Lead authors of forthcoming Community Health Paramedicine textbook join other thought leaders at CP 360 Community Paramedicine Conference.

CP360 Conference

Dr. Michael Wilcox, MD, FACEP, FAAFP (left) and Kai Hjermstad, AAS, NREMT-P, CP (right) of Hennepin Technical College relax after a great day at the inaugural CP 360 Maine Community Paramedicine Conference.

Community paramedicine thought leaders gathered at the inaugural CP 360 Community Paramedicine Conference in Maine this week, including Dr. Michael Wilcox, MD, FACEP, FAAFP and Kai Hjermstad, AAS, NREMT-P, CP, lead authors of the new Community Health Paramedicine textbook from Jones & Bartlett Learning. Mike and Kai contributed greatly to the conference’s discussion on how community paramedics can help fill a huge gap in the health care system in the United States: responding to the health care needs of underserved communities and ultimately improving the quality of life and health in these populations.

Community paramedicine programs assign community paramedics to work directly with patients and to collaborate with a dedicated network of health care providers to address minor and chronic health problems within their communities, reduce hospital readmissions, prevent unnecessary ambulance transports, and keep patients where they want to be: in their homes. In their home state of Minnesota, Mike and Kai have successfully established and grown the community paramedicine program, improving the lives of countless patients. They are dedicated to sharing their experience and expertise with new programs across the country to assist this rapidly growing profession to change patient’s lives.

With significant contributions from respected community paramedicine pioneers and experts from across the country, Jones & Bartlett Learning is thrilled to be working alongside Mike, Kai, and Al Benney NREMT-P, STP to develop the first-ever Community Paramedicine textbook and learning resources. Keep an eye out for its much-anticipated release in December 2016!

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First Aid

Bob Elling, MPA, EMT-Pcprstock

(Part 6 of a 6-part series: CPR, ECC, and First Aid Guidelines: Version 2015)

First Aid

A number of topics were addressed in the 2015 Guidelines on first aid that will be incorporated into updated protocols and procedures. Let’s take a closer look at the specifics here.

Positioning the Ill or Injured Person and Position for Shock

  • If the area is unsafe for the first aid provider or the person, move to a safe location if possible (Class I).
  • If a person is unresponsive and breathing normally, it may be reasonable to place him or her in a lateral side-lying recovery position (Class IIb).
  • If a person has been injured and the nature of the injury suggests a neck, back, hip, or pelvic injury, the person should not be rolled onto his or her side, but instead should be left in the position in which the individual was found, to avoid potential further injury (Class I).
  • If leaving the person in the position found is causing the person’s airway to be blocked, or if the area is unsafe, move the person only as needed to open the airway and to reach a safe location (Class I).
  • If a person shows evidence of shock and is responsive and breathing normally, it is reasonable to place or maintain the person in a supine position (Class IIa,).
  • If there is no evidence of trauma or injury (eg, simple fainting, shock from nontraumatic bleeding, sepsis, dehydration), raising the feet 6 to 12 inches (30 to 60 degrees) from the supine position is an option that may be considered while awaiting arrival of EMS (Class IIb).
  • Do not raise the feet of a person in shock if the movement or the position causes pain (Class III).

Oxygen Use in First Aid

  • The use of supplementary oxygen by first aid providers with specific training is reasonable for cases of decompression sickness (Class IIa).
  • For first aid providers with specific training in the use of oxygen, the administration of supplementary oxygen to persons with known advanced cancer with dyspnea and hypoxemia may be reasonable (Class IIb).
  • Although no evidence was identified to support the use of oxygen, it might be reasonable to provide oxygen to spontaneously breathing persons who are exposed to carbon monoxide while waiting for advanced medical care (Class IIb).

Medical Emergencies

Asthma and Stroke

  • It is reasonable for first aid providers to be familiar with the available inhaled bronchodilator devices and to assist as needed with the administration of prescribed bronchodilators when a person with asthma is having difficulty breathing (Class IIa).
  • Use of a stroke assessment system by first aid providers is recommended (Class I).

Chest Pain

  • Aspirin has been found to significantly decrease mortality due to myocardial infarction in several large studies. It is therefore recommended for persons with chest pain due to suspected myocardial infarction (Class I).
  • Call EMS immediately for anyone with chest pain or other signs of heart attack, rather than trying to transport the person to a health care facility yourself (Class I).
  • While waiting for EMS to arrive, the first aid provider may encourage a person with chest pain to take aspirin if the signs and symptoms suggest that the person is having a heart attack and the person has no allergy or contraindication to aspirin, such as recent bleeding (Class IIa).
  • If a person has chest pain that does not suggest that the cause is cardiac in origin, or if the first aid provider is uncertain or uncomfortable with administration of aspirin, then the first aid provider should not encourage the person to take aspirin (Class III).

