Mark Pinchalk, MS, EMT-P

Paramedic Crew Chief

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 ?