EMS Cast

Explore the nuances of stroke assessments, the challenges EMS professionals face in the field, and the impact of prehospital interventions on patient outcomes. Coco Wham, a former paramedic who's transitioned to a physician, and Dr. Layne Dylla, an associate professor of emergency medicine join us to dive into their ongoing research efforts aimed at defining what matters in prehospital stroke care and refining stroke response protocols. Hear firsthand how evidence-based practices are developed from the ground up in EMS settings. This episode is packed with valuable information to enhance your practice and understanding of stroke care in prehospital environments.

This is Part 2. Derek, an experienced clinician in burn care, joins us to delve into the intricacies and challenges of treating burn patients. This discussion provides valuable insights into the unique aspects of burn injuries, the importance of a comprehensive assessment, and the latest trends in burn treatment.

• Complexity of Burn Injuries: Derek begins by explaining why burn patients require a unique approach compared to other trauma patients. He highlights the potential for burns to mask other critical injuries, underscoring the necessity of a thorough and trauma-informed initial assessment.

• The 'Big Three' Considerations: The conversation shifts to what Derek refers to as the "big three" — polytrauma, airway loss, and inhalation injuries — which are crucial early considerations in burn care. He stresses the importance of recognizing these potentially life-threatening conditions alongside the burn injury itself.

• Fluid Resuscitation: A significant portion of the discussion is dedicated to fluid resuscitation, a critical aspect of burn care. Derek talks about the Parkland formula for calculating fluid needs based on the total body surface area affected by burns but a better simpler method is-

  • 500 ml/hr for an adult (<13 yo)
  • 250 ml/hr for a young kid (6-13 yo)
  • 125 ml/hr for a child (<5 yo)

• Pain Management and Ethical Concerns: Derek addresses the ethical and practical aspects of pain management in burn victims. Effective pain control not only improves patient comfort but also aids in overall patient management and long term healing, making it a critical component of the initial response.

• Assessment Tools and Techniques: Various assessment tools such as the Rule of Nines and the Palmer Method are discussed. Derek explains their applications and limitations, emphasizing that while these tools are helpful for initial assessments, more detailed evaluations are typically conducted at specialized burn centers. A link from ABA that may be helpful: https://ameriburn.org/resources/burnreferral/ Includes brief overview of severity/depth (with diagrams, not pictures), Rule of Nines & Palmar Method, plus a link for ABA referral criteria.

  Here is another great article for a deeper dive into pros & cons of different methods of estimating TBSA, although not exhaustive, per se.

  Gretchen C., Burn size estimation: A remarkable history with clinical practice implications,Burns Open, Volume 8, Issue 2, 2024, Pages 47-52, ISSN 2468-9122

  Evaluation and Optimization of the Wallace Rule of Nines for the Estimation of Total Body Surface Area in Obese and Nonobese Populations, The Journal of Emergency Medicine, Volume 65, Issue 4, 2023, Pages e320-e327.
• Burn depth estimates: There are free diagrams out there, but for actual real wound pictures, very little is open-license. UpToDate has a decent starting place, with four pictures embedded, and likely accessible for most.

https://www.uptodate.com/contents/assessment-and-classification-of-burn-injury?search=burn%20depth&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1

Other Scientific papers mentioned-

Burn resuscitation

First article is an overview of evolution of burn fluid resuscitation formulas & philosophy – although again, not exhaustive, per se.

Bacomo, F. K., & Chung, K. K. (2011). A primer on burn resuscitation.Journal of emergencies, trauma, and shock,4(1), 109–113.

Next article underscores the risks of fluid creep. Starting too high, being reluctant to titrate down, and the fact that giving too much fluid can actually CAUSE an increased need for fluids (vicious cycle).

Chung KK, Wolf SE, Cancio LC, Alvarado R, Jones JA, McCorcle J, King BT, Barillo DJ, Renz EM, Blackbourne LH. Resuscitation of severely burned military casualties: fluid begets more fluid. J Trauma. 2009 Aug;67(2):231-7; discussion 237. doi: 10.1097/TA.0b013e3181ac68cf. PMID: 19667873.

Derek, an experienced clinician in burn care, joins us to delve into the intricacies and challenges of treating burn patients. This discussion provides valuable insights into the unique aspects of burn injuries, the importance of a comprehensive assessment, and the latest trends in burn treatment.