Anaphylaxis, Hypoglycemia, and Dehydration

  • The recommended dose of epinephrine is 0.3 mg intramuscularly for adults and children who weigh more than 30 kg, 0.15 mg IM for children who weigh 15 to 30 kg, or as prescribed by the person’s physician. First aid providers should call 911 immediately when caring for a person with suspected anaphylaxis or a severe allergic reaction (Class I).
  • When a person with anaphylaxis does not respond to the initial dose, and the anticipated arrival time of advanced care will exceed 5 to 10 minutes, a repeat dose may be considered (Class IIb).
  • If the person is unconscious, exhibits seizures, or is unable to follow simple commands or swallow safely, the first aid provider should call for EMS immediately (Class I).
  • If a person with diabetes reports low blood sugar or exhibits signs or symptoms of mild hypoglycemia and is able to follow simple commands and swallow, oral glucose should be given in an attempt to resolve the hypoglycemia. Glucose tablets, if available, should be used to reverse hypoglycemia in a person who is able to take them orally (Class I).
  • It is reasonable to use dietary sugars as an alternative to glucose tablets (when not available) for reversal of mild symptomatic hypoglycemia (Class IIa).
  • First aid providers should wait at least 10 to 15 minutes before calling EMS and retreating a diabetic with mild symptomatic hypoglycemia with additional oral sugars (Class I).
  • If the person’s status deteriorates during that time or does not improve, the first aid provider should call EMS (Class I).
    • In the absence of shock, confusion, or inability to swallow, it is reasonable for first aid providers to assist or encourage individuals with exertional dehydration to orally rehydrate with CE drinks (Class IIa).
    • If these alternative beverages are not available, potable water may be used (Class IIb).

Toxic Eye Injury and Chemical Eye Injury

  • It can be beneficial to rinse eyes exposed to toxic chemicals immediately and with a copious amount of tap water for at least 15 minutes or until advanced medical care arrives (Class IIa).
  • If tap water is not available, normal saline or another commercially available eye irrigation solution may be a reasonable alternative (Class IIb).
  • First aid providers caring for an individual with chemical eye injury should contact their local poison control center or, if the poison control center is not available, seek help from a medical provider or 911 (Class I).

Trauma Emergencies

Control of Bleeding

  • There is no evidence to support the use of pressure points or elevation to control external bleeding, and this practice is not recommended (Class III).
  • The standard method for first aid providers to control open bleeding is to apply direct pressure to the bleeding site until it stops (Class I).
  • Local cold therapy, such as an instant cold pack, can be useful for these types of injuries to the extremity or scalp (Class IIa).
  • Cold therapy should be used with caution in children because of the increased risk of hypothermia in this population (Class I).
  • Because the rate of complications is low and the rate of hemostasis is high, first aid providers may consider the use of a tourniquet when standard first aid control does not control severe external limb bleeding (Class IIb).
  • A tourniquet may be considered for initial care when a first aid provider is unable to use standard first aid hemorrhage control, such as during a mass-casualty incident, with a person who has multisystem trauma, in an unsafe environment, or with a wound that cannot be accessed (Class IIb).
  • Although maximum time for tourniquet use was not reviewed in a 2015 ILCOR systematic review, it has been recommended that the first aid provider note the time that the tourniquet is first applied and communicate this information to EMS providers. It is reasonable for first aid providers to be trained in the proper application of tourniquets, both manufactured and improvised (Class IIa).
  • Hemostatic dressings may be considered by first aid providers when standard bleeding control (direct pressure with or without gauze or cloth dressing) is not effective for severe or life-threatening bleeding (Class IIb).
  • Proper application of hemostatic dressings requires training (Class I).

Open Chest Wounds

  • We recommend against the application of an occlusive dressing by first aid providers to an individual with an open chest wound (Class III).
  • In the first aid situation, it is reasonable to leave an open chest wound exposed to ambient air without a dressing or seal (Class IIa).

Concussion

  • Any person with a head injury that has resulted in a change in level of consciousness, has progressive development of signs or symptoms, or is otherwise a cause for concern should be evaluated by a health care provider or EMS personnel as soon as possible (Class I).
  • Use of any mechanical machinery, driving, cycling, or continuing to participate in sports after a head injury should be deferred by these individuals until they are assessed by a health care provider and cleared to participate in those activities (Class I).

Spinal Motion Restriction

  • Given the growing body of evidence showing more actual harm and no good evidence showing clear benefit, we recommend against routine application of cervical collars by first aid providers (Class III).
  • If a first aid provider suspects the patient has a spinal injury, he or she should have the person remain as still as possible and await the arrival of EMS providers (Class I).

Musculoskeletal Trauma

  • In general, first aid providers should not move or try to straighten an injured extremity (Class III).
  • In such situations, providers should protect the injured person, including via splinting in a way that limits pain, reduces the chance for further injury, and facilitates safe and prompt transport (Class I).
  • If an injured extremity is blue or extremely pale, activate EMS immediately (Class I).

Burns

  • Cool thermal burns with cool or cold potable water as soon as possible and for at least 10 minutes (Class I).
  • If cool or cold water is not available, a clean, cool or cold (but not freezing) compress can be useful as a substitute for cooling thermal burns (Class IIa).
  • Care should be taken to monitor for hypothermia when cooling large burns (Class I).
  • After cooling of a burn, it may be reasonable to loosely cover the burn with a sterile, dry dressing (Class IIb).
  • The following types of burns should be evaluated by a health care provider: Burns associated with or involving (1) blistering or broken skin; (2) difficult breathing; (3) the face, neck, hands, or genitals; (4) a larger surface area, such as the trunk or extremities; or (5) some other cause for concern (Class I).

Avulsed Tooth

  • In situations that do not allow for immediate reimplantation, it can be beneficial to temporarily store an avulsed tooth in a variety of solutions shown to prolong the viability of dental cells (Class IIa).
  • If none of these solutions is available, it may be reasonable to store an avulsed tooth in the injured person’s saliva (not in the mouth) pending reimplantation (Class IIb).
  • Following dental avulsion, it is essential to seek rapid assistance with reimplantation (Class I).

