DNR—Do Not Resuscitate

Greetings-

We will review our Do Not Resuscitate (DNR protocol) during this month’s lecture. It is an effort to provide end of life wishes for our patients, and the Ohio DNR law is the only law that encompasses EMS. The EMS providers need a valid state DNR form to honor a DNR; most providers have experienced a scene in which a family reports a patient is DNR, but no form can be found, or the form presented is not completed.  

When a patient can no longer express their wishes and a form is not available, basic CPR should be started. The providers need to contact medical control and have the online physician provide online directions. The decision maker in these situations, in descending order, is:

· The POA medical

· Spouse

· Children

The online physician can discuss the situation with the patient’s advocate and make the patient DNR online. If the patient is deemed DNR, CPR should be stopped, and the DOA (Dead on Arrival) protocol should be followed. 

The two choices on the Ohio DNR form are the DNRCC and the DNRCC Arrest. The DNRCC Arrest activates only in the event of cardiopulmonary arrest and the DNRCC Arrest patient should be treated like any other patient, which includes transfers and full protocol-level care until cardiopulmonary arrest. The DNRCC patient has some very specific dos and don’ts.

The DNRCC is always in place and represents care for a terminally ill patient. Care that can be provided for DNRCC:

· Suction the Airway

· Administer Oxygen, including CPAP and Bipap

· Position for comfort

· Splint or immobilize

· Control bleeding

· Provide pain medication

· Contact other providers to help guide care(Hospice, oncologist, home health care, or primary physician)

Care that can not be provided for DNRCC:

· Administer chest compressions

· Insert artificial airway

· Administer resuscitative medication

· Defibrillate or cardiovert

· Provide respiratory assistance

· Initiate resuscitative IV

· Initiate cardiac monitoring

The Ohio State DNR Law guides our pre-hospital providers in a clear direction on how to provide this respectful care. As always, thank you for all of your care and the empathy provided to these patients.

Sincerely, 

Don Spaner, MD  

Seizures - September 11, 2023

Prehospital Seizure Management

Prehospital providers across the country frequently encounter seizure disorders. An estimated 3.4 million people have active epilepsy nationwide, or 1.2% of the US population. Seizures can be simple, where the patient is still conscious, or complex, where the patient is unconscious. In addition, seizures may be focal, only involving one part of the body, or generalized, which involves the entire body. They can start as simple or focal, then progress to a complex generalized seizure. Patients can even have an absence seizure, which consists of staring spells, more common in the pediatric population.

Aside from having underlying epilepsy, seizures are caused by many things, including, but not limited to the following:

• hypoglycemia

• head trauma

• hypoxia

• electrolyte disturbances

• liver/kidney failure

• drugs

• alcohol withdrawal

• medication toxicity

• stroke

• brain tumors

• eclampsia

• hyperthermia

• infection

Assessment of the patient should also involve looking for these possible causes, especially in a patient without a prior history of seizures. Fingerstick glucose measurements should be performed for all seizure patients to rule out hypoglycemia as the underlying cause. In addition to seizures, syncopal episodes may appear similar to seizures and even involve shaking. Most often, these are short-lived, and the patient returns to baseline very quickly.

When encountering an actively seizing patient, the initial steps should emphasize the ABCs. It initially includes positioning, suctioning the airway, and monitoring to ensure adequate ventilation and decrease the risk of aspiration or injury. In some cases, further airway management may be required, such as utilizing a Bag-Valve Mask, nasopharyngeal airway adjuncts, or advanced airways.

Most seizures resolve spontaneously within a few minutes. If this occurs and the patient is in a post-ictal state, only supportive care is indicated. If not, further intervention will be required. Prehospital treatment is mainly limited to Benzodiazepine medications or Benzos. The most seen benzos are Midazolam (Versed) and Lorazepam (Ativan). Intramuscular Midazolam has become the most common first line in EMS since the 2012 research study;RAMPART Trial, which showed IM Midazolam to be more effective in stopping seizures and quicker to administer than IV Lorazepam. In addition, another study shortly after demonstrated that Midazolam does not degrade during storage in the prehospital environment, whereas Lorazepam had significant cellular degradation after 60 days, especially in hot conditions. Consequently, prehospital first-line usage of IM Midazolam rose from around 26% in 2010 to 62% in 2014 and continues to be the more popular choice.

While most EMS agencies will preferentially carry Midazolam, it is important to be comfortable with dosages of both medications. Medication shortages, and cost changes, are always possible, so you may find yourself with either medication as your only available Benzo. In the UH protocol, the Midazolam adult dosage is 2.5 mg IV/IO or 5 mg IM or intranasal with an atomizer. The dosage of Lorazepam is 1-2 mg for any route of administration.

In some instances, the patient may continue to seize or have additional seizure episodes after medication administration. These patients may require re-dosing of medications. Consider calling for medical command help for these patients whose seizures may be resistant or difficult to control. In addition, patients may have received a Benzodiazepine medication prior to medical arrival. Some seizure patients, especially pediatrics, may be prescribed rescue medications such as rectal Diazepam or newer intranasal Diazepam (Valtoco) devices. If given by family prior to your arrival, you may still treat the patient with your additional Benzo dose if warranted.

For pediatrics, the dosage is weight-based. Midazolam pediatric dosage is 0.1 mg/kg IV or IO (max 2 mg) or 0.2 mg/kg IM or IN (max 5 mg). For Lorazepam, the peds dosage is 0.05 to 0.1 mg/kg (max 2 mg) for all routes of administration. Pediatric patients can also have febrile seizures, which are seizures brought on by fevers. This can occur even with viral illnesses and often self-resolves or can be managed by cooling and treating the fever. Once the fever is treated, the patient will often not have any repeated seizures. These episodes may be very frightening for parents but do not come with an increased risk of seizures later in life, so parental reassurance is important.

