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This document summarizes data from 63 pre-hospital cardiac arrest cases where an advanced airway was attempted. It finds that the majority of arrests occurred more than 5 minutes after initial contact, with a mean time of 16 minutes. Respiratory cases had a longer mean time to arrest of 17.9 minutes compared to 14.6 minutes for non-respiratory cases. 73% of patients were moved to the ambulance prior to arresting. The document recommends improving physiological monitoring, managing airways more effectively, gaining IV access earlier, providing timely volume resuscitation and medications, and moving patients safely to allow for continued treatment.
Descrizione originale:
Crashing patients, EMS approaches, research directions
This document summarizes data from 63 pre-hospital cardiac arrest cases where an advanced airway was attempted. It finds that the majority of arrests occurred more than 5 minutes after initial contact, with a mean time of 16 minutes. Respiratory cases had a longer mean time to arrest of 17.9 minutes compared to 14.6 minutes for non-respiratory cases. 73% of patients were moved to the ambulance prior to arresting. The document recommends improving physiological monitoring, managing airways more effectively, gaining IV access earlier, providing timely volume resuscitation and medications, and moving patients safely to allow for continued treatment.
This document summarizes data from 63 pre-hospital cardiac arrest cases where an advanced airway was attempted. It finds that the majority of arrests occurred more than 5 minutes after initial contact, with a mean time of 16 minutes. Respiratory cases had a longer mean time to arrest of 17.9 minutes compared to 14.6 minutes for non-respiratory cases. 73% of patients were moved to the ambulance prior to arresting. The document recommends improving physiological monitoring, managing airways more effectively, gaining IV access earlier, providing timely volume resuscitation and medications, and moving patients safely to allow for continued treatment.
Pittsburgh EMS Strategies to Prevent Early Mortality 54 y/o female severe respiratory distress Hx: COPD, HTN, Asthma Vitals: GCS = 15 P: 140 R: 48 SpO2: 68% BP: not documented EKG: not documented Case Presentation 1 0000 Patient Contact 0002 Vitals 0006 CPAP SpO2 70% ??? pt was extricated from the house with extreme difficulty due to pts respiratory status, obesity and confinements of pts residence 0026 CPR Initiated 0027 EKG: sinus brady 0029 IO initiated 0030 EKG: asystole 0060 Arrived @ ED in Asystole Case Progression 75 y/o female c/o weakness: Hx: None Listed Vitals CAO, GCS = 15 P: 76 R: 20 SpO2: 97% BP: 88/64 EKG: Pacer rhythm Case Presentation 2 0000 Patient Contact 0000 Vitals ??? Pt moved to unit via stairchair to stretcher 0012 IV NSS Ux2, Blood glucose = 16 mg/dl 0020 IV NSS Sx1 20g, ? Fluids 0025 1 amp D50W IVP 0035 Transport to the Hospital 0040 Patient Arrests, pulseless V-Tach, Defibrillation 0065 Arrival @ ED, pt regains pulses Case 2 progression 63 cases: patients arrest during care Only includes cases where advanced airway was attempted Mix of Respiratory, Shock, AMS & Cardiac 7 cases early arrest within 5 minutes of patient contact 56 cases late arrest > 5 minutes after patient contact 1 JAN 2010 30 NOV 2013 Mean = 16.03 min (1 - 47) Patient Categories 44.4 7.9 12.7 25.4 9.5 Respiratory Cardiac Shock ALOC Other 68.3% GCS < 15 Mean 9.8 71% SpO2 < 94% 60% Respirations <12 or > 20 53.5% Heart Rate < 60 or >100 63.6%Abnormal EKG 43.9% Systolic BP < 90 Vital Signs General Group 0 10 20 30 40 50 60 70 80 90 100 Resp Heart Rate SBP SpO2 EKG EtCO2 Parameter measured Parameter measured Physiological Monitoring Documented Measurements: General Group All Cases: 16.03 minutes (1 47) Respiratory: 17.9 minutes (5 47) 1 early arrest Non-Respiratory: 14.6 minutes (1 - 40) 6 early arrests Time from Patient Contact to Cardiac Arrest Respiratory Cases N=28 Non-Respiratory Cases N=35 Mean GCS GCS < 15 11.25 57.2% 8.63 74.3 Respirations <12 or >20 78.6% 40.6% SpO2 < 94% 95% 44.4% Heart Rate < 60 or > 100 71.4% 36.7% Abnormal EKG 75% 52.9% SBP < 90 22.2% 60.9% 73% moved to ambulance prior to arrest Mean time to arrest 16.03 minutes Respiratory: 92.6% moved to ambulance prior to arrest Mean time to arrest 17.9 minutes