STEMI Treatment in the Field
Sayah AJ, Roe MT: ˙The role of fibrinolytics in the prehospital treatment of ST-elevation myocardial infarction (STEMI).Ó Journal of Emergency Medicine. 34(4):405-416, 2008.

Little progress has been made in the past 20 years in shortening the delays common to the treatment of ST-elevation myocardial infarctions (STEMIs). For most disease processes, time delays can be problematic but are rarely life altering; this isn’t the case with STEMI. These authors address the long-standing issues surrounding the prehospital delivery of fibrinolytics.

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Using American College of Cardiology and American Heart Association recommendations, the authors begin by explaining the rationale behind fibrinolytic delivery before hospital arrival. Next is an interesting, well-rounded, evidence-based discussion supporting prehospital fibrinolytic administration. The authors end by considering what would be required of an EMS system that wanted to implement this program. They also discuss the type of fibrinolytic that would be ideal for the prehospital environment (i.e., easy to dose, no specialized storage requirements).

This is a thought-provoking article that could certainly provide the basis for developing a research project to address the feasibility of prehospital STEMI treatment in your area. The protocol change could save a lot of lives, but significant risks must be considered.

Side Air Bags & Injury Patterns
McGwin Jr G, Modjarrad K, Duma S, et al: ˙Association between upper extremity injuries and side air bag availability.Ó Journal of Trauma. 64(5):1297-1301, 2008.

The use of front air bags and seatbelts has dramatically reduced the rate of cervical spine and maxillofacial injuries in front-end motor vehicle crashes (MVCs). But do side air bags provide similar protection to upper extremities in a side-impact crash? According to these authors, most of the previous studies on side air bags had been done with cadavers, which demonstrated an increase in upper-extremity dislocations and complex wrist and elbow fractures. So they decided to design a study to evaluate side air bags in a real-world setting.

Accessing the NHTSA Crashworthiness Data System, the authors identified nearly 4,000 crashes that met inclusion criteria. What they found was interestingƒcars equipped with side air bags had significantly less intrusion than non-side air bag cars in crashes with the same amount of force. There was less risk of moderate to serious upper-extremity injuries in side air bag cars; however, passengers were more likely to suffer shoulder dislocations. Upper-extremity fracture rates were similar, but occupants in side air bag cars were more likely to suffer radius and ulna fractures.

Side air bags are becoming more common; therefore, first responders should be aware of the potential injuries they’re going to encounter with this type of vehicle crash.

Taking Orthostatic Blood Pressures
Guss DA, Abdelnur D, Hemingway TJ: ˙The impact of arm position on the measurement of orthostatic blood pressure.Ó Journal of Emergency Medicine. 34(4):377-382, 2008.

The accuracy of an orthostatic blood pressure reading is significantly affected by arm position, so it’s important that field providers know how to take it correctly. According to these authors, the arm must be parallel to the body in each body position.

They evaluated a convenience sample of 100 individuals and found that placing the arm perpendicular to the torso significantly reduced the blood pressure. When the arm was parallel in the supine position and perpendicular in the standing position, significantly more patients met the criteria for being orthostatic.

When you’re doing standbys and need to evaluate patients for possible transport based on being orthostatic, remember that arm position can have an impact on orthostatic blood pressure.

Saving Closed Head-Injury Patients
Jain S, Dharap SB, Gore MA: ˙Early prediction of outcome in very severe closed head injury.Ó Injury. 39(5):598-603, 2008.

Severe closed head injuries are devastating. It’s very difficult to know if the patient has a chance at survival and whether resources should be fully expended ˙just in case.Ó As health care becomes more difficult to access, either because of overcrowding or lack of facilities, decisions on resource allocation must be made. These authors present the findings from the evaluation of 102 closed head-injury patients who arrived at the hospital with a Glasgow Coma Scale (GCS) score of < 5.

The three things they found to be most predictive of survival were adequate spontaneous respiration, brisk pupillary light reactivity at time of admission and an increase in the GCS score by at least two points in the first 24 hours. When none of these things were present at the time of admission, the survival rate was 6%. If one condition was present, the survival rate increased to 15%; with two, the rate increased to 52%; and when all three were present at the time of admission, the survival rate increased to 57%.

EMS providers are the first to see the head-injured patient, the first to make an assessment, and the only ones who can prevent a secondary injury caused by hypoxia. Give these individuals the best possible chance at survival.„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.