Category: Podcast Episodes

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Pain perception is complex.

Pain perception is a complex phenomenon that involves both physical and emotional components. In this podcast episode featuring Dr. Spencer Tomberg, a physician in the Department of Emergency Medicine and Orthopedics at Denver Health, the intricate nature of pain perception is explored.

Dr. Tomberg begins by discussing the different ways in which pain is perceived. He highlights the fact that pain is not just a physical sensation but also has a significant emotional component. While medical professionals tend to focus on treating the physical aspect of pain, it is crucial to consider the individual’s emotional experience and support them accordingly.

Pain perception varies among individuals. There are measurable differences in the action potential and synaptic regions related to pain perception between person to person. This means that one person’s perception of pain may differ from another’s. For example, individuals with chronic pain may have more pain receptors in their neurons or a lower threshold to fire that neuron, leading to increased sensitivity to pain. This insight challenges the notion of a universal treatment approach for pain and emphasizes the importance of considering the individual aspects of each patient.

Furthermore, the podcast highlights the role of the visceral system in pain perception. While most pain signals from the extremities and skin travel through the spinal cord, signals from the organs in the abdomen take a different route, primarily through the vagal nerve. This explains why patients with spinal cord injuries can still experience pain in their abdomen. Additionally, referred pain occurs when signals from different parts of the body converge in the brain, leading to a misinterpretation of the source of pain. Understanding these mechanisms helps us as healthcare professionals better comprehend and address the source of our patients’ pain.

The podcast also touches on the challenges of pain management in the emergency setting. Studies have shown that adequate pain control is often lacking, with approximately 75% of patients reporting inadequate pain control in acute trauma and ICU settings. This suggests that there is room for improvement in pain management practices. It is crucial for healthcare professionals to be aware of these statistics and strive to provide optimal pain relief for their patients.

Pain control is crucial, but biased.

Biases can impact the provision of adequate pain relief. Sometimes we may not feel comfortable giving the right amount of pain medication due to concerns about how it may affect future providers evaluation of the patient. This highlights a bias towards prioritizing evaluation over pain relief. But multiple studies have demonstrated that providing proper analgesia does not actually change our ability to get a good physical exam and treat the patient appropriately. In fact, it may just be the opposite. Providing adequate pain control can often help you get a more specific and targeted exam.

Another bias mentioned in the podcast is the differential treatment of patients with known drug use disorders. It is acknowledged that these patients may require higher doses of pain medication due to their tolerance to opiates. However, there is a tendency to undertreat these patients, possibly due to biases and stigmas associated with drug use disorders.

There are also disparities in pain control among different racial populations. Studies have shown that minority patients do not receive the same level of pain control as white male patients. This bias in pain management contributes to unequal healthcare outcomes and highlights the need for healthcare providers to be aware of their biases and strive for equitable treatment for all patients.

The discussion also touches on the challenges of pain management in acutely injured trauma patients who may already have opiates or other substances in their system. The approach to pain management in these cases needs to be individualized and take into account factors such as the patient’s level of intoxication and their long-term opiate use. This again highlights the need for healthcare providers to consider the specific circumstances of each patient when determining the appropriate pain management approach.

Untreated pain can have a significant impact on a patient’s healing and overall outcomes. Untreated pain can lead to increased rates of delirium, longer hospital stays, changes in the endocrine system, impaired wound healing, and cardiovascular and pulmonary changes. These complications can result in higher risks for both short-term and long-term complications.

Multimodal approach for chronic pain.

The podcast discusses the concept of a multimodal approach for chronic pain management. Relying solely on opioids for pain control may not always be effective, especially in chronic opiate patients. In these cases, alternative medications are considered as second-line options.

In the ICU settings, studies have shown that combining medications such as gabapentin, Tylenol, and NSAIDs with opioids significantly reduces opiate use while maintaining similar outcomes in terms of pain control, length of stay, and complications. This multimodal approach is also used in orthopedic clinics, where injections, gabapentin, Tylenol, and ibuprofen are utilized to provide pain relief.

Again, chronic pain management is not a one-size-fits-all approach. It requires a comprehensive strategy that addresses pain from different angles. With a goal to help patients achieve relative comfort and functionality in their daily lives, even if complete pain elimination is not possible.

In the emergency department, the healthcare provider’s initial approach to patients with chronic pain is to listen to their stories and understand their experiences. Giving patients the opportunity to share their journey can be therapeutic in itself. Based on the patient’s history and condition, the healthcare provider may consider adding medications such as gabapentin or ensuring that the patient is taking over-the-counter pain relievers like Tylenol.

The podcast also briefly touches on the use of medications like Haldol or anti-dopaminergics in the emergency setting. While these medications are not typically used for pain relief, they can be helpful in addressing the emotional component of pain. By decoupling the emotional and physical aspects of pain, healthcare providers can help reset the patient’s perception of pain and alleviate suffering.

In summary, the podcast highlights the importance of adopting a multimodal approach for chronic pain management. By combining different medications and addressing the biopsychosocial aspects of pain, healthcare providers can improve pain control and enhance the overall well-being of patients.

Ketamine is great, but does have risks.

One of the medications discussed in the podcast is ketamine, which is becoming more commonly used as an adjunct to opiates in pain management. While ketamine has proven to be effective in alleviating pain, it is important to acknowledge that it also carries risks.

Ketamine can induce hallucinations and dissociative states. This can be particularly concerning for individuals who have a history of psychiatric conditions such as post-traumatic stress disorder (PTSD).

To mitigate these risks, you may consider using lower doses of ketamine. Recent studies have shown that low doses of ketamine (such as 0.1 mg/kg) can be just as effective as higher doses in managing pain. By using the lowest effective dose, healthcare providers can minimize the likelihood of patients entering a dissociative state or experiencing psychological distress.

Definitely follow your local protocols and consult your medical directors when using ketamine for pain management or sedation and when treating any such side effects. But one strategy mentioned worth considering, if a patient accidentally enters a distressed psychological state while under the influence of ketamine, is to continue to fully dissociating them by giving more in order to increase your dose to that dissociative range (generally 1mg/kg IV). But most importantly just avoid such situations in the first place by adhering to protocols and being aware of the potential risks associated with various doses of ketamine.

When using larger dose of ketamine, there are more potential side effects that need to be considered. One such side effect is laryngospasm, where the glottis (the opening to the windpipe) locks shut, making it difficult for the patient to get air in or out. It is important to recognize and address laryngospasm promptly, as it can be life-threatening. First initial approach described is “forceful bagging”, the use of a BVM in an attempt to force air through the obstruction. But sometimes these patients require paralytics in order to relax that laryngospasm. Another side effect mentioned is excessive salivation, which can be managed with medications like atropine.

In conclusion, while ketamine can be an extremely effective medication for pain management, it is crucial to recognize and address the psychological risks it carries. Providers should be mindful of patients’ psychiatric history and consider using lower doses of ketamine to minimize the likelihood of distressing episodes. Additionally, prompt recognition and management of side effects such as laryngospasm and excessive salivation are essential.

Treating pain is crucial.

Treating pain is crucial in the field of medicine. Pain is a subjective experience that can greatly impact a person’s quality of life and overall well-being. Whether it is acute pain resulting from an injury or chronic pain stemming from a medical condition, addressing and managing pain is essential for the patient’s comfort and recovery.

In an emergency setting, the need to treat pain becomes even more critical. When someone is experiencing acute pain, it is important to provide immediate relief to alleviate their suffering. Pain can be a symptom of a more serious underlying condition, and by treating it promptly, healthcare providers can potentially identify and address the root cause of the pain.

Moreover, managing pain in the acute setting can have positive medical implications. Pain can trigger a stress response in the body, leading to increased heart rate, elevated blood pressure, and heightened levels of stress hormones. By effectively managing pain, healthcare providers can help mitigate these physiological responses, promoting a more stable and conducive environment for healing.

There are various methods and medications available for pain management, depending on the severity, duration, and type of pain.

Adopting a multimodal approach that combines various pain management strategies can provide more comprehensive and tailored care for patients, especially those experiencing subacute and chronic pain. This may include non-pharmacological interventions such as physical therapy, cognitive-behavioral therapy, and relaxation techniques, alongside pharmacological interventions.

Furthermore, it is crucial to recognize that pain management is not just about physical relief. Pain can have a significant impact on a person’s mental and emotional well-being. Addressing and managing pain effectively can improve a patient’s overall quality of life, reduce anxiety and depression, and enhance their ability to engage in daily activities and rehabilitation.

In conclusion, treating pain is crucial in the field of medicine, particularly in the emergency setting. Prompt and effective pain management not only alleviates suffering but also promotes healing and prevents potential complications. Healthcare providers should consider a multimodal approach, taking into account the potential risks of certain medications while also addressing the emotional and mental aspects of pain. By doing so, they can ensure safer and more effective pain management for their patients, ultimately improving their overall well-being and quality of life.

