EMS Protocol of the Week - Pulseless Electrical Activity (PEA) / Asystole (Adult)

Our specific cardiac arrest protocols are divided into two categories: VT/VF (the “shockable rhythms”) and PEA/Asystole (the “non-shockable” ones). The attached protocol for PEA/Asystole is probably the more common one our crews encounter prehospitally, and it’s worthwhile to know in order to better assist them over the OLMC phone when they call.

When paramedics arrive on the scene of a cardiac arrest and confirm the rhythm to be either PEA or asystole, their Standing Orders consist of continuing CPR, performing a needle decompression for suspected tension pneumothorax, obtaining an advanced airway (either endotracheal tube or supraglottic device) and intravascular access, administering D50 for hypoglycemia, and giving ACLS-dose epinephrine every 3-5 minutes. 

By the time medics call OLMC, they will have generally given a few doses of epinephrine, but they need physician approval to give sodium bicarbonate or calcium chloride, which are Medical Control Options (and as such are found under that section of the protocol). Why do you think this particular patient arrested? Hyperkalemia? TCA overdose? It might be worthwhile to administer one of those medications. Or do we think attempts at ROSC are futile? Maybe no medications are indicated, and we should instead consider Termination of Resuscitation (ToR). We’ll discuss ToR in a separate email, but these are the kinds of questions to consider when deciding whether to authorize a Medical Control Option.

That’s about it for PEA/asystole. What about the VF/VT arrests? Stay tuned til next week for the…shocking…conclusion!

Thank you, thank you. 

www.nycremsco.org and the protocols binder for more.

Dave

POTD: Mentorship

Some History:

The term mentorship is derived from Homer’s epic, The odyssey. Mentor was the name of a character that guided Telemachus on his journey to find his father Odysseus. Today a mentor means a wise and trusted counselor or teacher. Whether directly or indirectly, mentorship is pervasive in our culture and crucial to the advancement of society.

Mentorship is a key factor in promoting and maintaining fulfillment in medical practice. The mentor-mentee relationship benefits both parties in different ways. Mentors benefit from the altruistic success of helping others achieve their goals. Mentees benefit in the sense that they establish a person they can rely on for advice, suggestions, and coaching. Senior colleagues who share similar interests in clinical practice, research, administrative or community service serve as the best mentors. Mentors are role models who also act as guides for students and residents in both their personal and professional development.

 When should physicians start seeking out a mentor and how?

·       Mentors should be established early on in residency and even throughout medical school training when students find their niche and interests.

·       The best way to start a mentee-mentorship relationship is reach out to someone with a specific request that shares similar interests. These will naturally then develop into a mentorship.

·       Many national organizations (eg. EMRA) also offer mentorship and pair mentees with mentors of similar interests.

·       Establishing a mentor does not need to be a formal process many times this occurs informally

·       The best way to find a mentor is to find people you admire in your field or someone in a position that you might envision yourself in one day

 What qualities or traits should mentees look for in a mentor?

·  Find a mentor who you feel you can connect with and will inspire you and support you throughout your journey

·  A mentor should be someone that can celebrate you as an individual during the best of times and someone that can also help you overcome roadblocks

·  The key to mentorship is feeling comfortable with your mentor

 Can you only have one mentor or is it ok to have multiple mentors?

· It is good to have a few mentors as each mentor will likely have their own expertise. For example someone that is a great clinical mentor may be different then someone you may want to approach to help mentor you in research vs someone who can help guide your career path

 What is the Mentees role?

·      Mentees should take initiative in driving their relationships with mentors.

·      Be proactive around scheduling meetings and identifying topics of discussion with your mentor

·      The ability to critique oneself and make changes on the basis of advice and probing from a mentor is important to a mentee’s development

 Want to get involved in Mentorship here are a few places you can sign up to be a mentor for medical students:

·      https://medicalmentor.org/join-us/

·      https://www.emra.org/students/advising-resources/student-resident-mentorship-program/

“ A good mentor is a tremendous asset in this complex profession, so search for one. Once you have found one, cherish his or her time and wisdom. Mentors, in addition to teaching through words and deeds, show us care and respect and empower us to confidently approach the myriad complications inherent to the human condition.” Dr. Ahmed Mian

Go out there and find your mentors!

