Toxicology fellow extraordinaire Alexa Camarena-Michel, MD joins us again to talk about one of sickest overdose patients you may see. Calcium channel blocker and beta blocker overdose patients can be really sick and are often refractory to our standard therapies. Learn how to better manage these patients. 

A longer one than usual. We take a deep dive into hypothermia with wilderness medicine physician and expert Martin Musi.

Alexa Camarena-Michel teaches us a simple approach to caustic ingestions and more.

Dr. Wright joins us to discuss acute respiratory distress syndrome (ARDS). There has been a lot said about ARDS recently given some of it's similarities to the COVID-19 disease process. That being said ARDS has been around for a long time and is very much its own disease process. We discuss how to define it, how to recognize it, and how we treat it. There are some great media and pictures to help illustrate the points made in this episode on our website. Check out the show notes at https://emspodcast.com/acute-respiratory-distress-syndrome. 

Undiagnosed or misdiagnosed diabetes is common because of how vague the symptoms can be. Chief Harper from Denver Paramedics tells us his incredible personal story dealing with his son's diagnoses, his path to becoming an expert on diabetes, and how we should think about this as prehospital providers.

This month we sit down with Assistant Medical Director Whitney Barrett to discuss the dos and don'ts of calling in for medical control. 

This is still included in the A of ABCs but I got essentially no training on this in paramedic school. I honestly didn’t get much formal training on this after becoming an ED doc either. I just had to bug RTs and ICU docs to learn what I know now.

Airway problems are terrifyring without an approach to solve them. But when you have an approach you can fall back on that with a calm confidence. It’s like we’ve always heard: we don’t rise to the occasion, we fall to the level of training. With trach’s, we unfortunately have to train ourselves.

Check out our new website at emspodcast.com! We will have pictures and show notes corresponding to this episode there. 

We discuss where things go wrong with how we talk to each other and how we can do better.

EMS physician Whitney Barrett joins us to discuss some of the scariest and emotional calls we can go on and how we can manage these situations better. 

Caring for the critically ill pediatric patient is scary for all emergency providers. We discussed our approach to these calls with attending EM/EMS physician Dr. Whitney Barrett.

Background

• 2015 study: review of trip sheets showed wrong intervention, dosing errors in up to 65% of interventions on pediatric calls
• PREPARE Trial: only 34% of pediatric cardiac arrest patients received epinephrine
• EMS training in pediatrics is probably inadequate!

Human Factors

• Potential stressors:
  • Math is hard, especially when you’re stressed
  • Paradigm that “pediatric patients are not small adults” may lead providers to overthink resuscitation
• “Thinking Fast and Slow,” by Daniel Kahnemann: breaks down thought processes
  • System 1: unconscious, second nature
  • System 2: conscious, requires mental effort and focus
  • If we exhaust system 2 with calculations, we can’t effectively focus on patient care and scene control  
  • How can we turn system 2 thinking into system 1 thinking?
• The culture of pride in EMS may prevent some providers from using quick references or “cheat sheets.” There’s no shame in looking something up!
• Our own stress may contribute to a “hectic scene” as much as the scene itself
  • Don’t automatically “load and go”
  • Early ventilations and compressions—not early transport—save lives

Solutions

• Cheat sheets: have a pocket reference with normal pediatric vitals and doses by volume, which may be specific for your system. Using this sheet on every peds call you run—whether or not you need it—will help familiarize you with its contents for when you really need that info.
• Pediatric reference systems exist and are designed to help with cognitive offloading
  • Handtevy: estimated weight, vitals, doses, and necessary equipment separated by age. Used by the Denver Health Paramedic Division.
  • Broselow Tape: estimated weight, vitals, and doses listed on a length-based measuring tape. Designed for hospital use, EMS doses often much higher. Old school pearl: tape it flat to the pram so it’s ready for the patient.    
  • PediStat App
  • Pearl: age correlates very well with weight, and parents often know the weight!
• Pre-arrival visualization: on the way to the call, run it in your head based off dispatch information. Pull out your cheat sheet. What is your differential? What treatments might you need?