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Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

In the high-stakes world of emergency medicine, innovations continually push the boundaries of what’s possible. One such groundbreaking procedure is Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). In this blog post below and the podcast episode with Dr. Ernest E Moore above, we will explore what REBOA is and how it is being used to try and save lives in critical situations. Please note this is an emerging area of trauma resuscitation and as such is actively being studied to best understand if and when it is most beneficial.

Understanding REBOA

REBOA stands for Resuscitative Endovascular Balloon Occlusion of the Aorta. In essence, it’s a medical technique that involves temporarily blocking the aorta using a specialized balloon. This procedure is typically employed when a patient is experiencing severe trauma and concern for uncontrolled bleeding.

The Purpose of REBOA

The primary objective of REBOA is to temporarily control hemorrhage in patients who are in hemorrhagic shock due to severe injuries. The idea is to stop hemorrhage, augment blood pressure, and provide more time for resuscitative efforts and definitive management of the hemorrhagic source.

How REBOA Works

REBOA is usually carried out in a controlled medical environment, often in an operating room or emergency department. Although there are increasing reports of prehospital field use in Europe and the military. Here is a step-by-step breakdown of the procedure:

  1. Patient Evaluation: The first step is a thorough evaluation of the patient’s condition, including assessing the source and extent of bleeding. REBOA is considered when other methods to control bleeding, such as direct pressure or surgical intervention, are not feasible or have been unsuccessful.
  2. Balloon Placement: A specialized catheter with a balloon at its tip is inserted into a major artery, typically through the femoral artery in the groin. Using fluoroscopy or ultrasound guidance, the catheter is advanced until the balloon is correctly positioned within the aorta, ideally above the site of injury.
  3. Balloon Inflation: Once the catheter is properly placed, the balloon is inflated, temporarily blocking blood flow beyond to the injury site. This reduces blood loss and helps stabilize the patient’s condition, buying critical time for further treatment.
  4. Monitoring: Throughout the procedure, the patient’s vital signs, including blood pressure and oxygen levels, are closely monitored to ensure that the occlusion does not last longer than necessary.
  5. Deflation and Removal: After the patient is stabilized or when more definitive treatment becomes available, the balloon is deflated, restoring normal blood flow. The catheter is then removed.

The Zones

REBOA has three main zones of placement, each serving a distinct purpose in addressing specific types of injuries and hemorrhages:

  1. Zone 1 (Proximal Aortic Occlusion):
    • Location: Zone 1 is positioned in the segment of the aorta above the diaphragm.
    • Purpose: The primary goal of Zone 1 occlusion is to resuscitate the patient while also reducing bleeding from abdominal structures, particularly vascular injuries and liver hemorrhages.
    • Common Indications: Zone 1 REBOA is commonly used for severe abdominal and thoracic trauma.
    • Time Limit: The maximum recommended time for Zone 1 REBOA occlusion is typically around 30 minutes. Beyond this time frame, there is an increased risk of ischemic complications to vital abdominal organs, particularly the intestines. Prolonged occlusion can lead to bowel and liver ischemia, potentially causing significant irreversible damage.
  2. Zone 2 (Non-Utilized Area):
    • Location: Zone 2 is the area between Zone 1 and Zone 3, starting at the celiac axis (aortic branch supplying the upper abdominal organs) and extending down to the renal arteries.
    • Purpose: Zone 2 is considered a “no man’s land” for REBOA placement. It is not typically utilized because occluding this area could compromise blood flow to important organs like the kidneys without providing significant benefits in controlling bleeding. Therefore, REBOA is usually not placed in Zone 2.
  3. Zone 3 (Distal Aortic Occlusion):
    • Location: Zone 3 is located between the renal arteries (supplying the kidneys) and the iliac bifurcation (where the aorta splits into the common iliac arteries leading to the legs).
    • Purpose: Zone 3 is primarily used for pelvic fracture hemorrhages. When the balloon is inflated in this area, it can effectively control bleeding from pelvic fractures without significant complications associated with prolonged occlusion.
    • Common Indications: Zone 3 REBOA is frequently employed in cases of severe pelvic trauma, where rapid bleeding control is crucial for the patient’s survival.
    • Time Limit: Zone 3 REBOA can be used for a more extended duration compared to Zone 1. It may be safely deployed for a more extended period, often beyond 30 minutes. However, the duration of occlusion should still be carefully monitored, and the medical team must assess the patient’s condition and the need for continued REBOA use frequently.

It’s important to note that the choice of REBOA zone depends on the specific clinical scenario and the patient’s condition. Zone 1 is often used when there is a need to address both upper and lower abdominal bleeding, while Zone 3 is reserved for cases of isolated pelvic trauma. The decision on which zone to use is made based on careful evaluation and the patient’s specific needs. Additionally, the duration of occlusion should be closely monitored to prevent complications associated with prolonged blockage of blood flow to vital organs.

Benefits of REBOA

REBOA offers several advantages in critical situations:

  1. Rapid Hemorrhage Control: It provides a quick and effective means of controlling bleeding, which is crucial in trauma cases where every second counts.
  2. Minimally Invasive: REBOA is less invasive than open surgical procedures, making it particularly beneficial for unstable patients.
  3. Bridge to Definitive Treatment: It serves as a bridge to more definitive surgical interventions, allowing time for surgeons to prepare for complex procedures.

Considerations and Risks

While the hope is the use of REBOA can be life-saving, it is not without risks. Prolonged balloon inflation can lead to complications such as organ damage and lower limb ischemia (inadequate blood flow to the legs). Therefore, careful patient selection and monitoring are crucial to minimize these risks.

Conclusion

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a remarkable medical procedure that may revolutionize the treatment of severe trauma patients in hemorrhagic shock. By temporarily blocking blood flow to the injured area, the hope is that it will buy time for resuscitation and definitive management of patients in critical condition. While REBOA is not a panacea, its role in modern emergency medicine offers hope to those facing life-threatening injuries, maybe most importantly to those without ready access to a trauma surgeon. We owe a debt of gratitude to medical professionals like Dr. Ernest E. Moore, who tirelessly work to advance these life-saving techniques. You will find his name on most of the literature about REBOA.

Of note, a recent trial was presented at a conference that has gained a lot of publicity on social media. This is the first RCT looking at REBOA vs standard of care. The trial has not been peer reviewed or published yet so should be taken with a grain of salt but here is good a review of what was published at the conference: https://www.stemlynsblog.org/jc-the-uk-reboa-trial-has-the-balloon-popped-st-emlyns/

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Are you prepared for your next intubation?

L0018287 Photograph of intubation, using and laryngos Credit: Wellcome Library, London. Wellcome Images [email protected] http://wellcomeimages.org Photograp1h of intubation, suing and laryngoscope (1920) from an original in the possession of Dr David Wilkinson. Published: – Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/

Introduction: Welcome to another enlightening episode of EMS Cast, your source for high-level education designed specifically for frontline providers. Today, we’re thrilled to be coming to you live from the Rocky Mountain Trauma and Emergency Medicine Conference, where we have the distinct privilege of interviewing Dr. Stacey Trent. Dr. Trent is not only an Associate Professor of Emergency Medicine at the Denver Health Emergency Department but also serves as the Associate Director of Research in the Emergency Department. In this episode, we’ll be delving into her captivating lecture on airway management in the emergency setting.

The SOAP ME Mnemonic: Dr. Trent’s lecture kicked off with a brilliant mnemonic, SOAP ME, serving as a comprehensive checklist for prehospital intubations. SOAP ME stands for Suction, Oxygen, Airway Assessment, Pharmacy, Plan, Monitor, and Equipment. It’s a systematic approach to ensure providers are adequately prepared and equipped for every intubation.

  • Suction
  • Oxygen
  • Airway Assessment
  • Pharmacy
  • Plan
  • Monitor
  • Equipment

The Critical Role of Preoxygenation: While the SOAP ME mnemonic covers several crucial aspects, Dr. Trent emphasized the significance of preoxygenation, a topic sometimes overlooked in the chaos of emergency situations. She highlighted that preoxygenation involves giving patients as close to 100% FiO2 (Fraction of Inspired Oxygen) as possible for at least three minutes. This essential step is key to extending the safe apnea time and maintaining oxygen saturation levels.

Positioning for Success: Dr. Trent stressed the importance of positioning the patient optimally. Whether they can be fully upright, placed in reverse Trendelenburg, or have their head elevated to 20 degrees, these adjustments can significantly impact intubation success. Proper positioning can enhance lung mechanics and reduce complications.

The Upper Lip Bite Test: For patients who are awake and cooperative but may still pose challenges for intubation, Dr. Trent introduced the Upper Lip Bite Test. This simple assessment involves evaluating whether the patient can cover their upper lip with their lower teeth. If they cannot, it can be predictive of a difficult airway.