If you want to read all the details and background, take a look at the Supplement to Circulation, volume 132, number 18, supplement 2, November 3, 2015.

I hope this series of blog posts has been helpful in providing both an overview and information on many of the specific recommendations for changes to the 2015 Guidelines. Over the next few months, the ECSI authors and editors will be working very hard to update the instructor network and provide the highest-quality books and materials so you can train students to save lives in their communities. Thank you for all you do and keep up the great work of saving lives!

See you in the streets!


Bob Elling’s Bio

Bob Elling, MPA, EMT-P, is a clinical instructor with Albany Medical Center assigned to teach at the Hudson Valley Community College Paramedic Program in Troy, New York. He has served as a medic since 1978, originally in New York City, and currently with Colonie EMS Department, Times Union Center, and Whiteface Medical Services. He is a passionate advocate for the American Heart Association, serving on the Capital Area Board and the New York state advocacy committee, and has served on the National Faculty as well as the Founder’s Affiliate Board.

Bob’s proudest professional accomplishments include being the AHA Basic Science Editor for the 2005 Guidelines, being the Medical Editor of Caroline Emergency Care in the Streets (sixth to eighth editions), having trained thousands of EMTs in the past four decades, and being an ambassador to the Marine Corps Marathon.

Bob has authored 46 books and contributed to 33 other books. He has also written many video scripts and magazine articles.

He enjoys writing, traveling, riding his Harley or Trek road bike, distance running (having completed 31 marathons), listening to all types of music (mostly classic rock), skiing, and hanging out with his family and black Lab. He lives in Colonie and Lake Placid, New York.

 

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The Many Faces Behind the Jones & Bartlett Learning Public Safety Group

Ever wonder who creates our high quality EMS, Fire, and emergency care educational materials? No need to wonder any longer.

The Jones & Bartlett Learning Public Safety Group is pleased to present the first in a series of interviews with our highly esteemed authors and passionate employees.

First up?

3 questions for…Stephen J. Rahm, NRP! Meet the dedicated paramedic, educator, and author now:

 

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Now Available: The 2016-2017 Jones & Bartlett Learning Public Safety Group Catalog

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The 2016-2017 Jones & Bartlett Learning Public Safety Group Catalog is HERE!

Take a look at our catalog for a complete list of innovative course resources and training solutions, including Navigate 2, Fisdap, Emergency Care and Transportation of the Sick and Injured, Eleventh Edition, and Fire Fighter training with evidence-based research from UL/NIST.

View | Download your copy today!

 

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Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality

cprstockBob Elling, MPA, EMT-P

(Part 5 of a 6-part series: CPR, ECC, and First Aid Guidelines: Version 2015)

Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality

A number of topics were addressed in the 2015 Guidelines on both pediatric basic and advanced life support and CPR quality that will be incorporated into updated protocols and procedures. Let’s take a closer look at the specifics here.

Components of High-Quality CPR: Chest Compression Rate and Depth 

  • To maximize simplicity in CPT training, in the absence of sufficient pediatric evidence, it is reasonable to use the adult chest compression rate of 100 to 120 compressions per minute for infants and children (Class IIa).
  • Although the effectiveness of CPR feedback devices was not reviewed by this writing group, the consensus of the group is that the use of feedback devices likely helps the rescuer optimize adequate chest compression rate and depth, and we suggest their use when available (Class IIb).
  • In pediatric patients (younger than 1 year), it is reasonable that rescuers provide chest compressions that depress the chest at least one third of the anterior–posterior diameter of the chest. This equates to approximately 1.5 inches (4 cm) in children (Class IIa). Once children have reached puberty, the recommended adult compression depth of at least 5 cm, but no more than 6 cm, is used for the adolescent of average adult size.
  • Conventional CPR (rescue breathing and chest compressions) should be provided for pediatric cardiac arrest (Class I).
  • The asphyxia nature of the majority of pediatric cardiac arrests necessitates ventilation as part of effective CPR. However, because compression-only CPR is effective in patients with a primary cardiac event, if rescuers are unwilling or unable to deliver breaths, we recommend rescuers perform compression-only CPR for infants and children in cardiac arrest (Class I).

Pediatric Advanced Life Support

Prearrest Care Updates

  • Administration of an initial fluid bolus of 20 mL/kg to infants and children with shock is reasonable, including those with conditions such as severe sepsis (Class IIa) and malaria and dengue fever (Class IIb).
  • When caring for children with severe febrile illness (such as those included in the FEAST trial) in settings with limited access to critical care resources (ie, mechanical ventilation and inotropic support), administration of bolus IV fluids should be undertaken with extreme caution because it may be harmful (Class IIb).
  • Providers should reassess the patient after every fluid bolus (Class I).
  • Either isotonic crystalloids or colloids can be effective as the initial fluid choice for resuscitation (Class IIa).
  • The available evidence does not support the routine use of atropine prior to intubation of critically ill infants and children. It may be reasonable for practitioners to use atropine as a premedication in specific emergent intubations when there is a higher risk of bradycardia (eg, when giving succinylcholine as a neuromuscular blocker to facilitate intubation) (Class IIb).
  • A dose of 0.02 mg/kg of atropine with no minimum dose may be considered when atropine is used as a premedication for emergency intubation (Class IIb).

