EVOC consists of two parts – classroom and driving. The classroom is delivered in two nights, and the driving portion is part of a day. The course announcement details the dates, times, and location.

Contact Dave Tesh ASAP to sign up as spots fill quickly. This class is open to all Chesterfield County Rescue Squad members, and there is a finite number of seats available.

Recertification students welcome – no restriction on the number of recert students as long as you do not need to go through the driving portion of the class.

All squad members are welcome and invited to attend.

Sorry for the delay in the content from EMS Today 2012; another weekend of grad school took precedence. Without further delay:

How clean is your ambulance? (Katherine West, RN, B.S.N., M.S.Ed., JEMS Board of Editors member and infection control consultant with Infection Control/Emerging Concepts Inc.)

We go to great lengths to not get a disease from our patients, but we do little to prevent our patients being inoculated from our equipment.

A study of bacterial cultures from EMS units by Georgetown University noted 10 of 21 ambulances were positive for MRSA…think of surfaces that have multiple patient contacts i.e.: stethoscopes . UCLA Children’s Hospital found that community acquired MRSA can survive on nonporous surfaces for 8 weeks.

Frequently, cleaning products used in EMS for sanitation purposes are high level products to eliminate mycobacterium. We largely need lower level disinfecting and cleaning agents to address vegetative pathogens.

In order to decontaminate, must be cleaned first!

Correct procedure:

Wash w/soap and water, place in cold sterilants for time period recommended by manufacturer, remove with sterile instrumentation, rinse with sterile water, allow proper drying, package to reuse.

Pay careful attention to manufacturer’s guidelines for cleaning/disinfection of your durable equipment so not to void the warranty.

Earle H. Spaulding’s classification guides what level of disinfection to use on various pieces of equipment. http://www.cdc.gov/hicpac/Disinfection_Sterilization/2_approach.html
• Critical Items – equipment that is at high risk of transmitting infection if contaminated (surgical instruments, urinary catheters, medical implants, and internal ultrasound probes. Bottom line, EMS equipment does not fall into this category.
• Semi-critical items – equipment that contacts mucosal membranes, i.e.: laryngoscope blades. This category of equipment should be cleaned with at a minimum of high level disinfectants (i.e.: Cidex). Key point; after drying, equipment should be packaged in a manner to prevent recontamination.
• Non-critical items – equipment that comes in contact with intact skin, but not mucus membranes. This includes nearly all of the durable equipment used in EMS. Also consider surfaces on stretchers and inside ambulances (compartments, work surfaces, seats, sliding doors, interior and exterior handles & latches).

Bleach and water (CDC recommends 1:100 dilution and once solution is mixed, it good for 24 hours) an effective and cheap disinfectant, is effective against Clostridium Difficile (C. difficile), and lesser pathogens. 1:10 is a popular misconception. 1:100 does not damage equipment or cause corrosion. Don’t put in glass bottle. This content is from OSHA’s compliance directive CPL 2-2.69.

CDC recommended one minute contact time for manufactured wipes to eliminate pathogens. This would include those wipes we frequently use.

Soap and warm water will eliminate C. difficile in hand washing. Commercially available alcohol and foaming sanitizers don’t work on C. difficile.

If using a “Clorox” prepackaged wipe, must read label and determine if they in fact contain bleach.

There is no pathogen that requires “airing out a vehicle”.

OSHA requires that a cleaning schedule must be included in the department’s infection control plan and cleaning solutions must be specifically named. Decontamination of vehicles and equipment can occur in station bay area…this is really compliant! Solutions must be EPA approved and maintained for duration as recommended by manufacturer. Also, OSHA requires the use of commercial rubber gloves when performing any cleaning with chemical agents. Exam gloves do not meet this requirement.

Ms. West requested clarification from OSHA to who is responsible for cleaning EMS equipment left an a hospital for the purposes of patient care. OSHA responded that the hospital is responsible for decontamination.

Compliance with cleaning schedule must be assessed and records maintaine. i.e.: hand washing after glove removal and recording results of observational monitoring on calls.

Spray- fog is an unsatisfactory method of cleaning per CDC and is not suitable for patient care areas.

