Cardiac & Resuscitation, Patient Care

Research Review

Issue 10 and Volume 33.

Improving„Prehospital Pain Management
Thomas SH, Shewakramani S: ˙Prehospital trauma analgesia.ÓJournal of Emergency Medicine. 35(1):47Ï57, 2008.

EMSproviders frequently underestimate pain and, therefore, undertreat it. This excellent article looks at important aspects of prehospital pain management and is composed of four sections: 1) why pain management should be a high priority; 2) the current rate of prehospital analgesia administration; 3) the risks and barriers to pain management; and 4) some specific approaches to„EMS pain management.„

Emphasis is placed on the risks and barriers encountered by„EMS personnel. The authors present both sides of the argument and a conclusion based on current literature, expert opinion and common sense. Specific scenarios are addressed, from head assessment to patients with abdominal injuries. They also explain the various physiologic responses to opioids. Some of the barriers to pain management include determining the need for IV access, contacting medical control, underestimating pain and underdosing analgesia.

This article would work well as a starting point for discussion in a blog or journal club, especially regarding issues faced by„EMS providers in the provision of analgesia. We must recognize the challenges and develop some reasonable approaches to pain management in the prehospital environment.

Underestimating Heatstroke
Rae DE, Knobel GJ, Mann T, et al: ˙Heatstroke during endurance exercise: Is there evidence for excessive endothermy?ÓMedicine and Science in Sports and Exercise. 40(7):1193Ï1204, 2008.

It_s rare for a death to occur during or after endurance events, but when it does, it provides insight into the effects of cardiovascular stress on the body. This article evaluates the deaths of five cyclists during a 109-km race and the survival of one runner in a 56-km race. All of these individuals suffered exertional heatstroke followed by multiple organ failure and death.

These athletes had all participated in similar events in the past and had no significant medical history. The ambient temperature at the time of the races was moderately warm with low humidity. The authors calculate that each of the men should have been able to maintain their body temperature by sweating.„

At the time of admission to the hospital, the core body temperature for each athlete was in excess of 102_ F. None of the cyclists received any prehospital cooling measures, whereas the runner was immediately submerged in an ice bath for 50 minutes prior to transport. He was then transported with ice packs and fans to continue the cooling process. He required a total of 10 hours of aggressive cooling to reduce his body temperature to normal.„

Despite adequate training and mild temperatures, people can succumb to heatstroke. Survival may depend on rapid and aggressive cooling measures performed in the prehospital environment. There_s no way to predict which riders are at greater risk, so cooling measures should be a routine provision at these types of events.„

Identifying CO Poisoning
Hampson„NB,„Hauff„NM: ˙Carboxyhemoglobin levels in carbon monoxide poisoning: Do they correlate with the clinical picture?ÓAmerican Journal of Emergency Medicine. 26(6):665_Ï669, 2008.

Approximately 50,000 people seek treatment in an ED for carbon monoxide exposure every year. But, there may be many others whose condition goes undiagnosed due to vague symptoms. Some literature attempts to correlate the degree of blood carboxyhemoglobin level to the patient_s physical symptoms. These authors contend there_s little or no correlation between these two factors.

In an evaluation of 1,407 patients with documented carboxyhemoglobin levels greater than 2%, the authors found that patients rarely present with ˙typicalÓ signs or symptoms. For example, loss of consciousness was recorded at all carboxyhemoglobin levels, from as little as 2% to greater than 40%. Previous research had identified loss of consciousness as an indicator of significant CO poisoning requiring hyperbaric treatment. The authors also found that some individuals died with a carboxyhemoglobin level as low as 3%, while others survived with a level of greater than 50%.

This study should affect the evaluation and treatment of patients exposed to CO fumes. It may not be enough to provide 100% O2 on scene and then release the patients for follow up on their own. If you work in an area with a high rate of CO poisonings, you should discuss this with your medical director.

ECG Changes Can Mean More Than an MI
Catanzaro JN, Perwaiz MM, Zheng S, et al: ˙Electrocardiographic T-wave changes underlying acute cardiac and cerebral events.ÓAmerican Journal of Emergency Medicine. 26(6):716Ï720, 2008.

T-wave inversion on an ECG can be the result of cardiac or neurologic conditions. This article looks at T-wave morphology in two specific patient presentations, one with an underlying myocardial infarction (MI) and the other with only a neurologic condition.„

Cardiovascular causes of T-wave inversion can include myocardial ischemia, MI or ventricular hypertrophy with strain. Neurologic causes include subarachnoid hemorrhage, subdural hematoma and acute cerebrovascular accident (CVA). Interestingly, the neurologic causes for T-wave changes will commonly result in prolongation of the QT interval as well.„

As„EMS becomes more sophisticated and providers become more comfortable with the nuances of ECG interpretation, this type of information could be extremely valuable in early recognition of an acute neurologic condition. Getting the patient to the right type of care for their MI or CVA could change their outcome.„JEMS