GREEN BAY, Wis.— In the shadow of Lambeau Field, EMTs and paramedics gathered at the Wisconsin EMS Association annual conference for clinical education, professional development, product research and networking. The first day’s ALS track featured education sessions on sepsis, electrolyte imbalances, facial trauma and traumatic amputation. From these sessions, here are some of the top clinical takeaways and tips for prehospital providers.
#1 cause of hospital readmission
Sepsis, a systemic infection, is the leading hospitalization financial cost and a dangerous one, with one death every 90 seconds, according to the Sepsis Alliance. Sepsis mortality increases 4-9% every hour of delay in recognition. Sepsis is treatable (with early recognition, 80% of cases can be treated successfully), but sepsis is also the top cause of hospital readmission.
“These are often boring patients and most of my sepsis alerts started as lift assists,” Jason Joling, Chief of the Northwoods EMS District (Wis.) said in a presentation on sepsis.
Here are three clinical tips for sepsis recognition and treatment:
- Get a complete set of vital signs for every patient, even a lift assist.
- If a patient has an infection and two or more SIRS criteria, call a sepsis alert.
- Follow local protocols to administer oxygen, fluid and pressors. Administer warm fluids if you can and make sure to document the volume of fluid administered.
“Almost all septic patients have SIRS, but not all SIRS are septic,” Joling said. With that in mind, he reviewed the SIRS criteria.
- Heart rate > 90
- Respiratory rate > 20
- EtCO2 < 32 mm Hg
- Temp > 100.4 or < 96.8
Joling finished his presentation with this quote from a colleague as a reminder to have a high index of suspicion and to initiate treatment early, “They (sepsis patients) don’t suddenly crash. We just suddenly notice.”
7.35 to 7.45 is a “miniscule range”
Through a series of cases, WEMSA attendees explored causes of electrolyte imbalances, assessment and treatment. The electrolytes – potassium, sodium, chlorine, calcium and magnesium – regulate nerve and muscle function, control fluid balance and maintain acid-base balance.
“The human body is phenomenally picky,” Lucian Mirra, EMS Coordinator, Abermarle County (Va.) Fire-Rescue, said. “We have to have a pH range within this minuscule range.”
All electrolytes, like pH, have a specific normal range. Prehospital providers can suspect abnormal electrolyte values through patient history and physical exam findings. Here are four clinical pearls from Mirra’s presentation.
- Potassium: Treat hyperkalemia by driving potassium from the extracellular space into the cells with continuous albuterol, insulin and glucose. Eliminate excess potassium with fluids and dialysis.
- Sodium: If the patient has a seizure with no known history of seizure disorder, consider a sodium imbalance as the cause.
- Magnesium: “If you see Torsades (on the cardiac monitor), you should probably just give the magnesium,” Mirra said.
- Calcium:Trousseau’s signis a contraction (tetany) of the arm or hand as you inflate the blood pressure cuff on that arm. In addition, patients with a calcium channel blocker overdose do not have a low serum calcium level. Instead, the calcium just can’t get to where it needs to go.
Mirra also included this tip in a case discussion about a suspected overdose. “Always compare the fill date with the number of pills left in the bottle,” Mirra said as he discussed an empty bottle of verapamil, a calcium channel blocker, that had been filled three days earlier.
50% of lung volume is lost when lying flat
Allen Wolfe, senior director of clinical education for Life Link III, a nurse for 40 years and a flight nurse for 34 years, led a dynamic and informative session on facial trauma and airway management. Wolfe began his presentation by discussing the importance of using a checklist for airway management.
“Airway management is the single most important skill we use as prehospital providers,” Wolfe said. Here are four pre-intubation tips from Wolfe’s presentation.
- Resuscitate before you intubate. For example, if the patient is hypotensive, administer fluids and pressors, if indicated, before intubation.
- Validate that a blunt trauma patient doesn’t have a pneumothorax before you intubate. Check for bilateral breath sounds and treat a pneumothorax, if indicated, with needle decompression.
- Pre-oxygenate the patient with a nasal cannula before intubation, set oxygen flow to 10 L/min or higher until intubation is complete.
- Elevate the head of the bed during pre-oxygenation and intubation to increase the patient’s lung volume.
Wolfe shared numerous experiences as a flight crew observer in his role as a clinical educator. He had many examples of crews not using a checklist, missing important vital sign findings and overlooking necessary interventions because they are working from memory and not using a checklist.
Checklists keep us from making mistakes and reduce errors, but “a checklist is only as good as the person who uses it,” Wolfe said.
The second half of Wolfe’s presentation featured a series of facial trauma case studies from shotgun blasts, gasoline burns and knife wounds, discussing the airway management techniques used to care for these patients. All of the cases, though not easily treated, illustrated the importance of using a checklist to consider causes of airway compromise, thoroughly assess the patient and apply appropriate treatments based on assessment findings.
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90% increase in mortality
Wolfe delivered a second presentation on traumatic amputations with compelling and graphic case studies to discuss important assessment and treatment considerations, including how the trauma triad of death – hypothermia, acidosis and coagulopathy – increases mortality in trauma patients by 90%.
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Wolfe offered these trauma assessment and treatment tips:
- Stop the bleed. Apply tourniquets and hemostatic agents to stop life-threatening bleeding. Other resuscitative treatments will be ineffective if the patient is still bleeding.
- Keep the patient warm. Use passive methods, like removing wet clothes and increasing ambient temperature; as well as active methods, like administering warm IV fluids, to manage hypothermia.
- Recognize shock. Assess for the universal signs of shock – altered mental status; pale, cool, clammy skin; tachycardia; tachypnea; and cyanosis. Follow local protocols, including TXA administration and whole blood, to resuscitate shock.
In closing, Wolfe reminded paramedics to care for the amputated part and transport the patient to the most appropriate hospital.
