December 2, 2024

For years, the ask has been to create a crush injury protocol to add to our collection of protocol tools. In Paramedic school, most of us were trained that sodium bicarbonate was indicated in these cases. National EMS models list the considerations for its use, as do many other best practices. What has been lacking is any clear timing for its use. A crush with subsequent immediate release is unlikely to need this intervention in the field. Conversely, a patient with prolonged entrapment would likely benefit from the bicarbonate, but when? 

In the hospitals, this need is trended with lab work, triggering the use of bicarbonate. In the field, we do not have these indicators. Our regional Medical Directors have decided with the best available information that the 2-hour mark seems a reasonable time to expect these levels to require intervention with sodium bicarbonate.

Although we've focused on this in our training and it has a place, if it’s late in the event, it's not the mainstay of EMS treatment for these cases. IV fluids are the answer to the pollution caused by the crushed skeletal muscle cells. This simple treatment helps ensure kidney perfusion while diluting the nephrotoxic myoglobin released from the crush.  

In addition to nephrotoxic myoglobin, these patients are at risk for cardiotoxic hyperkalemia to develop. Despite the delayed use of sodium bicarbonate in crush, if there is ever evidence of hyperkalemia during the care of a crush (or any patient for that matter), then the patient should be immediately treated with albuterol (if no advanced airway is in place), calcium, and sodium bicarbonate per the hyperkalemia protocol. Recall the hyperkalemia EKG changes that EMS can pick up on: bradycardia, widening QRS, and peaked T waves in any combination or alone. For this reason, continuous cardiac monitoring, as well as frequent serial 12 lead EKGs are required during on-scene care and transport.  

What does all this look like?  

• Standard of Care Trauma Interventions 

• 1 liter fluid bolus then TKO, unless there is hypotension 

• Continuous cardiac monitoring with serial 12 lead EKGs every 30 minutes minimum 

• Placement of a tourniquet if not already done on any crushed or entrapped extremities in preparation for any bleeding after release 

If entrapped for greater than 2 hours, then 1 mEq/kg up to 100 mEq per dose q 30 minutes.

While none of these treatments are revolutionary, having them in one place should help EMS providers better manage these cases. 

Thank you,

Scott Wildenheim, Paramedic

Decmeber 9, 2024

Protocol Revisions for 2025: ECPR Protocol Addition 

Throughout this year, there have been multiple EMS educational pieces provided by UH EMS regarding ECPR, or extracorporeal membrane oxygenation (ECMO) CPR, including the Monthly CE and the November episode of the UH Prehospital Paradigm Podcast. This exciting new option for the management of patients in refractory VF/VT who have not responded to initial EMS interventions offers a chance of survival to patients who otherwise may not have had options. In addition, it is expected that the Cleveland Clinic Main Campus will come online as an ECPR center early in 2025. With two centers expected in the greater Cleveland area, and hopefully more to come, it was time to formalize a protocol for this new process. 

The reality is that there are few changes in prehospital therapeutic care in the ECPR paradigm. What is needed is early identification of candidates, then prompt transport after initial on-scene CPR and defibrillation. This starkly contrasts previous teachings and protocols that encourage the arrest to be worked on the scene.  

• Patients who are 18-70 years old who are not a DNR, a chronic patient at a long-term care facility, or have a terminal diagnosis: 

• With an initial VF/VT rhythm 

• Automated CPR device in place 

• Capnography >10 

• And within a 30-minute transport time to the ECPR center  

• Should be considered for ECPR

Early notification is key to making this work. Much like stroke, STEMI, and trauma, there aren’t providers standing around waiting for these patients. The multidisciplinary ECPR team must be mobilized from many places within the hospital. The earlier the notification, the quicker the patient may be put “on pump,” and the better the outcomes. 

Since only the timing is changed, not necessarily the clinical care for EMS, the existing VF/VT protocol was revised with the ECPR criteria. The protocol was reworded to Ventricular Fibrillation Pulseless Ventricular Tachycardia for ECPR Departments to accommodate these changes. Departments whose Medical Directors have informed them to follow this new protocol will use this for cases where patients are included in ECPR but continue to follow the traditional Ventricular Fibrillation Pulseless Ventricular protocol in cases that are excluded.  

The hope is that with the addition of the other center in Cleveland and increased EMS participation, more lives can be saved with this novel therapy.

Thank you,

Scott Wildenheim, Paramedic

December 16, 2024

This month in our Monday Morning Medical Director's Message, we have been reviewing some of the changes that will be a part of the 2025 Prehospital Care Protocol and Treatment Guidelines. In our October EMS Continuing Education Classes, we addressed sexual assault and strangulation. From those classes and feedback from you, we have added the Child / Adult / Elder – Domestic Violence / Sexual Assault / Trafficking policy to the 2025 Protocol. Below is an article from October from Dr. Stephine Gaines on strangulation / domestic violence. This article also contains the Strangulation Assessment Card that will be found in the 2025 Protocol.