Intra-arrest Care Updates

  • ETCO2 monitoring may be considered to evaluate the quality of chest compressions, but specific values to guide therapy have not been established in children (Class IIb).
  • It is reasonable to administer epinephrine in pediatric cardiac arrest (Class IIa).
  • For shock-refractory VF/pVT, either amiodarone or lidocaine may be used (Class IIb).
  • It is reasonable to use an initial dose of 2 to 4 J/kg of monophasic or biphasic energy for defibrillation (Class IIa), but for ease of teaching, an initial dose of 2 J/kg may be considered (Class IIb).
  • For refractory VF, it is reasonable to increase the energy dose to 4 J/kg (Class IIa).
  • For subsequent energy levels, a dose of 4 J/kg may be reasonable and higher energy levels may be considered, though not to exceed 10 J/kg or the adult maximum dose (Class IIb).
  • For infants and children remaining comatose after OHCA, it is reasonable either to maintain 5 days of continuous normothermia (36 to 37.5°C) or to maintain 2 days of initial continuous hypothermia (32 to 34°C) followed by 3 days of continuous normothermia (Class IIa).
  • Continuous measurement of temperature during this time period is recommended (Class I).
  • Fever (temperature 38°C or higher) should be aggressively treated after ROSC (Class I).
  • It may be reasonable for rescuers to target normoxemia after ROSC (Class IIb).
  • It is reasonable for practitioners to target a Paco2 after ROSC that is appropriate to the specific patient condition, and to limit exposure to severe hypercapnia or hypocapnia (Class IIb).

The next section of this blog will cover the specifics of first aid. If you want to read all the details and background, take a look at the Supplement to Circulation, volume 132, number 18, supplement 2, November 3, 2015.

See you in the streets!

 

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Special Circumstances of Resuscitation

cprstockBob Elling, MPA, EMT-P

(Part 4 of a 6-part series: CPR, ECC, and First Aid Guidelines: Version 2015)

Special Circumstances of Resuscitation 

A number of topics were addressed in the 2015 Guidelines on special circumstances of resuscitation (i.e., pregnant patient, pulmonary embolism, and opioid overdose) that will be incorporated into updated protocols and procedures. Let’s take a closer look at the specifics here.

Cardiac Arrest Associated With Pregnancy

  • Priorities for the pregnant woman in cardiac arrest are provision of high-quality CPR and relief of aortocaval compression (Class I).
  • If the fundus height is at or above the level of the umbilicus, manual LUD can be beneficial in relieving aortocaval compression during chest compressions (Class IIa).
  • Because immediate ROSC cannot always be achieved, local resources for a PMCD should be summoned as soon as cardiac arrest is recognized in a woman in the second half of pregnancy (Class I).
  • Systematic preparation and training are the keys to a successful response to such rare and complex events. Care teams that may be called upon to manage these situations should develop and practice standard institutional responses to allow for smooth delivery of resuscitative care (Class I).
  • During cardiac arrest, if the pregnant woman with a fundus height at or above the umbilicus has not achieved ROSC with usual resuscitation measures plus manual LUD, it is advisable to prepare to evacuate the uterus while resuscitation continues (Class I).
  • In situations such as nonsurvivable maternal trauma or prolonged pulselessness, in which maternal resuscitative efforts are obviously futile, there is no reason to delay performing PMCD (Class I).
  • PMCD should be considered at 4 minutes after onset of maternal cardiac arrest or resuscitative efforts (for the unwitnessed arrest) if there is no ROSC (Class IIa).

Cardiac Arrest Associated With Pulmonary Embolism

  • In patients with confirmed PE as the precipitant of cardiac arrest, thrombolysis, surgical embolectomy, and mechanical embolectomy are reasonable emergency treatment options (Class IIa).
  • Thrombolysis may be considered when cardiac arrest is suspected to be caused by PE (Class IIb).
  • Thrombolysis can be beneficial even when chest compressions have been provided (Class IIa).

Cardiac or Respiratory Arrest Associated With Opioid Overdose

  • It is reasonable to provide opioid overdose response education, either alone or coupled with naloxone distribution and training, to persons at risk for opioid overdose (Class IIa).
  • It is reasonable to base this training on first aid and non-health care provider BLS recommendations rather than on more advanced practices intended for health care providers (Class IIa).
  • Empiric administration of IM or IN naloxone to all unresponsive patients with opioid-associated life-threatening emergency may be reasonable as an adjunct to standard first aid and non-health care provider BLS protocols (Class IIb).
  • Victims who respond to naloxone administration should receive advanced health care services (Class I).
  • For patients with known or suspected opioid addiction who have a definite pulse but no normal breathing or only gasping (ie, a respiratory arrest), in addition to providing standard BLS care, it is reasonable for appropriately trained BLS health care providers to administer IM or IN naloxone (Class IIa).
  • Standard resuscitative measures should take priority over naloxone administration (Class I), with a focus on high-quality CPR (compressions plus ventilation).
  • It may be reasonable to administer IM or IN naloxone based on the possibility that the patient is not in cardiac arrest (Class IIb).
  • Responders should not delay access to more-advanced medical services while awaiting the patient’s response to naloxone or other interventions (Class I).
  • Unless the patient refuses further care, victims who respond to naloxone administration should receive advanced health care services (Class I).
  • Bag-mask ventilation should be maintained until spontaneous breathing returns, and standard ACLS measures should continue if ROSC does not occur (Class I).
  • After ROSC or return of spontaneous breathing, patients should be observed in a health care setting until the risk of recurrent opioid toxicity is low and the patient’s level of consciousness and vital signs have normalized (Class I).
  • If recurrent opioid toxicity develops, repeated small doses or an infusion of naloxone can be beneficial in health care settings (Class IIa).
  • Naloxone administration in post-cardiac arrest care may be considered to achieve the specific therapeutic goals of reversing the effects of long-acting opioids (Class IIb).

