Cervical spine immobilization is a big change in the EMS protocol over several years.
Cervical collars were developed for rehabilitation after neck or spine surgery, but became a tool for prehospital treatment of undifferentiated trauma patients that may or may not have injured the neck.
There is no real evidence that the cervical collar prevents secondary spinal cord injury.
The problem is that these patients may not even exist. The forces to injure the cervical spine – transect the bones or tear ligaments – are so great the it is unlikely that the cervical spine was not also injured during the initial trauma.
Deterioration of a patient with a possible cervical spine injury are likely due to increasing edema and ischemia in the spinal cord.
The cervical collar does not diminish the force on the neck even with restriction of movement.
Defibrillation is used to depolarize the heart and reset the electrical activity. How can the success of defibrillation be maximized for a patient with persistent Vfib and has been shocked several times previously by EMS.
Success is dependent on the contact of the pads with the chest. Drying off a patient, removing hair and increasing pressure can all improve success, but so can dual sequential defibrillation.
Dual sequential defibrillation is the use of 2 simultaneous defibrillators to increases the amount of electricity reaching the heart.
One set of pads from each defibrillator are placed in the AP lateral position and the other set of pads are placed in the AP posterior position.
This is generally considered a safe technique to increase the electricity to the heart and the chances of success of defibrillation.
The most recent data on value on interventional neuroradiology suggests that the patients who receive the most benefit from neuroradiology are those with a large vessel occlusion, and can have up to 50% reduction in mortality.
The question is for EMS, when should you bypass other hospitals to go directly to a comprehensive stroke center with neuroradiology.
The CPSSS – Cincinnati prehospital stroke severity score – is an augmentation of the Cincinnati prehospital stroke scale to help identify a large vessel occlusion.
CPSSS is a 4 point score: 2 – eye deviation, 1- abnormal LOC, 1 – arm drift.
A score of 2 or more is 80% sensitivity for a large vessel occlusion. However the specificity is not of this scale is not as good.
There is a large push to standardize the CPSSS to allow EMS to bypass other hospitals in order to get to comprehensive stroke center.
The Canadian Medical Association Journal published a study this year looking at the association between what floor people live on and cardiac arrest survival.
In the US, 2% of patients with out-of-hospital cardiac arrest survive with a favorable neurologic outcome and 5% survive to discharge from hospital.
The study found that if you live on the first, second, or third floor, you have a 5.3% rate of survival to hospital discharge. If you lived above the third floor, the survival to hospital discharge rate was 2.7%. If you lived above the 16th floor, the survival to hospital discharge rate was 1.0%. If you lived above the 25th floor, the survival to hospital discharge rate was 0.0%.
These findings indicated a strong, statistically significant association between a patient’s location in a building and the chances of surviving an out-of-hospital cardiac arrest.
In Colorado, the snake that people start worrying about in the spring and summer is that rattlesnake. However, 25% of bites are dry bites, meaning no venom, and there are only about 10 lethal snake bites per year in the US.
The new anti-venom is CroFab, an immunoglobulin from sheep that has antibody to the toxin of the crotalinae. The anti-venom is expensive, but very safe for use.
Swelling is generally the initial symptom; dangerous places include the hand and face. In the case of any significant swelling, get anti-venom treatment immediately.
Treatment with anti-venom consists of 4-6 vials of antivenom then tracking swelling, and another dose of 4-6 vials if swelling continues within an hour.
Rarely patients develop compartment syndrome, most resolve with antivenom and don’t need surgery
In the United States, first aid is generally not needed as long as you keep calm and get to a hospital. It is even discouraged because it can cause more damage than benefits.
There are two types of patients that should be resuscitated for a long period of time after losing pulses – hypothermia and lightning strikes.
The low temperature can decrease the loss of neurological function associated with lost pulses. Patient’s with hypothermia should be resuscitated until their body temperature is 35 degrees Celsius.
Patient’s who have been struck by lightning can also be resuscitated for longer than normal because the myocardium is usually only stunned, despite being in asystole. Patient’s with lightning strikes normally have abnormal electrolyte imbalance.
ED ECMO or Emergency Department Extracorporeal Membrane Oxygenation is a technology that can provide respiratory and cardiac support to patient’s in respiratory or cardiac failure with a higher rate of saving the patient than ACLS alone.
Over the last few years, general consensus has strayed away from pre-hospital intubation in the field. This is because it has been found that interruptions to CPR (namely intubation and airway management) decrease the success of the patient.
This was believed to be solved via the quick placement of a King Tube or a supraglottic device.
This was believed widely until there was a study done on the placement of supraglottic devices in pigs during cardiac arrest decreased carotid blood flow.
Multiple observational studies have shown patients have a higher rate of return of spontaneous circulation, greater rate of admission, and better neurological status upon discharge with endotracheal intubation in the field versus supraglottic device placement.