Non-Respiratory: 60% moved to the ambulance prior to arrest Mean time to arrest: 14.6 minutes Interventions Documented interventions Prior to Arrest Move Patient to Ambulance 73% Oxygen 60.3% PPV BVM 38.1% IV Initiated 28.6% Advanced Airway Placed 17.5% BLS Airway Adjunct Placed 14.3% CPAP 12.7% NSS Bolus 12.7 0 10 20 30 40 50 60 70 80 90 100 Move Pt O2 CPAP PPV-BVM BLS ADJ ADV Airway RESP MED Respiratory vs. Non-Respiratory Respiratory Non-Respiratory Documented Interventions Prior to Arrest Interventions in Sepsis: 206 Philadelphia EMS Patients 17.9 8 9.6 14.9 12 14.6 0 7.5 11.4 9.8 0 0 0 0 0 2 4 6 8 10 12 14 16 18 20 ARREST TIME CPAP PPV-BVM ADV AIRWAY IV RESP NON-RESP . Time to Key Interventions Respiratory Cases Non-Respiratory Cases VF/VT Asystole PEA VF/VT Asystole PEA Arrest Rhythm Overall: 30.2% Respiratory: 32.1% Non-Respiratory: 28.6% Post crash ROSC @ ED Physiological Exhaustion Hypoxia Hypercarbia Hypotension Acidosis Didnt think the patient was that bad Patient was really bad and need to get moving Wanted to move the patient to the unit to begin interventions Conditions/bystanders at scene would hinder care More comfortable working in the ambulance Didnt believe that interventions at the scene would help Root Cause Analysis for Early Move to the Ambulance Load and Go OK Trauma Uncontrolled hemorrhage Acute Stroke Load and Go not OK Respiratory Distress/Failure Medical Shock Cardiac Load and Play? Crashing Patients Stay and Play: Non Traumatic Shock Medical Shock is 10x as common as traumatic shock Wang, Crit Care 2011 Less than 50% receive IV access If IV access obtained Patients received larger volumes of fluid during their ED care Trended to meeting resuscitation goals -Seymour, PEC 2011 Prehospital Fluid Administration for Sepsis time to goal MAP Seymore (2013) An IV has never saved anyone .. Seymore et al., Ann Emergency Med. (2012) Intravenous access during pre-hospital emergency care of non-injured patients: a population-based outcome study Seymore (2013) timely pre-hopsital interventions make a positive difference in the sickest patients When seeking to optimize EMS systems to improve outcomes, the findings support a strategy which favors early, targeted intravenous access particulary among those with evidence of most severe illness Seymour, et al. (2012) Sepsis In the medical arrest cohort, the presence of a presence of a peripheral IV prior to crew arrival(was) associated with ROSC at destination (p=0.05) Rittenberger, et al., Resuscitation (2008) Aeromedical Cardiac Arrest Stay and Play: CHF CHF Patients given O 2 and Nitrates for CHF in the field had increased survival OR 2.5 Treatment was initiated 36 minutes sooner than those brought to the ED POV. Before the era of BiPAP -Wuerz, AEM 1992 Stay and Play: Respiratory Distress OPALS: Adding ALS decreased mortality in respiratory distress patients from 14.3% to 12.4% Mortality changes by diagnosis CHF -4.2% COPD -0.2% Pneumonia -3.7% Asthma +1% Stiell, NEJM 2007 Oxygen Inhaled B2 Agonist Subcutaneous Adrenergic Agents Corticosteroids Magnesium Sulfate CPAP/BLVAP Intubation Rosens Emergency Medicine, 5 th ed (2002) Management of Acute Asthma in the ED Key issues: Application of Physiological Monitoring Rapid assessment and management of ABC issues CPAP, PPV via BVM, Advanced Airway Early IV/IO access Maximal Medical Therapy Safe Movement of the Patient Pittsburgh EMS Crashing Patients Program Physiological monitoring difficult or not done Unable to manage airway No IV Delayed volume resuscitation & medical administration Bad physiology allowed to persist to exhaustion Hypoxia Hypercarbia Hypotension Acidosis Early patient movement issues Physiologic Monitoring Full set of vital signs SpO2 Oxygenation EKG Capnography Ventilation Lactate/Glucose after IV access SpO2 gives information on oxygenation EtCO2 gives information on Ventilation Perfusion Status of the lower airway Non-Invasive Capnography Decreasing EtCO2 = Early Shock 70 y/o female Unresponsive GCS 3 Central Pulses, no peripheral pulses or BP. HR 50, R=30 shallow Intubated, EtCO2 = 13 mm/hg Pt had a PE 26 y/o M, SOB, wheezing, asthma 54 y/o, SOB, wheezing asthma Pulse: 116 Resps: 30 BP: 110/80 SpO2: 100% EtCO2: 32 mm/hg Pulse: 120 Resps: 24 BP: 124/70 SpO2: 94% EtCO2: 51 mm/hg PaCO2 > 50 associated with Near-Fatal Asthma (Nowak & Tokarski, 