The next section of this blog will go into the specifics on pediatric basic and advanced life support and cardiopulmonary resuscitation quality. If you want to read all the details and background, take a look at the Supplement to Circulation, volume 132, number 18, supplement 2, November 3, 2015.

See you in the streets!

 

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Advanced Cardiovascular Life Support and ACS

cprstockBob Elling, MPA, EMT-P

(Part 3 of a 6-part series: CPR, ECC, and First Aid Guidelines: Version 2015)

Advanced Cardiovascular Life Support and ACS

A number of topics were addressed in the 2015 Guidelines on adult advanced cardiovascular life support (ACLS) and acute coronary syndromes (ACS) that will be incorporated into updated protocols and procedures. Let’s take a closer look at the specifics here.

Advanced Cardiovascular Life Support

Adjuncts to CPR

  • When supplementary oxygen is available, it may be reasonable to use the maximal feasible inspired oxygen concentration during CPR (Class IIb).
  • Although no clinical study has examined whether titrating resuscitative efforts to physiologic parameters during CPR improves outcome, it may be reasonable to use physiologic parameters (quantitative waveform capnography, arterial relaxation diastolic pressure, arterial pressure monitoring, and central venous oxygen saturation) when feasible to monitor and optimize CPR quality, guide vasopressor therapy, and detect ROSC (Class IIb).

Adjuncts for Airway Control and Ventilation

  • Either a bag-mask device or an advanced airway may be used for oxygenation and ventilation during CPR in both in-hospital and out-of-hospital settings (Class IIb).
  • For health care providers trained in their use, either a supraglottic airway (SGA) device or an endotracheal tube (ETT) may be used as the initial advanced airway during CPR (Class IIb).
  • Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an ETT (Class I).
  • If continuous waveform capnography is not available, a nonwaveform CO2 detector, esophageal detector device, or ultrasound used by an experienced operator is a reasonable alternative (Class IIa).
  • After placement of an advanced airway, it may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths/min) while continuous chest compressions are being performed (Class IIb).

Management of Cardiac Arrest

  • Defibrillators (using BTE, RLB, or monophasic waveforms) are recommended to treat atrial and ventricular arrhythmias (Class I).
  • Based on their greater success in arrhythmia termination, defibrillators using biphasic waveforms (BTE or RLB) are preferred to monophasic defibrillators for treatment of both atrial and ventricular arrhythmias (Class IIa).
  • In the absence of conclusive evidence that one biphasic waveform is superior to another in termination of VF, it is reasonable to use the device manufacturer’s recommended energy dose for the first shock. If this dose is not known, defibrillation at the maximal dose may be considered (Class IIb).
  • It is reasonable that selection of fixed versus escalating energy for subsequent shocks be based on the specific device manufacturer’s instructions (Class IIa).
  • If using a manual defibrillator capable of escalating energies, higher energy for the second and subsequent shocks may be considered (Class IIb).
  • A single-shock strategy (as opposed to stacked shocks) is reasonable for defibrillation (Class IIa).
  • Amiodarone may be considered for VF/pVT that is unresponsive to CPR, defibrillation, and vasopressor therapy (Class IIb).
  • Lidocaine may be considered as an alternative to amiodarone for VF/pVT that is unresponsive to CPR, defibrillation, and vasopressor therapy (Class IIb,).
  • The routine use of magnesium for VF/pVT is not recommended in adult patients (Class III).
  • There is inadequate evidence to support the routine use of lidocaine after cardiac arrest. However, initiation or continuation of lidocaine may be considered immediately after ROSC from cardiac arrest due to VF/pVT (Class IIb).
  • There is inadequate evidence to support the routine use of a beta-blocker after cardiac arrest. However, the initiation or continuation of an oral or intravenous beta-blocker may be considered early after hospitalization from cardiac arrest due to VF/pVT (Class IIb).
  • Standard-dose epinephrine (1 mg every 3 to 5 minutes) may be reasonable for patients in cardiac arrest (Class IIb).
  • High-dose epinephrine is not recommended for routine use in cardiac arrest (Class III).
  • Vasopressin offers no advantage as a substitute for epinephrine in cardiac arrest (Class IIb).
  • Vasopressin in combination with epinephrine offers no advantage as a substitute for standard-dose epinephrine in cardiac arrest (Class IIb).
  • It may be reasonable to administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm (Class IIb).
  • For patients with OHCA, use of steroids during CPR is of uncertain benefit (Class IIb).
  • In intubated patients, failure to achieve an etco2 of greater than 10 mm Hg by waveform capnography after 20 minutes of CPR may be considered as one component of a multimodal approach to decide when to end resuscitative efforts, but should not be used in isolation (Class IIb).
  • In non-intubated patients, a specific etco2 cutoff value at any time during CPR should not be used as an indicator to end resuscitative efforts (Class III).