Takeaways

• Prehospital management of critical pediatric patients needs improvement
• Prepare for stress by anticipating it.
  • Pediatric reference systems help minimize system 2 thinking and should be used whenever possible.
  • Math is hard, and cheating should be encouraged. Have a cheat sheet and familiarize yourself with it.
  • On the way to the call, consider differentials and treatment plans.
• If all else fails, pump the brakes. If this were an adult, what would I do right now? Fall back on your ABC’s.

Sample Cheat Sheet

• This Handtevy “badge buddy” doesn’t have vitals, but it does have estimated weight by age, doses by volume, and airway adjunct sizing. It’s also color-coded and easy to follow.

Maria Moreira joins us to to discuss the intricacies to managing penetrating neck wounds. There are a lot of important structures in the neck and damage to these structures are often life threatening and require quick action to stabilize. We break down how to organize these structures in your mind and develop a treatment plan based on what you're seeing on exam. We'll also take it one step further and discuss how we're going to care for these patients once they hit our doors in the ED.

We sit down with Whitney Barrett to talk about where some of the stuff everyone is hearing about COVID comes from. Spoiler alert: there isn't a lot of data. We discuss things like 6-feet apart, what type of mask to use, paramedic-initiated refusals, and more. Stay safe out there.

First and foremost, we would like to thank all pre-hospital providers for the work you do. You are all underpaid, understaffed, and under appreciated. However, the unsung work that you do matters now more than ever. We go to work every day in order to be there when the public needs us. Much of the focus as of late has been on COVID. And probably rightfully so. But patients continue to have MI’s, strokes, overdoses and many other emergencies. And these emergencies still deserve our excellent care and diligence not to miss. So although we plan to have another special-edition, COVID-update episode we don’t want to neglect these other emergencies. So let's talk about Large Vessel Occlusions.

Ep. 2 Large Vessel Occlusion (LVO) Show Notes

First and foremost we would like to thank all prehospital providers for the work you do. You are all underpaid, understaffed, and under appreciated. However, the unsung work you do now more than ever matters. We go to work every day in order to be there when the public needs us. Much of the focus as of late has been on COVID. And probably rightfully so. But that being said, patients continue to have MI’s, strokes, overdoses and many other emergencies. And these emergencies too still deserve our excellent care and diligence not to miss. So although we plan to have another special edition COVID update episode soon we don’t want to neglect these other emergencies. This month we talk Large Vessel Occlusions.

• Endovascular Stroke therapy (EST) for large vessel occlusion (LVO) - This is the hottest therapy since PCI - 12 studies since 2013, 5 studies in 2015 alone 
  • https://rebelem.com/endovascular-therapy-for-acute-ischemic-stroke-the-new-shiny-toy-in-stroke-care/
  • For a nice review of all of the studies and evolution of endovascular therapy visit:

• How is EST performed? 
  • A catheter is guided through one of the femoral arteries and up through the carotid and into the distal internal carotid, anterior cerebral artery or the middle cerebral artery
  • A clot retrieval device is fed through the catheter in order to retrieve the clot
  • Unlike tPA which has only shown very marginal benefit in just a few studies that were admittedly methodologically flawed. EST has recently had multiple strongly positive trials showing impressive benefits (although these benefits are likely over estimated, see the link above for a deep dive on the researches strengths and weaknesses)