Addressing the Cardiovascular Challenge: Dr. Trent discussed the use of fluid boluses and push-dose pressors to prevent cardiovascular collapse during intubation has not been proven in the literature. While a fluid bolus has been studied and has not had the desired effect of preventing peri-intubation hypotension, the question for push-dose pressors remains unanswered and may still be helpful to maintain blood pressure during this high risk procedure.

Choosing the Right Tools: The conversation also touched on the choice between video laryngoscopy and direct laryngoscopy. Dr. Trent highlighted the advantages of video laryngoscopy, particularly for providers with lower intubation volumes. However, she encouraged training in both methods to ensure preparedness for challenging cases.

Conclusion: In this captivating podcast episode, we had the privilege of hearing from Dr. Stacey Trent, a leading expert in emergency medicine. Her insights into prehospital intubation, the SOAP ME mnemonic, preoxygenation, positioning, and cardiovascular support provide valuable guidance for healthcare providers in the field. Dr. Trent’s emphasis on continuous learning and preparation underscores the importance of staying up-to-date with the latest advancements in airway management.

For more educational content and resources on prehospital intubation and other critical topics, stay tuned to EMS Cast and explore reputable sources like JournalFeed, which offers valuable summaries of high-impact articles in the field of emergency medicine and critical care.

Remember, mastery of prehospital intubation requires ongoing education, practice, and a commitment to providing the best possible care to patients in need.

Plus check out this new trail on DL vs VL for intubation that Dr. Trent co-authored and eluded to at the end of this episode- https://www.nejm.org/doi/pdf/10.1056/NEJMoa2301601

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Pediatric Disaster Preparedness

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Episode 46: Pediatric Disaster Preparedness with Dr. Jeffery Upperman

Dr. Jeffery Upperman M.D.

Surgeon In Chief at the Monroe Carell Jr. Children’s Hospital in Nashville, TN

Chair Department of Pediatric Surgery

  • Disaster Olympix Gamified Preparation.  This helps draw out creativity and problem solving. Builds teamwork.  You need this in big situations.
  • “Disasters are agnostic” Unless it is someone with intent on harm
  • “Train with Spontaneity”
  • “We are all concerned with our own mortality”
  • “Know your team”
  • “Identify stakeholders”
  • “Build Relationships”
  • “Know your staff and their families”
  • “Training can be easy and fun”

LA Childrens Disaster Olympix

In this episode we sat down with Dr. Jeffery Upperman while attending the Rocky Mountain Trauma and Emergency Medicine Conference in Breckenridge, CO.  Dr. Upperman is a pediatric surgeon by specialty but has extensive experience in leadership and preparedness.  He has served in the United States Army and several large Childrens Hospitals including Los Angeles Childrens and the Monroe Carell Jr. Children’s Hospital at Vanderbilt.  Dr. Upperman takes the subject of pediatric disaster preparedness to a new level of enthusiasm.  His lecture, designed to be energetic and thought provoking, was both.  His message was simple but also not easy.  Focus on key principles when preparing for these unplanned events.  As soon as complex plans are created, something will come along and “break the mold.”  Have some flexibility in the way you think.  Cultivate this through regular training but training that is fun, light, and engaging.  The following are his key principles.

Know your Team

His first message was simple and valuable.  Know your team.  Know who works with/ for you. Know their children.  A pediatric disaster triggers a response in parents to protect.  If anyone you work with has children of their own, their mind may be “out of the game” when responding to an event.  There may be times where the best thing for a team is for one member to leave and take care of their family.  If your members are able to respond and be present, they will eventually need to attend to the needs of their families.  Dr. Upperman gives the example of a natural disaster that may include a widespread power outage.  Leaders may need to set up shelter or daycare for the children of their team members.  Give you people a save place to bring their family.  Good leaders take care of their team.  Without their team they are unable to accomplish their goals and their mission.

Knowing your team can also include underutilized strengths they may possess.  In a disaster or unplanned event, creativity of problem solving will be valuable.  People are going to draw on their experience. A teammeber that regularly works as a paramedic, may also have skills which better serve the group in a slightly different capacity.

Remember Basic Needs

If you do end up taking care of children, do you have diapers?  Do you have entertainment?  You may need to take care a large group of uninjured children.  Perhaps their siblings or parents are patients and are unable to entertain their child/ family member.  Be able to shelter and care for children that do not have immediate medical needs.

Identify Stakeholders

Dr. Upperman’s next principle was, “know your stakeholders and grow your Rolodex.”  To rephrase in different words, grow your team.  During an unplanned event that is stretching your capability you will call upon resources that are infrequently used or being used in ways not commonly considered.  Dr. Upperman gave the example of physically walking around your area of responsibility or facility and introduce yourself to people.  He goes further to explain if there is a restaurant that is adjacent to his hospital and his hospital has a disaster, he may call upon that restaurant to help feed his team.  When your staff is working extra hours or difficult hours, meeting their physical needs speaks volumes to successful leaders.  It is much easier to build these relationships in calm times than in the heat of a situation.  Another illustration is, know who fixes your stuff.  Sounds simple, but seriously.  Know the people that work on your equipment and keep your operation running.  They will be needed during a large event.

Train

The word training gets thrown around quite a bit, for good reason.  Training and practicing are critical disciplines.  Dr. Upperman added some context that was valuable.  He said training should have some spontaneity, be fun, and doesn’t always need to be complex.  He gave more than one example of having tabletop discussions with his staff as an opener or conclusion to a meeting.  Throwing out questions to spur thought.  “What would we do if ____ happened.”  Speaking personally.  This is something I have found incredibly valuable.  While working for the Denver Health Paramedic Division I was one of three command staff members that oversaw Denver International Airport.  A literal city within a city.  We would regularly eat meals together as a staff and I loved asking our paramedics, what if questions.  I learned from them.  I learned new ways to get from one place to another.  I learned about resources in our complex environment.  I learned about new relationships to foster.  These things always pay dividends when you are in the middle of something unannounced and out of the norm.

LA Disaster Olympix

To illustrate this point, check out this YouTube video about an event Dr. Upperman helped create in Los Angeles.  His disaster Olympix gamified preparedness.  Teams of staffers would work together to solve preparedness type problems in a friend competition environment.  What does this mean?  In our conversation he talked about two scenarios.  First, teams had to move five-gallon bucks or pretend radioactive waste without spilling any.  You may be thinking, “why?!”  He explains their Cancer Unit produces radioactive run off. When staff was asked what to do if the mitigation systems in place failed, they answered, “call___.”  His response was simple, “what if you can’t call _____?”  Patient care must continue, how are you going to solve the problem?

Sure, his staff will hopefully not be faced with this exact situation however it forced them to be creative.  It forced them to work together.  It forced them to get to know each other.  I would also wager that staff members who do not work on or near the cancer unit started to consider what hazards exist in their unit.  It got them to think in a preparedness mindset.  Another example he gave which stuck out to me, was centered around patient movement.  “What if you need to move 20 patients?”  Olympix participants then had to move several patient simulators.  This is near and dear to me because so many people in preparedness or response roles do not consider how long and how labor intensive it is to move people.  It takes a lot of people to successfully move one non-ambulatory patient.  Ask anyone that has worked Search and Rescue.  These professionals work this problem every time they get deployed. 

If you are a frontline worker or lead a small team, remember training can be simple.  Keep it focused on shifting someone’s mindset.  Get them out of their normal grind and have them think creatively with you about how to solve a problem. 

Thank you Dr. Upperman for your time.  This topic is not regularly discussed but is of great importance.  Attached are some valuable resources.

LA Childrens Disaster Olympix

Pediatric Disaster Resource and Training Center

Report on the 2010 Chilean Earthquake and Tsunami Response

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Spinal Emergencies – A Closer Look At Back Pain

Be vigilant and curious with atraumatic back pain.

In this podcast episode we chatted with, Dr. Bo Burns, from the University of Oklahoma, about spinal emergencies. Dr. Burns emphasized the importance of being vigilant and curious when it comes to evaluating patients with atraumatic back pain. It can be easy to dismiss or overlook these patients, but we need to replace judgment with curiosity in order to uncover the underlying cause of their pain. Which might be a true emergency.

Dr. Burns discusses how atraumatic back pain is a common reason for prehospital calls, and highlights the fact that there are various spinal emergencies that could be causing the pain. These emergencies include infection, fracture, herniation with compression, cancer with compression, and vascular emergencies of the spine. He also mentions several risk factors that should be considered, such as age over 55, cancer, trauma, coagulopathy, immunodeficiency, and recent spinal procedures or injections.