Post-Cardiac Arrest Care

Cardiovascular Care and Hemodynamic Goals 

  • Coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG (Class I).
  • Emergent coronary angiography is reasonable for selected (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG (Class IIa).
  • Coronary angiography is reasonable in post–cardiac arrest patients for whom coronary angiography is indicated regardless of whether the patient is comatose or awake (Class IIa).
  • Avoiding and immediately correcting hypotension (systolic BP less than 90 mm Hg, MAP less than 65 mm Hg) during post-resuscitation care may be reasonable (Class IIb).

Targeted Temperature Management (TTM) and Other Critical Care Interventions

  • We recommend that comatose (ie, lack of meaningful response to verbal commands) adult patients with ROSC after cardiac arrest have TTM (Class I), LOE B-R for VF/pVT OHCA (Class I) for non-VF/pVT (ie, “non-shockable”) and in-hospital cardiac arrest.
  • We recommend selecting and maintaining a constant temperature between 32°C and 36°C during TTM (Class I).
  • It is reasonable that TTM be maintained for at least 24 hours after achieving the target temperature (Class IIa).
  • We recommend against the routine prehospital cooling of patients after ROSC with rapid infusion of cold intravenous fluids (Class III).
  • We recommend that all patients who are resuscitated from cardiac arrest but who subsequently progress to death or brain death be evaluated for organ donation (Class I).
  • Patients who do not have ROSC after resuscitation efforts and who would otherwise have termination of efforts may be considered candidates for kidney or liver donation in settings where such program exist (Class IIb).

Acute Coronary Syndromes

Diagnostic Interventions

  • Prehospital 12-lead ECG should be acquired early for patients with possible ACS (Class I).
  • Prehospital notification of the receiving hospital (if fibrinolysis is the likely reperfusion strategy) and/or prehospital activation of the catheterization laboratory should occur for all patients with a recognized STEMI on prehospital ECG (Class I).
  • Because of high false-negative rates, we recommend that computer-assisted ECG interpretation not be used as the sole means to diagnose STEMI (Class III).
  • We recommend that computer-assisted ECG interpretation be used in conjunction with physician or trained-provider interpretation to recognize STEMI (Class IIb).
  • While transmission of the prehospital ECG to the ED physician may improve PPV and therapeutic decision making regarding adult patients with suspected STEMI, if transmission is not performed, it may be reasonable for trained-nonphysician ECG interpretation to be used as the basis for decision making, including activation of the catheterization laboratory, administration of fibrinolysis, and selection of the destination hospital (Class IIa).

Therapeutic Interventions

  • The usefulness of supplementary oxygen therapy has not been established in normoxic patients. In the prehospital, ED, and hospital settings, the withholding of supplementary oxygen therapy in normoxic patients with suspected or confirmed ACS may be considered (Class IIb).
  • Where prehospital fibrinolysis is available as part of a STEMI system of care, and in-hospital fibrinolysis is the alternative treatment strategy, it is reasonable to administer prehospital fibrinolysis when transport times are more than 30 minutes (Class IIa).
  • If fibrinolytic therapy is provided, immediate transfer to a PCI center for cardiac angiography within 3 to 24 hours may be considered (Class IIb).
  • Regardless of whether the time of symptom onset is known, the interval between first medical contact and reperfusion should not exceed 120 minutes (Class I).
  • When STEMI patients cannot be transferred to a PCI-capable hospital in a timely manner, fibrinolytic therapy with routine transfer for angiography may be an acceptable alternative to immediate transfer to PPCI (Class IIb).
  • When fibrinolytic therapy is administered to STEMI patients in a non-PCI-capable hospital, it may be reasonable to transport all post-fibrinolysis patients for early routine angiography in the first 3 to 6 hours and up to 24 hours later, rather than to transport post-fibrinolysis patients only when they require ischemia-guided angiography (Class IIb).

The next section of this blog will go into the specifics on special circumstances in resuscitation. If you want to read all the details and background, take a look at the Supplement to Circulation, volume 132, number 18, supplement 2, November 3, 2015.

See you in the streets!

 

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Systems of Care and Continuous Quality Improvement

Bob Elling, MPA, EMT-Pcprstock

(Part 2 of a 6-part series: CPR, ECC, and First Aid Guidelines: Version 2015)

A number of topics were addressed in the 2015 Guidelines on systems of care and continuous quality improvement (CQI) that will be incorporated into updated protocols and procedures. This section is extremely important, as those communities that take the time to focus on improving all the links in the chain of survival will see the greatest improvements in survival. Whose responsibility is this? All of us have a responsibility as first aiders, EMS providers, health care professionals, and interested members of the public to step up and help implement all sections of the Guidelines!

Let’s take a closer look at the specifics here.

Public-Access Defibrillation

  • It is recommended that PAD programs for patients with OHCA be implemented in communities at risk for cardiac arrest (Class I).

Dispatcher Recognition of Cardiac Arrest

  • It is recommended that emergency dispatchers determine if a patient is unconscious with abnormal breathing after acquiring the requisite information to determine the location of the event (Class I).
  • If the patient is unconscious with abnormal or absent breathing, it is reasonable for the emergency dispatcher to assume that the patient is in cardiac arrest (Class IIa).
  • Dispatchers should be educated to identify unconsciousness with abnormal and agonal gasps across a range of clinical presentations and descriptions (Class I).
  • We recommend that dispatchers provide chest compression-only CPR instructions to callers for adults with suspected OHCA (Class I).