• Who Qualifies for EST?
  • Similar to the early days of PCI for myocardial infarctions when cath lab centers were farer and fewer between
  • Will likely vary based on your stroke center and may change with future studies so make sure you stay up to date with your local protocols.
    • Initial studies looked at less than 6 hour time window and is what the American stroke guidelines currently recommend. 
    • A lot of places have started pushing this time window further out and locally here we us a cut off of less than 24 hours
  • Initially studies for all comers with stroke receiving EST found no benefit
  • It wasn’t until they identified a subset of patients with Large Vessel Occlusions (LVO) that they began to see these impressive benefits
  • An LVO is defined as clot located in either the distal internal carotid, proximal anterior cerebral artery (ACA), or the proximal middle cerebral artery (MCA)
  • Not every stroke center has the capability to perform EST
  • What is the timeline to qualify for EST
• So do we need to start re-organizing our transport priorities and transporting all of our suspected strokes to EST centers similarly to how we transport all of our STEMI’s to cath centers?
  • With STEMI we have a clear diagnostic tool with our EKG to determine if somebody needs the cath lab. 
    • In order to know for sure if our patient would need EST we would need a CT scanner. And not just CT but also the ability to do CT with contrast in order to see which vessel the clot is in.
    • If there is even a clot at all. Given so many mimickers of stroke on a very small percentage of patients evaluated for concern for stroke actually end up having a stroke
  • Which brings us to the second point of why we don’t want to start transporting to only EST centers: Only a select number of stroke patients, those with clots in the large proximal vessels, will benefit from this therapy. 
    • It wasn’t until later trials when they narrowed the patients they were treating to those with identified LVO in the arteries mentioned before: distal internal carotid, proximal ACA, and proximal MCA that they started finding benefit. 
    • It turns out that only 1 in 770 of stroke patients will have an occlusion meeting criteria for EST. 
    • And that's in patients who WE KNOW are having a stroke. Can you imagine what that number would be if we included everyone we just suspected of having a stroke? We would overwhelm the hospital. 
    • Early trials from 2013 looked at utilizing this therapy for all comers with stroke and found no benefit when compared to tPA alone. 
    • So even if we were sure our patient was having a stroke based on our exam they still would only benefit from transport to an EST if it was in one of these specific large and proximal vessels.
  • No, here’s where we don’t wanna get ahead of ourselves

• So are there any physical exam findings to help us determine those likely to have a LVO and thus should be transported to one of these centers?
  • There’s not strong enough evidence to suggest such a protocol yet so for now keep transporting to your nearest local stroke center per your protocol 
  • But there are researchers looking at some prehospital scores to help with this question and we should be aware of and keep on the lookout for future data and research on this. See some of the prehospital scores and their associated ealy research below.

• • • VAN score - vision, aphasia, neglect
      • 62 patients, 31% (19) were VAN positive
      • 90% of those had an LVO and no LVO’s occured in the VAN neg group. 
      • This is a small feasibility study. This means it was a smaller study done solely to determine if a larger more robust trial should be completed. Feasibility trials should not be used to change current care.
      • Start with bilateral arm raise for 10 seconds
        •  if any drift then proceed with the VAN assessment, 
      • If any of the following are positive in a patient with arm drift then they are considered VAN positive
        • Check all 4 quadrants one eye at a time
        • I cover one eye and ask 1 or 2 fingers in each quadrant. 
        • If the patient is having difficulty cooperating you can blink to threat in all quadrants. 
          • Move your hand quickly towards their eye from the quadrant you are testing (but don’t actually hit them).
          • If they blink you assume the vision is intact.
          • Blink to threat
        • Aphasia either expressive or receptive. 
          • Can’t say words or doesn’t say the right words 
          • Unable to understand what you are saying. 
          • Expressive
          • Receptive
        • Important: 
          • Aphasia is different from dysarthria which is slurred speech.
          • Dysarthria is not what we are testing or scoring here.
        • Have the patient close both eyes and then you touch both of their arms with your fingers and ask which arm you are touching, if the patient fails to identify the weak arm (the arm you identified with a drift earlier) this is considered neglect. 
        • Other signs of neglect are an inability to track your finger beyond midline or a forced gaze deviation to one side. 
        • Visual fields
        • The next component is Aphasia
        • Finally Neglect
      • About the data: https://jnis.bmj.com/content/neurintsurg/9/2/122.full.pdf
      • How do you do the exam?