One specific atraumatic emergency that Dr. Burns focuses on is epidural abscess. He explains that these patients can be challenging to diagnose because their symptoms start off as nonspecific and become more specific over time. As the abscess grows within the epidural space, it puts pressure on the spinal cord, leading to more dramatic symptoms. Dr. Burns emphasizes the need for vigilance and diligence in evaluating patients with severe atraumatic back pain, as they require thorough evaluation and attention to catch this disease process.

The podcast also touches on history and physical exam tricks for these patients. Dr. Burns acknowledges that assessing strength can be difficult, especially in older patients with a higher BMI and reduced skeletal muscle mass. He advises prehospital providers, who are often the first point of contact for these patients, to gather as much information as possible, as it can be valuable in guiding further evaluation and treatment. Ask what if anything is different about their pain today. Have they been seen for this recently. Do they have any fevers. Any weakness. What are their risk factors, such as diabetes, immune deficiency, recent procedure.

Overall, the key takeaway from the podcast is the importance of being vigilant and curious when evaluating patients with atraumatic back pain. My favorite quote from the episode is- “replace judgment with curiosity”. Approach these cases with a thorough and open mindset. By doing so, we can ensure that patients receive the appropriate evaluation and treatment for their condition.

Importance of history and physical.

The podcast emphasizes the significance of history and physical examination in the evaluation of patients with atraumatic back pain. Dr. Burns emphasizes that pre-hospital providers have the ability to gather important information through these methods, without the need for imaging or diagnostic tools.

One important aspect highlighted in the podcast is the ability to assess mobility. Dr. Burns mentions the importance of documenting whether the patient requires assistance or is able to stand on their own. This information helps in risk stratification and provides valuable insights into the patient’s condition.

The podcast also discusses the importance of understanding what is new and what is chronic for the patient. Dr. Burns mentions that patients with back pain may already experience it as a part of their normal day. Therefore, it is crucial to determine what has changed and why they sought medical attention today. This can help in identifying any alarming symptoms or underlying conditions.

In addition to mobility and changes in symptoms, the podcast emphasizes the significance of other aspects of the physical examination. For example, the ability to extend the leg and engage the quadricep muscle, even without getting out of the chair, can provide valuable information about the patient’s condition. Asking about incontinence, weakness, or new radiation distribution can also help in assessing the severity and potential causes of the back pain.

The podcast also highlights specific risk factors to consider when evaluating patients with back pain. IV drug use is mentioned as a significant risk factor for epidural abscess. Other risk factors include recent fractures, recent bacteremia, recent antibiotic use, and certain medical conditions like diabetes. Realize that diabetes is actually the number one risk factor for this condition followed by IV drug use. Recognizing these risk factors can help in identifying potential sources of infection and ensuring appropriate management.

Overall, the podcast emphasizes the importance of being thorough and diligent when evaluating patients with atraumatic back pain. Healthcare providers are encouraged to gather as much information as possible through history and physical examination, as these methods can provide valuable insights into the patient’s condition. Gathering this information on scene or en route can help clue us in at the hospital and help the hospital make the appropriate diagnosis quicker.

Epidural abscess is a time-sensitive emergency.

One specific condition that healthcare providers should be aware of when evaluating patients with back pain is epidural abscess. The podcast highlights that epidural abscess is a time-sensitive emergency, meaning that early diagnosis and intervention are crucial in preventing severe complications and long-term disability such as permanent weakness or paralysis.

Epidural abscess is a condition characterized by the collection of pus in the epidural space, which is the area between the spinal cord and the boney spine. The podcast explains that while some cases of epidural abscess may be a result of recent spinal procedures or surgeries, the majority of cases are caused by hematogenous spread or the spread of bacteria through the bloodstream. Risk factors for epidural abscess include IV drug use, diabetes, immunocompromised states, and chronic kidney disease.

One interesting point made in the podcast is that the classic triad of symptoms associated with epidural abscess (fever, pain, and neurologic dysfunction) is actually present in only 10 to 13 percent of cases at the time of diagnosis. This highlights the importance of being diligent and considering the risk factors and presentation of the patient when evaluating back pain. The podcast emphasizes that healthcare providers should approach patients with atraumatic back pain with the same level of concern and attention as they would for a patient with chest pain.

The morbidity associated with epidural abscess is significant. As the disease progresses, more compression of the spinal cord occurs, leading to ischemia and potentially paralysis. The podcast notes that most patients with neurologic deficits do not recover them, underscoring the urgency of early diagnosis and intervention. The podcast also mentions other complications that can arise from epidural abscess, such as osteomyelitis of the spine, discitis, and fractures, which can result in permanent disability.

It is important to recognize the progression of the disease and the nonspecific nature of the initial symptoms. Patients with epidural abscess often seek help for the same back pain within a short period of time. This should increase the suspicion of healthcare providers and prompt them to consider the possibility of epidural abscess. Gathering information about previous visits and changes in symptoms can be valuable in identifying the progression of the disease.

In the pre-hospital setting, paramedics and EMTs are encouraged to gather information from the scene and from family members, as well as to ask the patient about previous visits and changes in symptoms. This information can be relayed to the emergency department, helping to increase suspicion and prompt further evaluation. By identifying patients who are at risk for epidural abscess, healthcare providers can ensure that these patients receive the appropriate evaluation and treatment in a timely manner with the goal of preventing or minimizing long term disability.

In conclusion, the podcast emphasizes that epidural abscess is a time-sensitive emergency. Early diagnosis and intervention are crucial in preventing severe complications and long-term disability. We need to be thorough and diligent when evaluating patients with atraumatic back pain, gathering as much information as possible through history and physical examination. By being vigilant and curious, healthcare providers can potentially prevent devastating outcomes associated with epidural abscess by diagnosing this and initiating appropriate treatment earlier in the disease course.

Epidural abscesses require urgent diagnosis and treatment.

The typical workup that occurs in the emergency department for patients with atraumatic back pain will depend on the severity of their symptoms and the risk factors we already discussed. A broad range of tests and evaluations may be conducted. For example, in the case of a diabetic patient with heart disease and a recent toe amputation who presents complaining of acute back pain, the healthcare provider would be concerned about an epidural abscesses. They would perform blood cultures, sepsis evaluations, and assess fluid administration. Inflammatory markers such as ESR and CRP are also examined, with a CRP level over 30 indicating a potential issue.

The podcast emphasizes the importance of context when interpreting these results. If the patient’s CRP is solely related to the foot amputation, without concern for new or worrisome back pain, it may not be indicative of an epidural abscess. However, if the patient presents with new onset weakness and severe back pain, the healthcare provider becomes more concerned about the possibility of an epidural abscess. In such cases, an MRI is typically performed to confirm the diagnosis.

Once an epidural abscess is diagnosed, treatment falls within the realm of spine surgery and neurosurgery. Most cases are managed operatively through aspiration, although there are some instances where non-operative management may be attempted with just antibiotics. The decision to pursue surgery or non-operative management may vary depending on the location and healthcare system.

To aid in the decision-making process, the podcast highlights a clinical decision tool called the S-I-R-C-H tool. This tool, published in the Western Journal of Emergency Medicine, helps healthcare providers assess the risk of spine infection and determine the need for an MRI. A SIRCH score greater than three is found to be 96% positive for finding an epidural abscess on MRI, providing valuable guidance for clinicians in making treatment decisions.

The podcast also highlights the importance of maintaining a high index of suspicion for epidural abscesses, especially for pre-hospital providers and agencies that respond to lift assists. Atraumatic back pain may not initially appear as a serious emergency, but it can be a presenting symptom for patients with epidural abscesses. Therefore, healthcare providers should remain vigilant and consider the possibility of epidural abscesses in such cases.

In conclusion, the podcast emphasizes that epidural abscesses require urgent treatment. Early diagnosis and intervention are crucial in preventing severe complications and long-term disability.

Cauda Equina

The podcast also discusses the topic of cauda equina syndrome. Cauda equina means horses tail. And that is the appearance the spinal cord has when it terminates around L1-L2 vertebrae and the nerve roots fan out like a horses tail. Cauda equina syndrome refers to the compression of these nerve roots, specifically the L2 to L5 and S1 to S5 nerve roots. This compression can lead to a range of symptoms, including lower extremity weakness and anesthesia, as well as bladder and bowel dysfunction.

There is a lack of specific diagnostic criteria for cauda equina syndrome, with over 14 different definitions in the literature. However, one common feature among these definitions is the presence of bladder dysfunction. This can manifest as incontinence of urine, which is a cause for concern. The podcast distinguishes between different types of incontinence, such as overflow incontinence, stress incontinence, overactive bladder, and temporary incontinence from a urinary tract infection. It emphasizes the importance of teasing out these different causes to determine the underlying issue. Patients who have overflow incontinence, in other words their bladder fills until it can’t anymore and they pee on themselves, often do not have the sensation that they need to urinate. They just suddenly urinate on themselves unexpectedly and do not know why. This is concerning for cauda equina syndrome. This is because the bladder receives nerve innervation from the S2-S4 nerve roots. So if these are compressed the bladder will not be able to function correctly. As the compression progresses, the bladder can fill without the patient’s knowledge, leading to overflow incontinence. This is particularly worrisome as it indicates an advancing compression of the nerve roots.