Use of Social Media to Summon Rescuers

  • Given the low risk of harm and the potential benefit of such notifications, it may be reasonable for communities to incorporate, where available, social media technologies that summon rescuers who are willing and able to perform CPR and are in close proximity to a suspected victim of OHCA (Class IIb).

Transport to Specialized Cardiac Arrest Centers

  • A regionalized approach to OHCA resuscitation that includes the use of cardiac resuscitation centers may be considered (Class IIb).

Immediate Recognition and Activation of the Emergency Response System

  • It is recommended that emergency dispatchers determine if a patient is unresponsive with abnormal breathing after acquiring the requisite information to determine the location of the event (Class I).
  • If the patient is unresponsive with abnormal or absent breathing, it is reasonable for the emergency dispatcher to assume that the patient is in cardiac arrest (Class IIa).
  • Dispatchers should be educated to identify unresponsiveness with abnormal breathing and agonal gasps across a range of clinical presentations and descriptions (Class I).

Untrained Lay Rescuer

  • Untrained lay rescuers should provide compression-only CPR, with or without dispatcher assistance (Class I).
  • The rescuer should continue compression-only CPR until the arrival of an AED or rescuers with additional training (Class I).

Trained Lay Rescuer

  • All lay rescuers should, at a minimum, provide chest compressions for victims of cardiac arrest (Class I). In addition, if the trained lay rescuer is able to perform rescue breaths, he or she should add rescue breaths at a ratio of 30 compressions to 2 breaths.
  • The rescuer should continue CPR until an AED arrives and is ready for use or until EMS providers take over care of the victim (Class I).

Health Care Provider

  • It is reasonable for health care providers to provide chest compressions and ventilation for all adult patients in cardiac arrest, from either a cardiac or noncardiac cause (Class IIa).

Delayed Ventilation

  • For witnessed OHCA with a shockable rhythm, it may be reasonable for EMS systems with priority-based, multitiered response to delay positive-pressure ventilation by using a strategy of up to 3 cycles of 200 continuous compressions with passive oxygen insufflation and airway adjuncts (Class IIb).

Recognition of Arrest

  • Dispatchers should instruct rescuers to provide CPR if the victim is unresponsive with no normal breathing, even when the victim demonstrates occasional gasps (Class I).

Suspected Opioid-Related Life-Threatening Emergency

  • For a patient with known or suspected opioid overdose who has a definite pulse but no normal breathing or only gasping (ie, a respiratory arrest), in addition to providing standard BLS care, it is reasonable for appropriately trained BLS health care providers to administer intramuscular or intranasal naloxone (Class IIa).
  • For patients in cardiac arrest, medication administration is ineffective without concomitant chest compressions to ensure drug delivery to the tissues. Thus naloxone administration may be considered after initiation of CPR if there is high suspicion for opioid overdose (Class IIb).
  • It is reasonable to provide opioid overdose response education with or without naloxone distribution to persons at risk for opioid overdose in any setting (Class IIa).

Chest Compression Rate

  • In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120 compressions per minute (Class IIa).

Chest Compression Depth

  • During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches (5 cm) for an average adult, while avoiding excessive chest compression depths (greater than 2.4 inches [6 cm]) (Class I).

Chest Wall Recoil

  • It is reasonable for rescuers to avoid leaning on the chest between compressions to allow full chest wall recoil for adults in cardiac arrest (Class IIa).

Minimizing Interruptions in Chest Compressions

  • In adult cardiac arrest, total preshock and postshock pauses in chest compressions should be as short as possible (Class I).
  • For adults in cardiac arrest receiving CPR without an advanced airway, it is reasonable to pause compressions for less than 10 seconds to deliver 2 breaths (Class IIa).
  • In adult cardiac arrest with an unprotected airway, it may be reasonable to perform CPR with the goal of keeping the chest compression fraction as high as possible, with a target of at least 60% (Class IIb).

Layperson: Compression-Only CPR Versus Conventional CPR

  • Dispatchers should instruct untrained lay rescuers to provide compression-only CPR for adults with sudden cardiac arrest (Class I).
  • Compression-only CPR is a reasonable alternative to conventional CPR in the adult cardiac arrest patient (Class IIa).
  • For trained rescuers, ventilation may be considered in addition to chest compressions for the adult in cardiac arrest (Class IIb).

Open the Airway: Lay Rescuer

  • For victims with suspected spinal injury, rescuers should initially use manual spinal motion restriction (eg, placing a hand on either side of the patient’s head to hold it still) rather than immobilization devices, because use of immobilization devices by lay rescuers may be harmful (Class III).

Bag-Mask Ventilation

  • As long as the patient does not have an advanced airway in place, rescuers should deliver cycles of 30 compressions and 2 breaths during CPR. The rescuer delivers breaths during pauses in compressions and delivers each breath over approximately 1 second (Class IIa).

Ventilation With an Advanced Airway

  • When the victim has an advanced airway in place during CPR, rescuers no longer need to deliver cycles of 30 compressions and 2 breaths (ie, they no longer need to interrupt compressions to deliver 2 breaths). Instead, it may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths per minute) while continuous chest compressions are being performed (Class IIb).

Passive Oxygen Versus Positive-Pressure Oxygen During CPR

  • We do not recommend the routine use of passive ventilation techniques during conventional CPR for adults, because the usefulness/effectiveness of these techniques is unknown (Class IIb).
  • In EMS systems that use bundles of care involving continuous chest compressions, the use of passive ventilation techniques may be considered as part of that bundle (Class IIb).