• Complexity of Burn Injuries: Derek begins by explaining why burn patients require a unique approach compared to other trauma patients. He highlights the potential for burns to mask other critical injuries, underscoring the necessity of a thorough and trauma-informed initial assessment.

• The 'Big Three' Considerations: The conversation shifts to what Derek refers to as the "big three" — polytrauma, airway loss, and inhalation injuries — which are crucial early considerations in burn care. He stresses the importance of recognizing these potentially life-threatening conditions alongside the burn injury itself.

• Fluid Resuscitation: A significant portion of the discussion is dedicated to fluid resuscitation, a critical aspect of burn care. Derek talks about the Parkland formula for calculating fluid needs based on the total body surface area affected by burns but notes that real-time adjustments are often necessary to avoid complications like over-resuscitation.

• Pain Management and Ethical Concerns: Derek addresses the ethical and practical aspects of pain management in burn victims. Effective pain control not only improves patient comfort but also aids in overall patient management and long term healing, making it a critical component of the initial response.

• Assessment Tools and Techniques: Various assessment tools such as the Rule of Nines and the Palmer Method are discussed. Derek explains their applications and limitations, emphasizing that while these tools are helpful for initial assessments, more detailed evaluations are typically conducted at specialized burn centers.

• Part 2: This is just part 1. Part 2 will be coming May 1st. We will simplify our approach to fluid resuscitation and dive into some nuances of burns and burn care.

Blog post- https://emspodcast.com/the-critically-burned-patient/

Scientific papers mentioned-

Which comes first epinephrine or airway? Out of hospital cardiac arrests involve critical and often complex decisions with sequence and timing of various procedure. What should you prioritize? We examine the nuances of advanced interventions, such as epinephrine and advanced airway placement, through the lens of recent studies, including a notable piece of research published recently in JAMA Network Open. Take a deep dive into the practicalities and philosophies that underpin prehospital cardiac arrest management, emphasizing the significance of basic life support skills and the role of advanced techniques in the pre-hospital setting. This episode engages, educates, and challenges EMS providers on the best practices that could potentially save lives during those critical first minutes of a cardiac emergency.

Articles-

Sequence of Epinephrine and Advanced Airway Placement After Out-of-Hospital Cardiac Arrest. JAMA Netw Open. 2024 Feb 5;7(2):e2356863. doi: 10.1001/jamanetworkopen.2023.56863.

Association of timing of epinephrine administration with outcomes in adults with out-of-hospital cardiac arrest. JAMA Netw Open. 2021;4(8):e2120176. doi:10.1001/jamanetworkopen.2021.20176

Epinephrine in Out of Hospital Cardiac Arrest: A Network Meta-analysis and Subgroup Analyses of Shockable and Nonshockable Rhythms. Chest. 2023 Aug;164(2):381-393. DOI: 10.1016/j.chest.2023.01.033

A Randomized Trial of Epinephrine in Out of Hospital Cardiac Arrest. (PARAMEDIC2) New Eng J Med. DOI: 10.1056/NEJMoa1806842

The influence of time to adrenaline administration in the Paramedic 2 randomised controlled trial. Intensive Care Med. 2020;46(3):426-436. doi:10.1007/s00134-019-05836-2

Toxicologist Dr. Nik Matsler teaches us the critical topic of toxic alcohol poisoning. The discussion sheds light on the dangers lurking in everyday household and industrial products that contain methanol, ethylene glycol, and isopropyl alcohol—substances not far removed from the alcohol found in beverages yet capable of causing severe, sometimes fatal, health issues.

Blog Post- Toxic Alcohols

In the high-stakes environment of prehospital medicine, the ability to perform a successful intubation on the first attempt is critical. The complexity of prehospital airway management cannot be understated, given the challenging conditions and the acuity of patients encountered. This episode delves into the strategies and techniques that can significantly improve the success rates of prehospital intubations, focusing on preparation, positioning, and the SALAD (Suction-Assisted Laryngoscopy and Airway Decontamination) method.

Blog post- Art of Laryngoscopy- The SALAD technique

Additional Podcast Episode- Mac 3 vs 4 podcast episode

Additional Resources-

Youtube SALAD demonstration

Published Article on the SALAD Technique

YouTube video of the hypoepiglottic ligament in action

Airway Jedi blog post

Additional SALAD Resources

Despite the allure of consistent compressions and reduced provider fatigue, does the data actually show that mechanical CPR devices improve outcomes? Tune in for a nuanced exploration of evidence-based practice in emergency medical services.