To better evaluate bladder dysfunction, in the hospital, we might preform a post void residual evaluation. In other words, we have the patient urinate and then we measure the remaining urine in the bladder by either conducting a bladder scan or obtaining a catheterized specimen to measure the post-void residual volume. If the post-void residual is greater than 100 mLs, it indicates incomplete emptying of the bladder, which may be caused by compression of the nerve roots.

The most common cause of compression in cauda equina syndrome is central disc herniation, which can present with new onset pain down both legs. While disc herniations most commonly occur on the posterior lateral side causing pain down on leg or the other, central disc herniation will press on nerve roots going to both legs. Central disc herniation can account for about 40% of cauda equina cases. These patients often present acutely, experiencing severe pain down both legs and bladder dysfunction. Other less common causes include fracture with retropulsion of boney fragments, epidural abscess, spinal epidural hematoma.

In terms of physical examination, performing a sensory exam of the perianal and perineal area is important, as these are the regions innervated by the sacral roots. Preforming a perineal or rectal exam may not always be feasible on the ambulance where privacy is more difficult to maintain. So ask the patient about the ability to feel the areas of the bottom when sitting down. It’s also important to ask about any sexual dysfunction as this is another possible sign of cauda equina syndrome.

In conclusion, cauda equina syndrome is caused by nerve root compression of the spine in the L2-L5 and S1-S5 region. Cauda equina is a time sensitive emergency to prevent permanent disability. Cauda equina can cause bladder or bowel disfunction dysfunction, which can manifest as incontinence. Important physical exam findings to note are any loss of sensation (specifically in the perineal or perianal are), weakness, or pain radiating down bilateral legs. Cauda equina is most commonly caused by an acute central disc herniation and can present with acute severe pain radiating down bilateral legs, loss of perineal sensation, and urinary retention with overflow incontinence.

What you do matters

Atraumatic low back pain may not seem like an emergency but it can be. Although these patients don’t require lights and sirens, they do still require our thorough evaluation. By being vigilant and preforming a good history and physical exam, you can identify concerning findings that can help expedite diagnosis in a timely fashion. Remember, replace judgement with curiosity so you don’t miss the emergency lurking beneath.

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Taking Care of Pediatric Trauma Patients with Dr. David Bliss

Dr. David Bliss, pediatric trauma surgeon, joins us to discuss the challenges of treating pediatric trauma patients and how we can overcome our fears and be successful. 

Support psychosocial needs of children.

Supporting the psychosocial needs of children is a crucial aspect of providing care to pediatric trauma patients. Dr. David Bliss, a professor of Pediatric Surgery at Cedars-Sinai Health Systems, emphasizes the importance of recognizing the fear and anxiety that children experience during a traumatic event. Unlike adults, children do not have the context to understand what is happening to them. Therefore, healthcare providers must take measures to ensure that children feel safe and supported throughout the process.

One of the strategies that Dr. Bliss recommends is to communicate with children on their level. This means physically coming down to their level and interacting with them in a way that is not intimidating. For example, when a child is on a gurney, healthcare providers can come down to their level and communicate with them directly. This helps to establish a sense of trust and comfort, which can go a long way in alleviating their anxiety.

Another strategy is to be aware of one’s body language and verbal language. Be mindful of your tone and body position when interacting with children. Avoid using language that is too technical or intimidating, as this can further exacerbate the child’s anxiety. Instead, use language that is simple and easy to understand, while also being reassuring and supportive.

Dr. Bliss also emphasizes the importance of involving parents in the process. Parents are critical partners in the care of pediatric trauma patients, as they can provide valuable insight into their child’s behavior and responses. They can also help to calm their child and provide emotional support during a traumatic event. We as, healthcare providers, should take the time to communicate with parents and keep them informed about their child’s condition and treatment.

In cases where the child has special needs or is non-verbal, take extra care to support their psychosocial needs. Work closely with parents to understand the child’s needs and preferences, and adjust their approach accordingly. This may involve using alternative forms of communication, such as sign language or picture boards, to help the child feel more comfortable and understood.

In conclusion, supporting the psychosocial needs of children is a critical aspect of providing care to pediatric trauma patients. We must be mindful of the fear and anxiety that children experience during a traumatic event and take measures to ensure that they feel safe and supported. By communicating with children on their level, involving parents in the process, and adapting our approach to meet the child’s needs, we can provide the best possible care to pediatric trauma patients.

Recognize cues in pediatric patients.

One key aspect of providing care to pediatric trauma patients is recognizing cues that may indicate a child’s needs or emotions. This can be particularly challenging when dealing with pre-verbal or non-verbal children, or those with developmental delays. In these cases, paramedics and EMTs must rely on other cues such as facial expressions, body movements, and parental reactions to understand what the child is experiencing.

It is important for us to develop a heightened sense of awareness when working with pediatric patients. This includes being attentive to how the child is engaging with them, whether they are making eye contact or withdrawing, and whether they are exhibiting any signs of pain or discomfort. It is also important to involve parents in the process, as they may have valuable insights into their child’s communication patterns and behaviors.

Recognizing cues in pediatric patients requires a certain level of expertise, but it is not something that only pediatric specialists can do. As paramedics and EMTs we are already used to communicating with the adult stroke patient who may be nonverbal. Realize you’ve done this before and can rely on some of the same skills.

It is also important for prehospital providers to recognize their own anxiety and emotions when working with pediatric patients. The pressure to provide the best possible care to a child can be overwhelming, but it is important to acknowledge these feelings and realize it is a normal reaction that even pediatric specialists experience. Acknowledge those feelings and then move on to provide the best possible care.

In conclusion, recognizing cues in pediatric patients is a critical aspect of providing care to pediatric trauma patients. Prehospital providers must be attentive to nonverbal cues, involve parents in the process, and be mindful of their own emotions and anxiety. By doing so, we can provide the best possible care and support to pediatric trauma patients and help them to feel safe and supported during a difficult time.

Cheating is encouraged in medicine.

One of the key takeaways from the podcast is the importance of cheating in medicine.

Cheating is encouraged in medicine because healthcare providers cannot be expected to remember every piece of information about every patient or disease they encounter. Instead, we should rely on standardized shortcuts, cheat sheets, and other tools to help us cognitively offload and provide the best possible care.

For example, when treating a pediatric patient, we may not remember what a two-year-old’s heart rate should be. Instead of trying to remember this information, rely on cheat sheets or other tools to help you determine if the heart rate is normal or abnormal. If you’re unsure, ask or look it up, you can always ask questions or call ahead to the receiving facility for guidance.

Cheating is also encouraged because it can help paramedics overcome moments of stress and brain fog. When under stress, the brain can shut down, making it difficult to think clearly. By relying on cheat sheets and other tools, prehospital providers can overcome this moment of stress and make better decisions for our patients.

In conclusion, cheating is encouraged in medicine because it helps healthcare providers provide the best possible care to our patients. By relying on standardized shortcuts, cheat sheets, and other tools, we can overcome moments of stress and make better decisions for our patients. This is particularly important when treating pediatric patients.

Notes about the blood pressure.

One important aspect of providing proper care to pediatric trauma patients is using the appropriate size cuff for blood pressure readings. Using the appropriate size cuff can ensure accurate readings and prevent misinterpretation of vital signs. If you’re having trouble finding a small enough cuff for the arm, sometimes using the thigh is a good trick to find the appropriate fit. Remember the artery runs anteromedially on the thigh.

In addition, children have the ability to constrict their peripheral blood vessels much better than adults. When critically ill they will have the ability to maintain a normal blood pressure for longer. The old axiom, kids compensate and compensate until they fall off the cliff. But this does not mean there are not warning signs. They will increase their heart rate. They will increase their respiratory rate. You may see skin changes such as pallor or mottling. Realize these may be subtle signs that something is seriously wrong. Try not to fall into the cognitive trap of dismissing these subtle signs. It is important to be aware of these cognitive biases and avoid discounting one or two numbers when assessing vital signs. Subtle signs of deterioration may be missed if paramedics are too focused on confirming their initial assessment of a patient’s stability. We all want these kids to be well but we can’t miss when they’re not. By remaining vigilant and open-minded, we can catch signs of deterioration before it becomes a crisis.

Don’t be afraid of the IO

Paramedics should not be afraid to use intraosseous (IO) access if peripheral access is difficult in a critically ill patient. While the idea of poking a child’s bone may be daunting and emotionally challenging, it is often the best option for obtaining access and getting necessary labs. Realize that complications from intraosseous lines are incredibly rare and in a critically sick patient it may be the only or at least the fastest way to get access if peripheral attempts have failed.