CPR Before Defibrillation

  • For witnessed adult cardiac arrest when an AED is immediately available, it is reasonable that the defibrillator be used as soon as possible (Class IIa).
  • For adults with unmonitored cardiac arrest or for whom an AED is not immediately available, it is reasonable that CPR be initiated while the defibrillator equipment is being retrieved and applied, and that defibrillation, if indicated, be attempted as soon as the device is ready for use (Class IIa).

Analysis of Rhythm During Compressions

  • There is insufficient evidence to recommend the use of artifact-filtering algorithms for analysis of ECG rhythm during CPR. Their use may be considered as part of a research program of if an EMS system has already incorporated ECG artifact-filtering algorithms in its resuscitation protocols (Class IIb).

Timing of Rhythm Check

  • It may be reasonable to immediately resume chest compressions after shock delivery for adults in cardiac arrest in any setting (Class IIb).

Chest Compression Feedback

  • It may be reasonable to use audiovisual feedback devices during CPR for real-time optimization of CPR performance (Class IIb).

The next section of this blog will address specifics in the area of adult advanced cardiovascular life support and ACS. If you want to read all the details and background, take a look at the Supplement to Circulation, volume 132, number 18, supplement 2, November 3, 2015.

See you in the streets!

 

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Navigate 2 Customer Satisfaction Survey [Results]

The results are in!

EMS and Fire students and instructors recently completed a comprehensive survey about their experience with Navigate 2. Check out the infographic below to see how Navigate 2 is working for them:

infographicnav2

 

Want to learn how Navigate 2 can work for you? Contact your Public Safety Specialist today.

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CPR, ECC, and First Aid Guidelines: Version 2015

cprstockBob Elling, MPA, EMT-P

(Part 1 of a 6-part series)

Introduction to the 2015 Guidelines Changes

If there is one thing we can rely on in the medical field, it is change. Because many of the treatments we provide are often being evaluated in scientific studies, it has come to be an expectation that evaluation of the evidence will help guide our practice. When I was in my initial paramedic course, the physician who taught us made this statement: “About a third of what you are learning will be considered wrong in 10 years. The problem is we do not know which third.” Most of us who have practiced for a few decades can see the truth in that statement.

At 5-year intervals, experts in resuscitation from across the world publish a consensus on what the science of resuscitation tells us. It is that publication, and the process that leads up to its development, that rolls out in the United States as the “Guidelines.” The resulting documents were recently published in two peer-reviewed journals.

Resuscitation and Circulation

As you know, major changes were made to CPR and ECC practices in the 2005 Guidelines. The emphasis turned to improving the quality of chest compressions and strengthening the links in the chain of survival in every community. These changes were reinforced in 2010. The 2015 version of the Guidelines has just been published. So what does the first half of 2016 have in store for us as these updates roll out?

The good news is that clearly those communities that have implemented the spirit of the 2010 Guidelines are on the right track and are seeing success in terms of lives saved. I would sum up the 2015 Guidelines as a combination of defining limits, emphasizing teamwork, and focusing on high quality.

Looking at the new Guidelines from a “10,000-foot level” my initial impressions are as follows:

  • There are not a lot of major changes, so incorporating the Guidelines into practice should be relatively “painless.”
  • Because ILCOR and AHA are both working on first aid guidelines, there are a number of recommendations in this topic area (ie, naloxone for overdose, glucose for hypoglycemia, assisting with a bronchodilator, giving ASA to heart attack patients, no more pressure points or elevation for bleeding control, no more occlusive dressings for open chest trauma, assessing for stroke, spinal motion restriction and no collar for laypersons).
  • There are now maximums on both the rate of compression (100 to 120) and the depth of compression (2 to 2.4 inches).
  • There is a difference between the links in the chain of survival for out-of-hospital care versus in-hospital care. In-hospital care now stresses prevention.
  • There is no longer any reason to carry vasopressin, because it has no advantage over epinephrine and should not be used in pregnant women.
  • Although TTM (targeted temperature management) post ROSC is a Class I intervention, it should be done in the hospital and not with cold IV fluid in the field.
  • Trendelenburg position is back for nontraumatic causes of shock.
  • The Guidelines state several times that the frequency of training should be more often than once every 2 years.

The ECSI team of authors and editors is working very hard to update its instructor network, and to update any and all of our materials so that everyone who uses our valuable products can continue to train students to save lives.

Over the next five segments of this blog series, many of the specific recommendations will be listed. These specific topics will be covered:

Part 2: Systems of Care and Continuous Quality Improvement

Part 3: Adult Advanced Cardiac Life Support and ACS

Part 4: Special Circumstances of Resuscitation

Part 5: Pediatric Basic and Advanced Life Support and Cardiopulmonary Resuscitation Quality

Part 6: First Aid

Each recommendation in the Guidelines has a “class of recommendation” that corresponds to the strength of the recommendation and the quality of the scientific evidence that backs up the recommendation. The classes include:

Class I: strong

Class IIa: moderate

Class IIb: weak

Class III: moderate and provides no benefit

Class III: strong and causes harm

It is important to note only topics that changed are listed. Note also that I have not listed the levels of evidence, ethical issues, alternative techniques and ancillary devices to CPR, education, and neonatal topics. If you want to read all the details and background, take a look at the Supplement to Circulation, volume 132, number 18, supplement 2, November 3, 2015.

See you in the streets!

 

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