60 seconds. The authors found the tourniquet could successfully restrict blood flow in all locations. All of the participants agreed that the cloth/windlass was the easiest to apply. They also found that pressure points can successfully restrict blood flow; however, this method was effective for less than 40 seconds, and in one patient, restriction of blood flow was never achieved.

When faced with a life-threatening hemorrhagic event, use a tourniquet as close to the site as possible. The authors also recommend that instructors not teach the pressure-point method anymore, because it_s ineffective over the long term in controlling hemorrhage.

Physiologic Effect of Tasers

Bozeman WP, Hauda WE 2nd, Heck JJ, et al: "Safety and injury profile of conducted electrical weapons use by law enforcement officers against criminal suspects."Annals of Emergency Medicine. 53(4):480Ï490, 2009.

Several studies in the past couple of years evaluated the physiologic effects of the Taser, a conducted electrical weapon. These studies have usually been conducted on healthy volunteers. This study evaluated the physiologic effects when used on real suspects, in real situations.

The weapon was used 1,201 times in the course of the study period. Six law enforcement agencies from around the country were involved in the study. Every case underwent internal and external review, and each suspect received a full medical evaluation. They found that the injuries sustained by suspects were related to the fall or other trauma sustained following the shock. The risk of significant injury following use of the device was 0.25%ƒequal to other non-lethal weapons available to law enforcement. None of the suspects died or had cardiac or nervous system injury as a result of the Taser.

Conducted electrical weapons are an effective alternative to deadly force, and now we know they don_t likely cause direct bodily injury. Evaluation and treatment should be based on visible trauma or underlying medical or behavioral conditions.

Prehospital ETI in Seattle

Warner KJ, Sharar SR, Copass MK, et al: "Prehospital management of the difficult airway: A prospective cohort study."Journal of Emergency Medicine.36(3):257Ï265, 2009.

During the past few years, numerous studies have detailed the success rates and patient outcomes for prehospital endotracheal intubation (ETI). But this study is different, because despite the inconclusive data, the authors endorse the use of ETI with rapid sequence induction (RSI) and surgical cricothyroidotomy.

These authors collected information on all ETIs performed by the Seattle Fire Department during a four-year period. Their data show that a 96% success rate for ETI can be achieved in four intubation attempts, RSI improves first-attempt intubation rates, and there_s a group of patients that requires more invasive methodsto secure an airway.

This study provides no new information regarding use of prehospital ETI, and the data was self-reported, making it less reliable. It_s important that, as EMS moves forward with its search for a place in the health-care system, we_re not persuaded to continue less-than-optimal techniques simply because we admire the authorship of a study.JEMS

Elizabeth Criss,NP, MEd, MS, CEN, CCRN, is a nurse practitioner in the emergency department at Tucson Medical Center. She was a founding member of the Board of Advisors of the Prehospital Care Research Forum. Criss has been involved in emergency care and disaster management since 1982. Contact her

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Related Topics: Patient Care, Cardiac and Circulation, Trauma, ETI, prehospital endotracheal intubation, tasers, tourniquets, The Realistic Interpretation of Advanced Directives, TRIAD, Jems Research Review

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Elizabeth Criss, NP, MED, MS, CEN, CCRNElizabeth Criss is a nurse practitioner in the emergency department at Tucson Medical Center.


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