Yes, it will be painful, but so is poking peripherally over and over again until the patient feels like a pin cushion. Acknowledge that it will be uncomfortable but it will brief and then you can move on with getting necessary labs and giving necessary medications.

Don’t forget to warm patients.

A small amount of decrease in body temperature can lead to significant coagulopathy in a trauma patient. Children get cold very quickly and are not able to conserve heat or produce heat the way adults can. Therefore, it is important to warm them as soon as possible to prevent hypothermia-related complications. This is particularly important in rural environments where children may have to travel long distances to receive definitive care. It is important to visualize your trauma patients. So make sure you throughly expose and visualize your trauma patients to identify any possible life threats. And then after you’ve preformed a thorough exam don’t forget to cover them back up and keep them warm.

This can be done through the use of warm blankets, reflective field devices, and warm fluids. It is also important to remember that IV fluids can be a source of cooling if they are stored at room temperature. Use warm fluids whenever possible. One trick, if you don’t have an IV fluid warmer but have access to heat packs, tape the heat packs to either side of the IV fluid bag to warm the fluids during administration.

Tourniquets- use the appropriate size. Improvisation is better than nothing.

We should always use a commercially manufactured tourniquet when able. But unfortunately most of these are not sized to the pediatric patient. Some have the ability to wrap around twice allowing them to fit smaller extremities but realize they will need to be twisted tighter in these situations to get the same effect.

In situations where a commercially manufactured tourniquet is too big for a child, paramedics might need to be prepared to use whatever resources are available to control bleeding. As Dr. Bliss notes, this may involve using a piece of rubber, hose, or other stretchy device to create a makeshift tourniquet.

The reality is that improvisation may be better than doing nothing at all. Of course, improvisation should always be done with caution and with the patient’s best interests in mind. Paramedics must be aware of the potential risks and side effects of any improvised treatments, and should always be prepared to seek additional medical advice from their physician control or the receiving facility.

Ultimately, the key to successful improvisation is a willingness to think creatively in the face of challenging situations. By remaining calm, focused, and resourceful, we can provide the best possible care for our patients, even in the most difficult and unpredictable circumstances.

Pause. Breath. Assess.

As we concluded the podcast, Dr. Bliss noted that we healthcare providers often have high levels of stress and adrenaline in these situations. This can often lead to physical overreactions during medical procedures. For example, when intubating a child, providers may insert the ET tube too far, leading to improper placement and potential complications.

Take a moment to pause. Acknowledge your stress and anxiety. Remind yourself that pediatric patients are smaller and as such the distance to structures will be shorter. By taking a moment to pause and assess the situation, we can ensure that we are performing the procedure correctly and safely. This concept of pausing to prevent medical errors can be applied to a variety of medical procedures, including IV insertion and other medical interventions.

What you do matters.

Dr. Bliss specifically wanted to give all prehospital providers “mad props” for what you do. As always, thank you for what you do. We can’t do what we do in the hospital without your amazing abilities in the field! What you do matters.

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Rocky Mountain Trauma and Emergency Medicine Conference

Earlier this month Ross and Will visited the Rocky Mountain Trauma and Emergency Medicine Conference. In addition to trauma games and sim wars, there were so many great lectures and EMS Cast was lucky enough to get to interview some of the speakers about their talks. We are excited to get to bring some of this great content to our listeners. Dr. Maria Moreira tells us about the conference and then Ross and Will sit down with Trauma Critical Care Fellow Dr. Chelsea Horwood to learn all the ins and outs of ECMO in the trauma patient. 

To see a list of this years lectures and events-

https://web.cvent.com/event/591e0026-80af-42cb-a801-ae94dd363ed6/summary

https://www.denverhealth.org/for-professionals/clinical-specialties/trauma/trauma-emergency-medicine-conference

To learn more about ECMO-

https://www.elso.org/

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Trauma Triage Guidelines Update

What is the ACS?

It is important to listen to experts in the field, and the American College of Surgeons (ACS) is a great example of a group of experts that can provide valuable insight. The ACS is a national group of physicians that come together to determine best practices and guidelines for surgery, especially trauma surgery. They look at the evidence, consider different perspectives, and come up with the best guidelines. When making recommendations they will point to the evidence and rank it based on its quality and strength, such as double-blind randomized controlled placebo trials. If there is no evidence at all, they use expert consensus to come up with the best guidelines.

The ACS recently revised their guidelines for field trauma triage and took a different approach than the traditional algorithm. Instead of a prescriptive, “if-then” model, they created lists of criteria that indicate a patient is red or yellow. This principle-based approach is more effective and can help us better assess and triage patients.

These new ACS recommendations can help us make the best decisions in the field and provide quality care to our patients. They provide valuable insight and guidance that can help us in our daily work. It is important to stay up to date with the latest guidelines and recommendations from the ACS so that we can best serve our patients.

The Update

Simplify trauma triage.

One of the most important aspects of providing quality care is being able to quickly and accurately triage patients in the field. This is especially important in a multiple casualty incident (MCI) situation, where time is of the essence and decisions need to be made quickly. The ACS has recently updated their trauma triage guidelines, which they hope will help simplify the process.

The new guidelines are designed to make triage easier and more efficient by removing the cognitive burden from the pre-hospital providers. Instead of relying on algorithms or complex acronyms, the new guidelines focus on quickly assessing the patient’s condition and providing the appropriate level of care. The guidelines also encourage pre-hospital providers to think critically and practice their understanding of pathophysiology. This helps them to make informed decisions about the best course of action for each patient.

The new guidelines also emphasize the importance of quickly assessing the patient’s condition and providing the appropriate level of care. Instead of trying to categorize all of the patients, the guidelines suggest that providers should focus on the reds and yellows and let the greens take care of themselves. This helps to reduce the cognitive burden and ensure that resources are being used efficiently.

Overall, the new guidelines from the ACS are designed to simplify trauma triage and make it easier for pre-hospital providers to quickly and accurately assess and treat patients in the field. By removing the cognitive burden and encouraging providers to think critically and practice their understanding of pathophysiology, the new guidelines can help to ensure that resources are being used efficiently and that patients are receiving the best possible care.

Develop clinical acumen.

Developing clinical acumen is essential for pre-hospital providers in order to provide the best care for their patients. Clinical acumen is the ability to quickly and accurately assess and treat patients in the field. It is the ability to think critically and to recognize patterns in patient presentations. It is also important to be able to recognize when a patient does not fit the typical pattern and to be able to adjust the treatment accordingly.

Developing clinical acumen requires practice and experience. Pre-hospital providers should take every opportunity to practice their skills and to learn from their mistakes. One way to do this is to take time to feel the radial pulse of every patient. This can help to give an indication of the patient’s heart rate, strength, and regularity. It also gives providers an opportunity to practice their physical assessment skills.

Pre-hospital providers should also take time to review after-action reports of multi-patient calls. This can help to provide a better understanding of how to identify and treat patients in a variety of situations. It is also important to read and understand the guidelines from the American College of Surgeons. This will ensure that providers are following the most up-to-date protocols and that they are using their resources efficiently.

Developing clinical acumen is essential for pre-hospital providers in order to provide the best care for their patients. It is important to take time to practice physical assessment skills, to review after-action reports, and to understand the guidelines from the American College of Surgeons. By doing these things, pre-hospital providers can ensure that they are prepared to handle any situation they may encounter and that they are providing the best possible care for their patients.

Assess body systems quickly.

One of the most important skills for pre-hospital providers is the ability to quickly assess body systems. This is especially important in emergency situations, where seconds can mean the difference between life and death. The American College of Surgeons has determined that only four body systems can lead to immediate death if they fail: the neurologic system, the respiratory system, the cardiovascular system, and the hematologic system. If any of these four systems fail, it is essential that pre-hospital providers are able to quickly assess the patient and determine the best course of action.

One way to quickly assess body systems is to feel for a pulse. This can be done as part of a handshake, and can provide valuable information about the patient’s cardiovascular system. In addition, pre-hospital providers should assess the patient’s ability to follow commands, their respiratory effort, and any gross blood loss. This assessment should be done on every call, regardless of whether it is an emergent or non-emergent response.

Pre-hospital providers should also be aware of the signs and symptoms of neurologic system failure. These can include difficulty tracking movements, slurred speech, and difficulty answering questions. By being aware of these signs and symptoms, pre-hospital providers can quickly assess the neurologic system and determine the best course of action.

In conclusion, pre-hospital providers must be able to quickly assess body systems in order to provide the best possible care for their patients. This is especially important in emergency situations, where seconds can mean the difference between life and death. Pre-hospital providers should be aware of the guidelines from the American College of Surgeons, and should practice physical assessment skills in order to be prepared to handle any situation they may encounter.