Given the risk associated with this, we should give serious consideration to collaborating with our emergency services colleagues with any enhancements to our infection control plan, rather than try to recreate the wheel.

Traumatic Head Injuries (Connie Mattera)

Incidence is 1.6 million cases per year with 4:1 prevalence in males as compared to females.

Increase prevalence in elderly with falls from standing height. Falls do not have to be of significant height, but surface with which impact is against also has bearing.

35% of on-scene deaths are secondary to CNS trauma.

Neurological injury is defined in two phases- primary from insult, and secondary from acidosis, hypoxia, hypoglycemia, etc… The latter phase is where EMS can make a difference to salvageable areas of cells surrounding those damaged by primary insult.

Five “Rs” for optimal outcomes from traumatic head injury: Right patient, Right hospital, Right amount of time, Right physician (neurosurgeon), and rehab.

Average intercranial pressure is 10 mm Hg, and MAP of 60 mm Hg is required to perfuse the brain. EMS teams may have to maintain systolic pressure of 110 mm Hg or higher to meet this goal (this is different from the hypovolemic patient in the setting of thoracic or abdominal trauma). One systolic blood pressure less than 90 pre-hospitally doubles mortality.

Glasgow score should be obtained after hypoxia and hypoglycemia have been corrected. This enables more accurate assessment of true GCS.

• 13-15 historically mild head injury
• 9-12 moderate injury
• < 8 severe injury and potentially comatose

If GCS drops more than 2 points on reassessment, prognosis is declining.

Zofran should be given liberally to head injury patients to prevent airway complications.

Sedatives should be given to combative patients to decrease the risk of harm from immobilization efforts.

Concussions are no longer considered insignificant injuries. High grade concussions can take 6-12 months of recovery to return to pre-concussion state.

Significant hyperventilation in head injury does not improve outcomes. Only hyperventilate rate of 20 in setting of herniation and maintain PCO2 30-35 (requires capnographic monitoring). Intubation does not equate to improved outcomes.

Traumatic brain foundation no longer recommends use of steroids in head injury patient.

Versed is better anticonvulsant b/c it’s faster acting, water soluble and can be given intra-nasally.

Ms. Matters advocated for the use of sedatives in intoxicated patient with head injury when the patient is/will be combative…this is a paradigm shift from the passive approach of gaining compliance to medical evaluation at E.D. by acquiescing and not immobilization patients.

One more to come!

Chris Wholley

I’ve been encouraged by some of the online and off line discussions that have resulted from my first submission. More content from the EMS Today 2012 conference in Baltimore:

ACLS Update- Corey Slovis, M.D., (Medical Director Nashville FD & Nashville Int’l ARFF, Department of Emergency Medicine, Vanderbilt University Medical Center)

No evidence of improved outcomes in cardiac arrest with ETT as compared to supraglotic airways. Literature clearly indicates early compression and defibrillation are best indicators of improving outcomes.

Compression only CPR avoids increased intrathoracic pressure, improves preload cans relies on O2 reserves already in blood stream. A 2009 study compared active manual ventilation vs passive mask only in witnessed VF arrest (yes, they put a non-rebreather on a cardiac arrest patient). Better outcomes were noted with in passive O2 cohort because emphasis on compressions!

Study from Wake Co. noted improved ROSC outcomes to discharge, highest with no ETT attempts, second highest with single ETT attempt without success and subsequent BLS airway manuvers. No attempts to ETT increased survival to discharge by factor of 5.46. This study didn’t examine supraglotic airways i.e.: king airway.

Recommendation is for SaO2 in cardiac arrest is 95-98%. Aiming for 100% SaO2 actually decreases outcomes.

New England Journal of Medicine (NEJM) article noted no difference in outcomes in cases when impedance threshold devices were used and cases of cardiac arrest without ITD use. Jury is still out on these devices.

Study in Circulation Journal examined the concept of on hands on defibrillation; I know, this sounds scary. In the setting of good pad contact, no flowing oxygen over the patient, and use of pads only, defibrillations were delivered while provider was actively performing CPR. The provider was wearing exam gloves and a third electrode also connected to rescuer. Defibrillations at 360 joules were not felt at all by the rescuer! This is coming! Much of this is driven by the following values; takes 5-10 compressions to perfuse coronary arteries. To peruse brain, takes 30-40 seconds.

