Potential of Cath Labs
Reynolds JC, Callaway CW, El Khoudary SR, et al: "Review of a large clinical series: Coronary angiography predicts improved outcome following cardiac arrest: Propensity-adjusted analysis."Journal of Intensive Care Medicine.24(3):179Ï186, 2009.
Prehospital cardiac arrest continues to have one of the worst outcomes. It seems impossible to predict who will neurologically survive. Currently, a hypothermic environment for the brain is being created, which some indicate will improve neurologic outcome. These authors evaluated another possible tool to improve recoveryƒcardiac catherization following return of spontaneous circulation.
Of the 241 cardiac arrest patients evaluated, 96 met criteria for cardiac catherization. Of these 96, just over half had a good outcome after receiving catherization following their arrest. Of the non-catherization group, only 24% were found to have a good outcome (neurologically intact or able to be transferred to a rehab facility). Interestingly, individuals who were perceived to have a better chance of neurologic recovery were the ones who received catherization. The authors admit that the use of hypothermia in this population will reduce the bias of neurologic recovery. They also found that outcome wasn_t affected by whether the catherization occurred immediately or later in the hospital stay.
If it_s determined that there_s an immediate need for catherization, hospitals with cath labs will be overwhelmed. And what will happen to the STEMI patients who arrive at or near the same time? If a more rational approach pervades, then this study will have relatively no impact on prehospital transport following cardiac arrest; however, it may have a significant impact on survivability.
Pain Management Bias
Lord B, Cui J, Kelly AM: "The impact of patient sex on paramedic pain management in the prehospital setting."American Journal of Emergency Medicine.27(5):525Ï529, 2009.
Numerous studies have looked at the frequency and adequacy of prehospital pain management. And most have found that EMS does a poor job at managing pain. So if EMS has difficulty effectively treating pain, then the next question is: Who_s most likely to receive inadequate pain management? These authors evaluated the rate of morphine administration versus inhaled methoxyflurane for pain management.
Of the 1,766 patients reporting pain, no difference was found between genders regarding the administration of analgesia. But there was a difference in the analgesia type offered. Females, despite reporting higher pain scores, were less likely to receive morphine. (Overall, EMS was more likely to administer morphine to patients with pain scores of 8Ï10. Only 20% of patients with pain scores of 4Ï7 received morphine.)
As health-care professionals, it_s not our job to decide who is in pain. Hospital guidelines are quite clear that the patient-reported pain score is to be utilized to determine pain management needs. Are there flaws in the way you dispense pain medications? It may be time to talk with your medical director.
IV Catheter Placement vs. Use
Kuzma K, Sporer KA, Michael GE: "When are prehospital intravenous catheters used for treatment?"Journal of Emergency Medicine.36(4):357Ï362, 2009.
Obtaining and maintaining IV access is a vital part of prehospital care. But how many times is the IV actually used, either by EMS or the hospital, when it_s placed in the field? The placement of IV catheters presents a risk to the provider and patient, as well as the potential delay of transport.
These authors reviewed the records of 34,585 patients. They found that 60% of the patients received an IV in the field. And of this group, only 17% of the IVs were actually utilized for fluid or medication administration. Patients who had hypotension, bradycardia, delayed capillary refill or abnormal vital signs were the most likely to have their IV utilized for prehospital treatment. Interestingly, hypertension, tachycardia and tachypnea alone did not prompt administration of an IV in the field. Even a Glasgow Coma Scale less than 15 (without another indicator), was not found to be a reason to utilize the IV.
IVs are easy and don_t delay transport, plus many ED personnel are upset when the IV hasn_t been initiated in the field. But they do expose you to blood-borne pathogens, and the patient to potential infection or complications. So this might be a controversy to bring up with your medical director and receiving hospitals.
Using Psychologic Scores
Talbert S: "Changing physiological status predicts severe injury and need to specialized trauma center resources."Journal of Trauma Nursing.16(1):18Ï23, 2009.
All EMS systems have criteria for trauma center admission; the purpose of this study was to determine if there_s a way to quantify the subjective data involved in trauma center criteria.
In a retrospective study of a regional trauma registry, this author compared the Revised Trauma Score from the prehospital andemergency department admission to determine if there was improvement, deterioration, or no change in patient condition. This information was then compared with actual patient outcome to quantify the trauma center criteria. The Revised Trauma Score change predicted the need for trauma center admission and the severity of the injury, independent of any other data.
This is a mathematically complex article, making it a bit challenging to read; however, the findings could be important in the development of trauma center criteria. This type of research will help identify the patient with minor mechanism of injury but severe trauma who truly needs to go to a trauma center.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 firstname.lastname@example.org.