Assess age, comorbidities, vitals.

When it comes to assessing a patient in a pre-hospital setting, there are a few key elements that must be taken into consideration. One of the most important elements is to assess age, comorbidities, and vitals. Age and comorbidities can help provide insight into a patient’s overall health status, while vitals can help provide a baseline for the patient’s current condition.

When assessing age, pre-hospital providers should be aware of the general guidelines from the American College of Surgeons. These guidelines suggest that patients over the age of 65 should be considered a higher priority for care. Additionally, pre-hospital providers should be aware of any comorbidities that a patient may have. Comorbidities can include conditions such as diabetes, heart disease, or hypertension. Knowing these conditions can help pre-hospital providers better understand the patient’s overall health status and prioritize care accordingly.

Finally, pre-hospital providers should assess the patient’s vitals. This includes taking the patient’s temperature, blood pressure, pulse, and oxygen saturation. These vitals can provide a baseline for the patient’s condition and can help pre-hospital providers determine if the patient is in need of immediate care or can wait for transport to a hospital.

Assessing age, comorbidities, and vitals is an essential part of providing pre-hospital care. Pre-hospital providers should be aware of the American College of Surgeons guidelines and should practice physical assessment skills in order to be prepared to handle any situation they may encounter. By assessing these elements, pre-hospital providers can provide the best possible care for their patients.

Deliberate repetition yields growth.

Deliberate repetition yields growth in the pre-hospital setting. Pre-hospital providers must practice physical assessment skills in order to be prepared for any situation they may encounter. This repetition helps to build the skills necessary to quickly and accurately assess a patient’s condition. By repeating the same assessment steps over and over, pre-hospital providers can become more adept at recognizing subtle changes in a patient’s condition.

The pre-hospital provider must also be aware of the American College of Surgeons guidelines for pre-hospital care. This includes assessing age, comorbidities, and vital signs. By being familiar with these guidelines, pre-hospital providers can quickly identify the most important factors to consider when assessing a patient. Additionally, they can determine the best course of action for each patient.

The pre-hospital provider must also take into account the patient’s environment and other factors. This includes looking at the patient’s skin color, eyes, response to movements, and response to questions. By taking these elements into account, pre-hospital providers can quickly assess the patient’s condition and determine if they are sick or not.

In addition to assessing the patient’s condition, pre-hospital providers must also consider the patient’s risk factors and medical history. This helps to ensure that the provider is providing the best possible care for the patient. By taking into account these elements, pre-hospital providers can better prepare for any situation they may encounter.

Deliberate repetition is essential for pre-hospital providers. By repeating the same assessment steps over and over, pre-hospital providers can become more adept at quickly and accurately assessing a patient’s condition. Additionally, by being familiar with the American College of Surgeons guidelines and considering the patient’s environment and risk factors, pre-hospital providers can provide the best possible care for their patients.

Practice system one thinking.

System one thinking is a term used to describe the cognitive process of making quick decisions based on past experiences. System one thinking is automatic and requires little effort, allowing pre-hospital providers to make decisions quickly and efficiently. System one thinking is especially important in pre-hospital care because of the often chaotic and unpredictable nature of emergency situations. Pre-hospital providers need to be able to make decisions quickly and accurately, and system one thinking allows them to do so.

System one thinking is not only important for pre-hospital providers, but it is also important for all healthcare providers. System one thinking can help healthcare providers make decisions quickly and accurately in a variety of situations. For example, a healthcare provider may need to make a decision about which patient to prioritize first or which treatment to use in a particular situation. By being familiar with the patient’s history and the current situation, healthcare providers can make decisions quickly and accurately using system one thinking.

System one thinking is essential for pre-hospital providers. By practicing system one thinking, pre-hospital providers can make decisions quickly and accurately in emergency situations. Additionally, system one thinking can help healthcare providers make decisions quickly and accurately in a variety of situations. Pre-hospital providers should strive to practice system one thinking in order to provide the best possible care for their patients.

Trust your gut.

One way that pre-hospital providers can practice system one thinking is by trusting their gut. In the podcast, the speaker emphasizes the importance of “honing your gut” and trusting it. This is a reference to system one thinking, which relies on intuition and instinct. System one thinking allows pre-hospital providers to make decisions quickly and accurately in a variety of situations.

In the podcast, the speaker gives several examples of when pre-hospital providers should trust their gut. For example, if a patient has been ejected from a vehicle, the pre-hospital provider should trust their gut and prioritize that patient for transport to the trauma center. Additionally, if a pre-hospital provider is evaluating two patients and one of them is on anticoagulants, the pre-hospital provider should trust their gut and prioritize that patient for transport. Finally, if a pre-hospital provider is concerned about a patient, they should trust their gut and transport the patient to a trauma center.

Trust your gut is an important skill for pre-hospital providers to practice. System one thinking is essential for pre-hospital providers, as it allows them to make decisions quickly and accurately in a variety of situations. Pre-hospital providers should strive to practice system one thinking, and trust their gut, in order to provide the best possible care for their patients.

Trust your gut, over-triage.

One of the most important aspects of pre-hospital care is the ability to trust your gut and make decisions quickly. Pre-hospital providers are often faced with complex situations that require them to make decisions quickly and accurately. System one thinking is a form of thinking that allows pre-hospital providers to make decisions quickly and accurately, without having to spend too much time analyzing the situation. System one thinking involves trusting your gut and making decisions based on your intuition and experience.

Trust your gut and over-triage is an important concept for pre-hospital providers to understand. Over-triage is the practice of sending more patients to a higher-level care facility than is necessary. This practice is encouraged by the American College of Surgeons (ACS) guidelines, which suggest that a certain margin of over-triage is beneficial and should be practiced. The reason for this is that it is better to err on the side of caution and send a patient to a higher level of care than to not send them at all.

Pre-hospital providers should strive to practice system one thinking and trust their gut when making decisions. This is especially important in situations where there are multiple patients and the provider must make decisions quickly. In these situations, it is important for the provider to consider all the factors and make decisions based on their experience and intuition. Additionally, pre-hospital providers should strive to practice over-triage in order to ensure that their patients receive the highest level of care possible.

Overall, trust your gut and over-triage is an important concept for pre-hospital providers to understand and practice. System one thinking is essential for pre-hospital providers, as it allows them to make decisions quickly and accurately in a variety of situations. Pre-hospital providers should strive to practice system one thinking, and trust their gut, in order to provide the best possible care for their patients. Additionally, pre-hospital providers should strive to practice over-triage in order to ensure that their patients receive the highest level of care possible.

Practice quick physical exams.

One of the most important concepts for pre-hospital providers to understand is the importance of system one thinking and trust your gut. System one thinking is the ability to make quick decisions in a variety of situations. This type of thinking is essential for pre-hospital providers, as it allows them to make decisions quickly and accurately in a variety of situations. Pre-hospital providers should strive to practice system one thinking in order to provide the best possible care for their patients.

Another important concept for pre-hospital providers to understand is the importance of over-triage. Over-triage is the practice of providing the highest level of care possible to a patient, regardless of the severity of their condition. This practice is essential for pre-hospital providers, as it ensures that their patients receive the highest level of care possible. Pre-hospital providers should strive to practice over-triage in order to ensure that their patients receive the highest level of care possible.

Finally, pre-hospital providers should strive to practice quick physical exams. A quick physical exam is a type of exam that is conducted in the first five seconds of any patient interaction. This type of exam allows pre-hospital providers to look for key indicators of injury, some of which can be subtle. Pre-hospital providers should strive to practice quick physical exams on every single call, in order to ensure that they are able to identify and treat potential injuries as quickly as possible.

In conclusion, pre-hospital providers should strive to practice system one thinking, trust their gut, and practice over-triage in order to provide the best possible care for their patients. Additionally, pre-hospital providers should strive to practice quick physical exams in order to ensure that they are able to identify and treat potential injuries as quickly as possible. By practicing these concepts, pre-hospital providers can ensure that their patients receive the highest level of care possible.

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The Truth About Nitro: Separating Fact from Fiction

EKGs from the case

Nitroglycerin for acute coronary syndrome.

Nitroglycerin is a medication commonly used to treat acute coronary syndrome, a condition in which the coronary arteries become narrow or blocked, leading to chest pain and other symptoms. Nitroglycerin works by dilating the blood vessels and increasing blood flow to the heart (or so we hoped). It is typically administered in the form of a spray, tablet, or paste; and is primarily used to relieve chest pain.

When it comes to treating acute coronary syndrome, is nitroglycerin an effective medication? Sort of. At the doses we are giving, it likely only dilates the venous system and not the coronary arteries like originally thought. Studies have shown that it can reduce chest pain, but only in 40-50% of cases. It has shown to have a mortality benefit when given IV in the first 24 hours and this is the data we extrapolate to recommend giving sublingual nitro in the field. But even when given IV, the number of patients you would need to treat (NNT) with nitroglycerin to prevent 1 death is somewhere between 125-250. Compared to aspirins NNT in ACS, which is somewhere between 10-42.