Nearly all recent studies on ETT noted superior first attempt placement and with video laryngoscopes. This will become new gold standard. Cost may be prohibitive for high end devices, but multiple devices are forthcoming. New and far superior devices have lithium batteries and LED bulbs for light source, ” incandescent bulbs are so 1957!”

Therapeutic hypothermic clearly indicated for VF arrest with ROSC and patient is not responding to questions. Survival to hospital discharge and good neuro status increasds by 50% in conjunction with PCI. At present time, there is no evidence that field initiation of hypothermia in ROSC patients improves outcomes. Dr. Slovis advocates initiating hypothermia in systems with transport times over 30 minutes.

Eagles Lightening Round (town hall meeting with Corey Slovis, M.D., Paul Pepe, M.D., Eric Beck, D.O., Raymond Fowler, M.D., and Joe Holley, M.D.)

The administration of intravenous Epinephrine in the non-cardiac arrest patient is one of the most frequent medication errors observed. Epinephrine is clearly the medication of choice for anaphylaxis or severe asthma. If the patient is in extremis and not responding as hoped with Epinephrine 1:1,000 0.3 mg subcutaneously/intramuscularly, a follow up dose of intravenous can be life saving. In presence of severe anaphylaxis or status asthma and you need to give IV epinephrine, mix 1 mg of Epinephrine in 1 liter of saline, and administer 1 ml/min (1 mcg/min) to save this patient. If they don’t improve in 1 minute, double the dose (2 mcg/min). If they don’t improve after another minute, double to 4 ml/min (4 mcg/min). This Epinephrine infusion must be “piggy backed” to a running normal saline infusion.

The concept of the impedance threshold device seemed like great idea but didn’t materialize. Initial trial supported 30% increase in survival to hospital admission. A subsequent study showed neutrality in outcomes. This does not appear to justify the cost of $100 per device. From content of medical directors in attendance, jury is still out on ITDs.

Consensus of intubation question is that there is no solid recommendation. Bottom line is that if your system supports intubation by ALS providers, they must be well trained, practice frequently, and have robust medical oversight. Direct laryngoscopy is thing of the past the era of video laryngoscopy is here.

There is some concern that the inflation of the king balloon decreased carotid artery perfusion and this is being studied currently. Remember goal is good ventilation regardless of approach.

Reoccurring idea noted concept of “pit crew” approach to cardiac arrest management:
2 persons- roles divided between 2 persons
3 persons-roles divided between 3 persons and so on…

Collectively supported concept of better integration though feedback from hospital and disposition of patients transported to Emergency Departments.

NFPA 1710 standards define response time of 60 second out of chute and 8 minute response time. This is based on a 1979 study looking at cardiac arrest survival when defibrillators were only in hands of EMS providers. This was found to be unrealistic because of time to obtain caller information, dispatch time, out of chute time, response time, time to access patient. There is no current evidence to support arrival to a call < 8 minutes and 59 seconds improves outcomes. Municipalities falsely hang their hats on this standard. Much of this is due to the ease with which this metric is measured. Better measures are those that impact patient outcomes, community door to balloon times, rate of bystander CPR, etc…

Drowning & Cold Water Immersion (Edward Dickenson, M.D., NREMT-P – University of Pennsylvania Dept. of Emergency Medicine, Philadelphia, PA)

Terms of drowning and near drowning are no longer valid. Drowning is now a universal definition with fatal drowning defining those that succumb to water immersion.

The prevalence of this is largely in males involved higher risk activities and is the second largest cause of death in children ages 1-14 years. Overwhelming distribution of mortality under age of 14 are in black and Hispanics. Deaths in whites increases above 15 years old.

Statistical risk factors in drowning deaths:

• 50% of deaths in Adults and adolescents involve alcohol consumption.

• 2/3 of all fatal pediatric drownings occur between 12-8 PM on weekends between May and August.

• At risk groups are: Persons with seizure disorders, children with developmental disabilities, individuals with pacemakers and AICDs.