Sources:

·      https://www.nejmcareercenter.org/article/physician-mentorship-why-it-s-important-and-how-to-find-and-sustain-relationships-/

·      https://pubmed.ncbi.nlm.nih.gov/29691796/

·      https://www.jacr.org/article/S1546-1440(10)00385-6/pdf

·      https://www.prospectivedoctor.com/the-importance-of-mentorship/

·      https://www.prospectivedoctor.com/the-importance-of-mentorship/

POTD: Blunt Cerebrovascular Injury

Todays POTD will be a trauma topic we frequently talked about at Shock Trauma but less frequently at Maimo.

 Blunt Cerebrovascular injury (BCVI): refers to a spectrum of injuries to the cervical carotid and vertebral arteries secondary to blunt trauma.

 Why is this Important?

If left untreated, patients with BCVI are at increased risk for stroke. Mortality may reach as high as 43%. Rare diagnosis which makes it even more important to consider evaluating for in all of your trauma patients that meet criteria and have the associated risk factors .

 Pathology:

The injury is caused by longitudinal stretching and injury to the vessels. Acceleration and deceleration can cause rotation and hyperextension of the neck, stressing the craniocervical vessels. This will lead to disruption of the intima. The intima tear then becomes a source of platelet aggregation that has a potential to cause downstream effects such as an embolic stroke or vessel occlusion

 Risk Factors:

·      High energy transfer mechanisms

·      LeFort II or III fractures

·      Mandibular fractures

·      Complex skull fracture/basilar skull fracture/occipital condyle fracture (most common risk facture)

·      Closed head injury with GCS < 6

·      Cervical spine fracture, subluxation, or ligamentous injury at any level

·      Near hanging with anoxic brain injury

·      Clothesline type injury or seat belt abrasion with significant swelling, pain, or AMS

·      Traumatic brain injury with thoracic injuries

·      Scalp degloving

·      Blunt cardiac rupture

·      Upper rib fractures

 Signs/Symptoms:

·      Arterial hemorrhage from neck/nose/mouth

·      Cervical bruit in patient < 50 years old

·      Expanding cervical hematoma

·      Focal neurologic defect

·      Neurologic defect inconsistent with CT head findings

·      Stroke on CT or MRI

 Diagnostics:

• ·      Standard of care CTA (80% sensitive and 97% specific)

• Should be considered when patient has one or more of the risk factors or signs and symptoms

• ·      Can also do MRI or arteriography but this is time consuming and labor intensive

 Grading Scale:

1.     Grade 1: Intimal irregularity or dissection < 25 % of luminal narrowing noted

2.     Grade 2: Dissection or intraluminal hematoma with > 25% luminal narrowing, intraluminal clot or visible intimal flap

3.     Grade 3: Pseudoaneurysm

4.     Grade 4: Complete occlusion

5.     Grade 5: Transection with active extravasation

 Management:

·       Antithrombotics (heparin) or Antiplatelets (aspirin, Plavix) 

·       Operative repair

·       Endovascular stenting

·       Grade 1 and 2 injuries: single antiplatlet agent (aspirin 81 or 325mg)

·       Grade 3: dual antiplatelets or therapeutic anticoagulation (heparin drip with PTT at goal)

·       Grade 4 and above: Dual antiplatelets or therapeutic anticoagulation as well as operative or endovascular intervention

·       Many low grade injuries heal within 7-10 days therefore early repeat CTA is recommended. Otherwise treatment may need to be continued for 3-6 months.

 References:

·      https://www.emra.org/emresident/article/blunt-cerebrovascular-injury/

·      https://rebelem.com/blunt-cerebrovascular-injury-bcvi-universal-imaging-for-all/

·      https://jss.amegroups.com/article/view/3790/html

·      https://radiopaedia.org/articles/blunt-cerebrovascular-injury?lang=us

·      https://www.east.org/education-career-development/practice-management-guidelines/details/blunt-cerebrovascular-injury

·      https://www.aliem.com/guideline-review-east-blunt-cerebrovascular-injury/