There are some important considerations to keep in mind when using nitroglycerin for acute coronary syndrome. For example, it should not be used in patients with low blood pressure (<90mmhg systolic) or in combination with other phosphodiesterase inhibitors such as viagra or Cialis as it can cause an additive effect and lead to a sudden drop in blood pressure. Be aware that patients with pulmonary hypertension are now commonly being placed on long-acting phosphodiesterase inhibitors, such as sildenafil and tadalafil and so it is important to recognize and ask about these medications before administering nitro. In addition, it should be avoided in patients with aortic stenosis, as it can decrease preload and reduce cardiac output.

Overall, nitroglycerin is an effective medication for treating acute coronary syndrome. It is generally well tolerated and side effects are often short live and respond to supportive treatment. It can be used to relieve chest pain and decrease myocardial oxygen demand. However, it is important to be aware of the potential risks and contraindications.

Nitro relieves chest pain.

Nitro is often used to treat chest pain, and has been used for many years in the out of hospital, prehospital, and emergency department settings. Nitro works by dilating the blood vessels, and in doing so, decreases preload and may help to dilate coronary arteries (although probably only at high IV doses). Nitro can help to relieve chest pain, and reduce the oxygen demand of the heart.

Anecdotally, patients often report that nitro helps to relieve their chest pain. However, it is important to note that there can be uncomfortable side effects, such as headaches and dizziness.

It is also important to note that nitro is not a diagnostic tool. While it may help to reduce chest pain, it does not necessarily mean that the patient is having a coronary event. Nitro can also help to reduce pain from other causes, such as esophageal spasm or GERD.

Nitroglycerin reduces sympathetic outflow.

Nitroglycerin is a smooth muscle vasodilator that works by decreasing pain and in return sympathetic outflow. This decrease in sympathetic outflow can decrease ventricular wall stress and myocardial oxygen demand.

Nitro paste not an ideal treatment in the acute setting

Nitro paste is often touted as an effective treatment for acute coronary syndrome, but it is not the ideal option. The paste is applied directly to the skin, and it takes 10-30 minutes to start seeing the full effect. This is much longer than the five minutes it takes for sublingual tablets and sprays to take effect. So it may not be the best option for patients in the emergent setting or if you have a short transport time. In these cases, sublingual spray or tablets may be a better choice.

Additionally, the paste is dosed in inches, which can lead to a lot of variability in terms of absorption. The sublingual tablets and sprays are the preferred option for treating acute coronary syndrome, as they are much faster and more predictable. They can be used to achieve a peak concentration in less than five minutes, and they have a predictable response. The paste, on the other hand, is meant to provide anginal chest pain relief for up to eight hours. This makes it better suited for long-term use, rather than for treating acute symptoms.

Nitroglycerin and right ventricular MI’s

It is important to consider the potential risks when deciding to use nitro. It has long been feared that inferior right ventricular MIs may be worsened by nitro, as it can decrease preload and potentially lead to hypotension and cardiac collapse. Despite this, recent evidence suggests that nitro is safe to use in these cases, as it has not been found to have a profound effect on hemodynamics. And what effect it does have is generally short lived and responds to a fluid bolus.

Avoid opioids with MI.

When it comes to treating Acute Coronary Syndrome (ACS), the traditional treatment was the MONA protocol: Morphine, Oxygen, Nitro, and Aspirin. However, new evidence has shown that this protocol may not be the best option for treating ACS. Morphine, Oxygen, and Nitro can all have detrimental effects on the patient. Morphine, for example, has been suggested to decrease the effectiveness of anti-platelets, which are essential for reducing mortality. Oxygen has been shown to be toxic and increase ischemic area when titrated to 100%. And nitro can have detrimental effects on your blood pressure.


It is important to be aware of the potential risks associated with the use of opioids in patients with MI. While opioids can be used to reduce pain and decrease sympathetic outflow, they can also have detrimental effects on aspirin absorption. Aspirin, on the other hand, is the only treatment that has been shown to consistently reduce mortality with a low NNT. Therefore, it is important to be cautious when using opioids, such as fentanyl or morphine, as they can delay gastric emptying and absorption of aspirin.

Opioids might be called for in some cases of ACS but it is necessary to weigh the risks and benefits and patient centered goals when considering the use of opioids.

Summary of evidence-based treatment for ACS.

Evidence-based treatment for ACS is a critical component of patient care. Acute coronary syndrome (ACS) is a term used to describe chest pain due to a decrease in blood flow to the heart. It is a serious condition and requires prompt medical attention. The goal of evidence-based treatment for ACS is to reduce the risk of mortality and morbidity associated with the condition.

The most important evidence-based treatment for ACS is the administration of aspirin. Aspirin has been shown to reduce mortality in patients with ACS with a NNT as low as 10.

Nitroglycerin is another evidence-based treatment for ACS. It is used to reduce chest pain and decrease myocardial oxygen demand.

Opioids are also sometimes used for ACS. However, the evidence for their use is not as strong as it is for aspirin and nitroglycerin. Studies have shown that morphine can increase the risk of adverse outcomes in patients with ACS. Therefore, it is important to weigh these risks with specific patient centered goals.

Oxygen saturations in ACS should be titrated to 90-95%. Any higher than this may increase free radicals and lead to a larger area of ischemic injury.

In summary, nitroglycerin is an important medication used in the treatment of Acute Coronary Syndrome (ACS). While it is generally safe and effective, it should be avoided in certain cases, such as patients with hypotension, aortic stenosis, and those taking phosphodiesterase inhibitors.

Citations

Wilkinson-Stokes M, Betson J, Sawyer S. Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis. Emerg Med J. 2023 Feb;40(2):108-113. doi: 10.1136/emermed-2021-212294. Epub 2022 Sep 30. PMID: 36180168.

de Alencar Neto JN. Morphine, Oxygen, Nitrates, and Mortality Reducing Pharmacological Treatment for Acute Coronary Syndrome: An Evidence-based Review. Cureus. 2018 Jan 25;10(1):e2114. doi: 10.7759/cureus.2114. PMID: 29581926; PMCID: PMC5866121.

https://rebelem.com/death-mona-acs-part-iii-nitroglycerin/

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The GCS Sucks!

The Glasgow Coma Score (GCS) was developed in the 1970s initially as a research tool for admitted Neurosurgery patients. The original authors of the score and research advocated against it’s widespread use in acute care but nevertheless here we are: it is widely used in acute trauma and medical care.
 
Other than a score of 3 or a score of 15, there are multiple combinations of numbers that can get you various scores. This results in a poor ability to know what the patient is actually doing. The same combined score can represent two very different patients making the score difficult to interpret:
 
 
Patient 1
GCS = 10
Patient 2
GCS = 10
Eyes
4 = spontaneous
2 = open to pain
Verbal
5 = oriented
3 = inappropriate words
Motor
1 = No response
5 = localizes to pain
Which patient above are you more worried about?
 
There is some rationale to use GCS as triage tool for trauma center vs not:
GCS <13 –> level 1  (or highest available trauma center in your system)
GCS > 13 –> can go to lower level trauma center (if they don’t otherwise meet other system criteria for a level 1 trauma center)
 
In fact the most recent American College of Surgeons (the major trauma surgery body in the USA) field triage criteria have moved on to using a motor-GCS or M-GCS only:
M-GCS <6 –> level 1  (or highest available trauma center in your system)
M-GCS = 6 –> can go to lower level trauma center (if they don’t otherwise meet other system criteria for a level 1 trauma center):
Source: https://www.facs.org/quality-programs/trauma/systems/field-triage-guidelines/
 
Another score or called the Simplified Motor Score is something that is out there but it is pretty complex and not worth committing to memory. Stick to either total GCS or M-GCS.
 
With all of the above out of the way, the best thing to do is to be honest. The GCS is just trying to capture the exam in the form of a number. It’s hard to do math when you’re stressed. It’s much easier to describe what you are seeing. One example of this is to use the AVPU scale plus a qualifier if needed (eg Responds to pain but heavily intoxicated or status post sedation etc)
 
If your system loves the GCS and wants the GCS you just have to try to do the GCS. If you know they aren’t following commands and you use that information to transport to the highest available trauma center, you wont under triage or do wrong by the patient. End of the day be honest: “I’m having a hard time doing the math in the heat of the moment but here is what I’m seeing.”
 
Bottom Line:
  • Not following commands = go to the highest level trauma center available to you in your system
  • GCS is not that great but your system may love it
  • What the GCS is trying to capture is a neurological exam in the trauma patient. This is what is important.
  • Communicate the same information in an honest way that will get the pt the care they need.