Classic pathophysiology is sudden, unexpected immersion, struggle to orientate and surface, hypoxia then develops, water is ingested into stomach, and gag reflex draws in water into the lungs. Actual water aspiration is not that much and averages 4 ml/kg based on autopsy findings.

Because of relative low volume of water in lungs, it is futile to perform the Heimlich to expel water out of lungs.

Danger from small volume aspiration (1-3 ml/kg) is the washout surfactant, then resulting alveolar collapse, hypoxia, respiratory acidosis and death. CPAP is extremely useful in management of these patients. Porcine surfactant infusion post drowning has shown to be very helpful in restoring pulmonary function and gas exchange. This is the same surfactant that is given to premature neonates.

Salt water vs fresh water does not significantly change pathophysiology in most cases.

Factors that influence survival:

• Age influences survival ability, very young and elderly generally do not do well.

• Duration of immersion/submersion

• Water temperature

• Stimulation of mammalian dive reflex.

• Quality and timeliness of resuscitation

AHA’s recommendations are traditional ABC approach because of airway component and death secondary to respiratory component.

Article from Journal of Trauma supported not using spinal immobilization unless there is clear trauma. This takes time away from airway management. Retrospective analysis of drowning cases noted 11 of 2300 drownings had trauma indicators and required spinal precautions. The incidence of c-spine injury is 0.01-0.05%.

Don’t forget suction; 60% of drowning patients vomit large volumes.

More to come!

Chris Wholley

The EMS Today Conference and Exposition 2012 has wrapped and the conference sessions proved to be exceedingly high quality! Attendees hailed from 47 states and 22 countries; hardiest road warriors hailed from London, Mexico City, Seoul, Toronto, Brisbane, Tokyo, Riyadh, Oslo, and Berlin. I hoped to share some content from the sessions I attended.

Trauma Trends (Connie Mattera, RN, M.S., EMT-P – EMS Director and System Coordinator, Arlington Heights, IL)

Transition from the DOT standard curriculum to the national standards moves away from the “cook book” approach to protocols to evidence based practices.

Priorities will continue to be airway management and oxygenation. Recent research of traumatic head injury patients has shown worse outcomes with intubated patients as compared to those who who received other methods of airway management. Several studies have been done, some back as far as 2003, that deemphasize pre-hospital intubation in these patients. Theories on this drill down to the relaxation of the airway provider of the intubated patient and hyperventilation that subsequently occurs. Drop in CO2 from hyperventilation results in cerebral vasoconstriction. Current PHTLS recommendations only indicate hyperventilation rate of 20 in the head injury patient that is actively herniating (unequal pupils, Cushing’s Triad).

Challenging Airways:

Providers must be highly skilled at airway assessment, i.e.: Mallampati classifications, systems approach to airway management with back-up plan, and a strong sense of when not to attempt intubation on a patient. Key to remember, EMS does not perform “elective intubations” only absolutely needed intubations.

Corey Slovis, M.D. (E.D attending Vanderbilt University Medical Center, Medical Director of Nashville F.D. and Nashville Int’l Airport ARFF) advocates a hierarchical approach to pre-hospital airway management:
• Tier 1 – Endotracheal intubation for persons who are very familiar with airway assessment and who have routine practice with this skill.
• Tier 2 – Supraglotic airway use (King, Combitube) for persons who are not strong in intubation and airway skills.
• Tier 3 – Basic maneuvers for persons who occasionally manage airways.

The national benchmark for first pass success with endotracheal intubation is 85% and data from EMS systems nationwide notes much lower success rate. Video laryngoscopy has demonstrated significant improvement in first pass success rate. One study presented at EMS Today noted 90% in one EMS system. As this technology was first introduced, it was cost prohibitive to many organizations. In the last 12-18 months, new devices have come out to bring the cost of this technology down. See website on King Vision product: http://www.owntheairway.com/

Ms. Mattera strongly recommended that attendees read and digest Dr. Bledsoe’s recent article on “Rethinking ETI”. http://airway.jems.com/2012/02/rethinking-eti/

Ms. Mattera offered several tips to enhance airway management for pre-hospital providers:

• Strongly supported the pre-hospital adoption of the Bougie ETT inducer.
• Airway management of a patient in a cervical collar will be challenging, effectively increasing their Mallampati score. Consider temporarily releasing the cervical collar for airway management then, secure the collar for patient movement and transport.