• • • Cincinnati pre-hospital severity stroke scale
      • In the original derivation study it was found to have a sensitivity 83% and specificity 40% for identifying patients with a LVO. 
        • Katz BS, Mcmullan JT, Sucharew H, Adeoye O, Broderick JP. Design and validation of a prehospital scale to predict stroke severity: Cincinnati Prehospital Stroke Severity Scale. Stroke. 2015;46(6):1508-12.
        • Kummer BR, Gialdini G, Sevush JL, Kamel H, Patsalides A, Navi BB. External Validation of the Cincinnati Prehospital Stroke Severity Scale. J Stroke Cerebrovasc Dis. 2016;25(5):1270-4.
        • However, in an externally it was found to have a sensitivity of 70% and specificity of 86%. 
      • About the data:
      • See MDcalc for the scoring details: https://www.mdcalc.com/cincinnati-prehospital-stroke-severity-scale-cp-sss#next-steps
    • RACE
      • In the original study a RACE Scale value of ≥5 had a sensitivity 85% and a specificity of 68% for identifying an LVO. 
        • Pérez de la Ossa N, Carrera D, Gorchs M, et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion evaluation scale. Stroke. 2014;45(1):87-91.
      • A second study was designed to assess whether or not bypassing patients to a Comprehensive Stroke Center with a RACE Scale ≥5 would improve outcomes. 
        • Zaidi SF, Shawver J, Espinosa morales A, et al. Stroke care: initial data from a county-based bypass protocol for patients with acute stroke. J Neurointerv Surg. 2016; Jun 24. pii: neurintsurg-2016-012476. doi: 10.1136/neurintsurg-2016-012476. [Epub ahead of print]
        • The results of this study showed an increased treatment rate, improved door-to-CT times, and improved door-to-needle times. 
        • The rate of mechanical thrombectomy also increased with improved arrival-to-puncture and arrival-to-recanalization times as well. 
        • However, there was only a small trend toward improved outcomes that did not reach statistical significance.
      • About the data:
      • See MDcalc for the scoring details: https://www.mdcalc.com/rapid-arterial-occlusion-evaluation-race-scale-stroke
    • FAST ED
      • Lima FO, Silva GS, Furie KL, et al. Field Assessment Stroke Triage for Emergency Destination: A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes. Stroke. 2016;47(8):1997–2002. doi:10.1161/STROKEAHA.116.013301 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4961538/
      • https://www.ahajournals.org/doi/full/10.1161/strokeaha.116.016026
      • The data:
      • There’s an app for that
    • ELVO screen 

      • Kentaro Suzuki , Nobuhito Nakajima, Kenta Kunimoto, et. al. Emergent Large Vessel Occlusion Screen Is an Ideal Prehospital Scale to Avoid Missing Endovascular Therapy in Acute Stroke.. Stroke. 2018;49:2096–2101.

      • The data:
• American stroke algorithm for when to bypass and transport to an EST capable facility
  • Algorithm: https://www.heart.org/-/media/files/professional/quality-improvement/mission-lifeline/2_25_2020/ds15698-qi-ems-algorithm_update-2142020.pdf?la=en&hash=A0AB5E209AC78933C54E41C3FF235B60F9CC4A7C
  • Complete reference:

https://www.heart.org/en/professional/quality-improvement/mission-lifeline/mission-lifeline-stroke

• Join Triage App
  • https://apps.apple.com/us/app/jointriage/id1099779970
  • https://play.google.com/store/apps/details?id=net.allm.fasted&hl=en_US
  • Apple:
  • Google Play:

Information about COVID-19 is changing by the minute. We tricked Dr. Whitney Barrett, EMS physician, and all-things COVID hero, to come on and give us a prehospital take on coronavirus. If something sounds old or out-dated, it probably is and that is the nature of these trying times. Be safe out there. Thank you for what you do!

We talk about toxidromes with emergency physician and toxicologist, Dr. Janetta Iwanicki.

Matt Mendes and Ross Orpet talk about why they started this podcast.