Blog Post- https://emspodcast.com/the-truth-about-mechanical-cpr-devices-what-the-data-really-says/

Original Article- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328162/

Overcoming Fear in Neonatal Resuscitation: A Step-by-Step Guide

Blog post: Neonatal Resuscitation

Introduction: Welcome to another episode of EMScast, where high-level education meets real-world emergency medical scenarios. Today, we have Dr. Avery MacKenzie, an ER physician from Southwest Colorado, joining us to discuss a topic that often induces stress – neonatal resuscitation. Dr. MacKenzie shares her experiences and insights into handling neonatal emergencies in rural settings.

Summary: Dr. MacKenzie opens the episode by acknowledging the inherent fear associated with neonatal resuscitation, especially in rural emergency departments where one might be the sole provider. She emphasizes that despite the fear, the process is not hard, and providers already possess the necessary skills.

Key Takeaways: 1. **Facing the Fear:** - Dr. MacKenzie encourages listeners to remember that while neonatal resuscitation may seem intimidating, the skills required are well within their expertise.

2. **Algorithm Overview:** - The neonatal resuscitation algorithm is simplified into manageable steps, beginning with stimulating, warming, and drying the baby for the first 30 seconds. - The next 30 seconds involve providing positive pressure ventilation to initiate breathing. - Monitoring the heart rate is crucial, and if it remains below 100, providers should focus on correcting ventilation strategies.

3. **Initial Assessment:** - Dr. MacKenzie introduces a simple three-question assessment for determining the need for resuscitation: term gestation, good muscle tone, and respiratory effort.

4. **Positive Pressure Ventilation:** - The trigger for initiating positive pressure ventilation is if the heart rate is less than 100 or the baby is apneic or gasping. - The emphasis is on adequate ventilation, and adjustments, such as using the MR. SOPA mnemonic, can be made to improve ventilation.

5. **Advanced Airway Considerations:** - While advanced airways, such as intubation, are possible, Dr. MacKenzie highlights that pre-hospital protocols may favor supraglottic airways due to the challenging nature of neonatal intubation and the need to limit pauses in oxygenation and respiratory support.

6. **Continued Support:** - The algorithm emphasizes a continuous loop of assessment, correction, and reassessment, with the goal of maintaining the baby's heart rate above 100.

Conclusion: Dr. MacKenzie wraps up the episode by reassuring providers that familiarity with the neonatal resuscitation algorithm and periodic mental reviews can alleviate the fear associated with these critical situations. The key is to focus on what providers already know and apply those skills with confidence.

Dr. Nik Matsler is back to discuss the treatment of patients with crush injuries and crush syndrome. Dr. Matsler's insight as an emergency physician and a toxicologist are put to work helping us understand the pathophysiology of crush related injuries. We also try to discuss very practical approaches to these situations which are complex. No two crush injuries will present the same. Many variables contribute to the presentation of these patients. Duration of crush, amount of force applied, the size of the body part crushed, all play a role. There is much EMS folklore about treating these patients prophylactically in order to stave off deadly arrhythmia. Does this work? What treatments matter for these patients? Paramedics and EMS are the first line of care for these patients. How can you give them the best chance of survival?

This episode topic was submitted by a listener! Thank you, and please keep the ideas coming.

Jim Barrick has more than 37 years of experience in Emergency Medical Services and Helicopter Emergency Medical Services (EMS and HEMS). His humble approach makes him a wealth of wisdom for anyone in this career field. As kickoff for 2024 we depart from our normal format of short education topics to long term reflection. If you work in and around EMS and Critical Care Transport, learn from Jim. Take time to listen to those in your world that have years of experience and expertise. Take time to be humble and learn the lessons they pass forward. Many of them have been paid for with hardship. Take time to reflect on your goals as a provider and how you want to better yourself in 2024!

We sat down with Jim in the kitchen of his North Carolina home to learn about his experience with Orange County, North Carolina and Carolina Air Care. Jim was in a group of 5, that were the first Flight Paramedics in the state of North Carolina. They helped pioneer a program that is now a staple of EMS in the State of North Carolina. Carolina Air Care is a division of UNC Health, a part of the University of North Carolina system. They currently provide critical care transport to the entire state of North Carolina. They are affiliated with a level I Trauma Center, Burn Center, and a large multi-specialty educational institution. If it can happen, Jim has seen it.