Consider the “pit crew” approach to cardiac arrest management; team members with defined roles. Ms. Mattera’s system outside Chicago has 40% ROSC with this method.
• 30 minutes of uninterrupted compressions.
• King airway placement.
• IO as first line access for fluids and medications.

Spinal Immobilization:

Helmet removal must be a practiced skill and collaboration with local HS and college athletic trainers is essential to understand new helmet technology. Key point, know when to remove a patient’s helmet and when not to remove the helmet.

Recent research suggests that the types of patients EMS has historically immobilized should not have received this line of care. NAEMSP research committee recommended in January 2012 that EMS stop using backboards routinely, except in cases where their use is clearly indicated. Current guidelines are for patients to be off backboards within 10 minutes of arrival in the E.D. This is driven by increase in patient discomfort and corresponding increase in sympathetic stimulation. In addition, studies have shown that skin breakdown from pressure points can start in two hours. Publishing of this recommendation was deferred for 12 months to build consensus with trauma colleagues.

Please be diligent with the ground level fall in elderly patients; the majority of missed c-spine injuries involve elderly who fell from standing height.

Thoracic Trauma:

Treatment of the three most lethal chest traumatic injuries (tension pneumothorax, open pneumothorax, and flail chest) have not changed. Some points to consider:
• Leave simple pneumothorax alone; only decompress tension pneumothorax (as evidenced by hypotension).
• Consider CPAP treatment in patient with flail chest if there are alert and can maintain their airway (PEEP 5-7 cm H20). This has better outcomes as compared to those patients w/ flail chest who receive positive pressure ventilation (East, 2006).

Penetrating chest trauma patients need to have systolic blood pressure maintained at 80 mm Hg with mean arterial pressure (MAP) of 65-75 mm Hg. This is less likely to overpressure the clots formed at the site of internal injuries and further hemorrhaging.

Hemorrhage and Fluid Resuscitation:

Recent military conflicts have changed paradigm of fluid resuscitation. Military does not administer fluids in patients who are alert and have radial pulses.

If patient is presenting in shock and overt signs of hemorrhage are not seen, consider internal hemorrhage and spaces that can hold large volume of blood.

In the setting of pelvic trauma, don’t rock the pelvis; it will make things worse! Scrotal edema and ecchimosis to the perineal region are signs of significant pelvic injury. Consider treatment with devices like the Sam Sling or an inverted KED. Use of a bed sheet is unreliable in maintaining required pressure.

As a result of a Journal of Trauma study published in 2011, ATLS guidelines are being rewritten to recommend use of Lactated Ringers solution rather than Normal Saline. This typically results in a cascade change to PHTLS curriculum and pre-hospital providers could see this in the coming 1-2 years.

Hemorrhage control maxims are no longer absolutes (escalation from direct pressure, additional bandaging, elevation, and pressure points). Hemostatic dressings and tourniquets frequently better choices. Tell patients that tourniquets can be painful before application, secondary to accumulation of potassium and lactic acid distal to device.

Just 200 ml of room temperature fluid in shock patient will make them cold, thereby reducing clotting ability. Fluid in warmer expires after 21 days, discarded thereafter.

More to come!

Chris Wholley

Rescue College Brochure

INSTRUCTOR PRETEST DEADLINE: MONDAY, APRIL 9, 2012
REGISTRATION DEADLINE: MONDAY, APRIL 16, 2012
CANCELLATION DEADLINE: MONDAY, APRIL 30, 2012

PLEASE NOTE:
All participants are required to submit a $75.00 registration deposit per class.
Upon attendance in the class or classes for which you registered, your deposit will be returned. If you are a no show and have not cancelled your registration prior to the deadline, you will forfeit your registration deposit. If making deposit via credit card this will be charged after the event. If making deposit via check, your checks will be returned to you in class at the Rescue College.

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