2002) Respiratory Distress vs. Respiratory Failure Inadequate Tidal Volume Unable to speak Poor muscle tone Unable to support self Decreasing LOC SpO2 < 90% Increasing EtCO2 >> Hypoventilation pattern Decreasing heart rate Adequate Tidal Volume Able to Speak Good Muscle Tone Able to Sit Up CAO SpO2 > 90% Stable or decreasing EtCO2 Adequate heart rate Respiratory Distress vs. Failure Hypoventilation Pattern = Respiratory Failure Positive Pressure Ventilation High Flow O2 CPAP PPV via BVM ETI/King Airway Respiratory Progression Venous Access: IO Lidocaine 20-40 mg IO 10 cc NSS Bolus Use Pressure Infuser Albuterol +/- CPAP PPV and ETI as indicated For Asthma: Consider 0.3mg 1:1000 Epinephrine IM if age < 50 and no significant hypertension/Cardiac Hx Solu Mederol 125 mg IVP Magnesium 2 gm infusion Consider repeat Epinephrine 1:10,000 0.1-0.5 mg IVP in consultation with the MD Asthma/COPD CPAP +/- Albuterol PPV and ETI as indicated NTG SL Consider Lasix in consultation with MD CHF Non Cardiogenic Shock 500cc NSS boluses pressures infused to 2L Cardiogenic Shock 250-500cc boluses & reassess, continue as long as clear lung sound and no dyspnea Dobutamine for CHF & SBP 70-90 Dopamine for CHF & SBP < 70 Hypotension unresponsive to fluids Dopamine Hypotension On completion of the Crashing Patients Algorithm and arrival of assistance make a safe patient move to the ambulance 2 Pilot Phases Fall 2012 & Spring 2013 Approximately 50% of Personnel Trained Resulted in 78% of calls having at least one trained crew member on board Small unit training 2-4 personnel 2 hour session 2 pre test practical cases, didactic, 2 post test practical vases Pittsburgh EMS Crashing Patients Program Implementation Respiratory & Shock Pretest Cases on a simulator manikin Lecture on the concept of operations of the Crashing Patients program Respiratory & Shock Posttest Cases on a simulator manikin Training Program 375E5 Patient Outcomes: Pulse on ED Arrival (2008) Arrests Pulse @ ED % with pulse P value 375E5 Patients 149 51 34.29% 0.025 Standard Patients 225 69 23.47% Intervention Pre-Test Performed Pre-Test Time (sec) Post-Test performed Post-Test Time (sec) SpO2 93.8% 48.47 100% 22.88 EKG 100% 121 76.5% 75.46 Capnography 37.5% 339 47.1% 92.88 CPAP/PPV 100% 453.5 100% 161.77 IV 100% 439.44 100% 233.53 Solu Mederol 93.8% 529.87 94.1% 291.75 Magnesium 56.3% 592.11 88.2% 302.4 Epinephrine 12.5% 375 64.7% 260.55 Inappropriate Move 50% 0% Training Data Rated the course as excellent 100% Planned to use in Daily Practice 100% Actually employed the strategy on a call 61.8% Would like to attend future advanced resuscitation programs in this format 91.2% Post Course Survey 0 50 100 150 200 250 300 350 400 450 EtCO2 CPAP 2011 2013 EtCO2 & CPAP 2011 vs. 2013 (April 1 November 30) Crashing Patient Program Review 74 Personnel Trained thru 17 JULY 2013 Reviewed all charts with Albuterol Use Include: GCS < 15, SpO2 < 90, HR > 100, RR > 24 Exclude: Peds, No Transport 20 DEC 2011 31 JAN 2012 266 Reports, 199 Included 20 DEC 2012 31 JAN 2013 356 Reports, 240 Included 20 June 2013 20 July 2013 137 Reports, 87 Included Patient Monitoring 0 10 20 30 40 50 60 70 80 90 100 SpO2 EKG EtCO2 Pre CP Post CP 6/7 2013 p = 0.0018 P=0.0086 Interventions 0 10 20 30 40 50 60 70 CPAP IV/IO Solu Med Magnesium Pre CP Post CP 6/7 2013 p=0.8144 p=0.0392 p=0.0013 P=0.0024 0 2 4 6 8 10 12 14 16 18 20 2011 2012 2013 CP < 5 ROSC ED CP > 5 ROSC ED<5 Crashing Patients Cases 2011-2013 27 y/o SOB Hx: Asthma Vitals: Alert, CAOx4 P: 120 R: 24 SpO2: 94 EtCO2: 51 with shark-fin SBP: 138 EKG: sinus tachy Case 3 0000 Patient Contact, vitals 0002 O2 6 lpm, 5 mg Albuterol 0004 IV NSS Lock Sx1 0007 125 mg Solu Medrol IVP 0009 2 gm MagnesiumIV 0011 0.3 mg 1:1000 Epinephrine IM 0013 CPAP 0015 Transport initiated 0016 Repeat 5 mg Albuterol 0024 Arrive Hopsital CAO, GCS 15, P: 115, R: 22, SpO2: 100%, EtCO2: 54 mm/hg Pt recieves BIPAP, addition albuteol and epinephrine and does well Case 3 Progression Emergent Moves of Critically Ill Medical Patients is associated with increased mortality Physiological Monitoring is Paramount Aggressive BLS and ALS care should be immediately initiated to address ABC issues as a strategy to prevent prehospital cardiac arrest of these patients Then a safe move to the ambulance and transport can be effected Summary Questions ?