Strangulation is one of the most dangerous and lethal forms of interpersonal violence. Research shows that, for a victim who is strangled just once, they are 10 times more likely to die at the hands of their perpetrator. That’s why in April of 2023, the state of Ohio reclassified strangulation as a felony crime due to its severe implications and its strong correlation with future lethal domestic violence incidents.  

Strangulation is a form of asphyxia characterized by the closure of the blood vessels and/or airways by external pressure applied to the neck. It is a form of assault commonly used in intimate partner violence because it instills fear and control over the victim conveying the message, “I am so powerful that I can easily kill you by simply using the strength of my hands.” Despite being a common act, it, unfortunately, is often minimized and underreported due to the lack of visible injuries and even victims failing to realize the seriousness of the act.

Patients don’t usually disclose being strangled but may report being “choked,” seeing stars, blacking out, or often stating they were scared they were going to die. While there are different ways for strangulation to occur, most often (83%) strangulation is done manually where the assailant uses their hands to squeeze the neck. It doesn't take much force on the neck to inflict serious injuries. Only about 4.5 lbs of pressure is needed to obstruct the jugular veins to cause cerebral hypoxia and render someone unconscious in just a few seconds. If strangulation persists, brain death can occur in about 4-5 minutes. 

Intimate partner violence is a prevalent public health problem, and we must maintain a high index of suspicion, especially in patients with less obvious complaints or if their injury pattern doesn’t fit the picture of their story. Remember that strangulation is a significant predictor of future lethal violence, and it is something we should screen for and view as a sentinel event. Ask respectful, but direct questions about patient safety. It may be an opportunity for intervention and to potentially save a life. 

See below for the Strangulation Assessment Card that will appear in the 2025 Protocol.

Keep up the great work!

Stephanie Gaines, MD

December 23, 2024

In this week’s Monday Morning Medical Director's Message, we would like to review another change that will be a part of the 2025 Prehospital Care Protocol and Treatment Guidelines. In our September EMS Continuing Education Classes, as well as her Monday Morning Medical Director's article below, Dr. Regina Yaskey discussed what a BRUE, or Brief Resolved Unexplained Events, is in an infant and how to manage those patients. Please take a moment to read the article below and review the addition of BRUE in the 2025 Protocol. 

Good morning, everyone. Pediatric topics are back this month, starting with Brief Resolved Unexplained Event (BRUE). A BRUE is an event occurring in an infant less than one (1) year of age. The observer usually reports a sudden, brief and now-resolved episode of one or more of the following: 

1. Cyanosis 

2. Absent, decreased or irregular breathing 

3. Marked change in tone (hyper-or hypotonia) 

4. Altered level of responsiveness 

BRUEs are diagnosed after a history and physical examination fails to find an explanation for the event. It is important to note that BRUEs have replaced the term ALTE (Apparent Life-Threatening Event). ALTE was defined as a symptom rather than a diagnosis. Studies found that ALTEs gave the connotation that these events were benign and not “life-threatening.” 

Evaluation of BRUE: 

Low-Risk Category 

• Infant > 60 days of age 

• Gestational age ≥ 32 weeks and post conceptual age ≥ 45 weeks 

• Event lasted < 1 minute 

• No previous BRUEs 

• No need for CPR by a trained medical provider during the event 

• No family history of sudden cardiac death 

• No concerning medical or social history 

• No concerning features that indicate an underlying etiological condition 

High-Risk Category 

• Any of the lower risk criteria not met 

• Age ≦ 60 days 

• Gestational age <32 weeks and post-conceptual age ≦ 45 weeks 

• CPR done by a trained provider 

• Event lasted ≥ 1 minute in duration 

• Second, cluster or recurrent events 

• Concerning history e.g., family history of sudden cardiac death, concern for social, feeding or respiratory problems

Please remember that BRUEs are a diagnosis of exclusion. With that in mind, see below a list of diagnoses categorized by systems that should be on your differential for BRUEs.  

• Upper and Lower respiratory infections 

• Bronchiolitis, pertussis, pneumonia can cause apnea 

• Hematologic  

• Sepsis 

• Neurological  

• Meningitis, Seizures, Infantile botulism 

• Gastrointestinal 

• Gastroesophageal reflux  

• Cardiac 

• Prolonged QT syndrome, dysthymia 

• Endocrine 

• Metabolic disorders, electrolyte imbalance 

• Trauma  

• Child abuse 

Obtain a complete history and physical examination when evaluating these patients. DO NOT BE FOOLED BY THE PATIENT’S WELL APPEARANCE...always perform a detailed history and physical exam.  

In the prehospital setting, we recommended obtaining vital signs, 12 lead electrocardiogram, brief pulse oximetry monitoring with serial observations, and a D-stick. Remember that a history of BRUE may be the first sign of child abuse (head and other physical trauma, suffocation, Munchausen by proxy). Have a high index of suspicion when interviewing caregivers about social history concerning child abuse.  

BRUE should be suspected when there is no explanation for a qualifying event after conducting an appropriate history and physical examination. All infants ≦ 12 months of age with possible BRUE should be transported by EMS for further medical evaluation. If the family refuses transportation, please contact Medical Command for further instructions.

Have a great week and thank you for all the great work,

Regina Yaskey, MD.