While seizures can have varied presentations and causes, remembering the basics of recognition and treatment, as well as medication dosages, will help improve resolution and stabilization of these patients.

Frank Forde, MD

Sources:

Center for Disease Control and Prevention. (2020, September 30). Epilepsy Data and Statistics. https://www.cdc.gov/epilepsy/data/index.html

Lado FA, Moshé SL. How do seizures stop? Epilepsia. 2008;49(10):1651-1664. doi:10.1111/j.1528-1167.2008.01669.x

Silbergleit R, et al. "Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus". The New England Journal of Medicine. 2012. 366(7):591-600.

McMullan JT, Pinnawin A, Jones E, et al. The 60-day temperature-dependent degradation of midazolam and Lorazepam in the prehospital environment. Prehosp Emerg Care. 2013;17(1):1-7. doi:10.3109/10903127.2012.722177

Management of Dialysis Patients - September 18, 2023

Management of Dialysis Patients and Common Complications

There are over 660,000 kidney failure patients in the US; about 470,000 are on dialysis. In addition, Renal failure can develop for many different reasons, most commonly secondary to uncontrolled diabetes and/or hypertension. Other causes include autoimmune and inflammatory diseases, congenital disorders, and glomerular disorders.

Patients who progress to end-stage renal disease, or ESRD, will need dialysis to filter their blood. There are two types of dialysis, hemodialysis, and peritoneal dialysis, with hemodialysis being about 10 times more common. Peritoneal dialysis involves an exchange of abdominal fluid through a catheter to achieve filtration of blood waste products. It is often done at home. Hemodialysis, on the other hand, is mostly performed at dialysis centers and usually on a 3 time per week schedule, with each session lasting around 4 hours. During these sessions, the patient’s blood is filtered through a dialysis machine, allowing filtration and removal of waste products, then returned to the patient’s circulatory volume.

During dialysis, fluid and electrolyte shifts occur, which can cause problems. Hypotension may be noticed, causing dizziness or even syncope, but usually, this is transient. In addition to fluids, the shift of electrolytes can also cause symptoms like headaches, malaise, and even altered mental status. It also may be transient but sometimes will need to be corrected in the hospital if it persists.

Patients can receive hemodialysis via several modes of access. Some patients may have arteriovenous fistulas or grafts in the arm, allowing easy access to both arterial blood and venous return. Others may have indwelling subclavian or femoral catheters. Any indwelling catheters are always at risk of infection, which may quickly progress to sepsis. In addition, the regular gathering of multiple patients at dialysis increases the transmission of infections, especially during the COVID-19 pandemic. For these reasons, fevers and suspected infections in these patients are treated aggressively.

For patients with AV fistulas or grafts, bleeding is a possible complication after hemodialysis access. Due to the high pressure of these access sites, arterial flow is involved,  so hemostatic control is often difficult to achieve. Direct pressure is the most effective technique, but it may take time for bleeding to be controlled. Tourniquets are often ineffective and can damage the fistula or graft site.

Patients who miss dialysis can be at risk for severe complications, including hyperkalemia and fluid overload. Without dialysis sessions to remove excess fluid, patients can develop pulmonary edema, leading to respiratory distress. It can be managed similarly to other pulmonary edema patients, with oxygen and positive pressure as needed. Extra fluid volume can also accumulate in other spaces, leading to pericardial or pleural effusions.

Elevated potassium can lead to lethal ventricular arrhythmias and, needs to be quickly recognized and treated. The main signs of hyperkalemia in the prehospital setting are ECG changes. Large, peaked T waves are usually the first changes seen. As potassium levels rise, there is a loss of p waves and a widening of the QRS duration (>120 ms). If untreated, this can progress to a sinusoidal wave pattern, followed by cardiac arrest. If recognized appropriately, there are a few tools to help temporize hyperkalemia. Calcium, which stabilizes cardiac myocytes, should be given if ECG changes are consistent with hyperkalemia. It can act quickly to help prevent further cardiac rhythm deterioration. Albuterol nebulizers, as well as IV sodium bicarbonate, can also be given, which both help to shift potassium back into cells and out of the blood volume. All of these options should be used for suspected hyperkalemia. They can help prevent lethal arrhythmias until the patient can get definitive management, usually in the form of emergent hemodialysis.

Another possible complication of both missed dialysis or acute renal failure is uremic encephalopathy. Urea nitrogen is a normal waste product in the body that is filtered and removed by the kidneys. When the kidneys are not working properly, this waste product can build up to toxic levels, a condition called uremia. In addition to nonspecific symptoms like nausea/vomiting and fatigue, uremia can cause altered mental status. It can be anything from mild cognitive impairment to unresponsiveness. Until diagnosed with labs in the hospital, it can often be mistaken for other problems like stroke, traumatic brain injury, or alcohol/drug intoxication. It is important to remember this cause of altered mental status in patients who are at risk, especially those dependent on dialysis.

With a high likelihood of encountering dialysis patients on your runs, it’s important to be well aware of potential complications and ready to provide appropriate management in the prehospital setting.

Frank Forde, MD

Source:

National Institute of Diabetes and Digestive and Kidney Diseases (2016). Kidney Disease Statistics for the United States. https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease

Stroke Recognition and Assessment - September 25, 2023

Stroke Recognition and Assessment

Each year, about 795,000 people have a stroke in the United States.1 Stroke is a leading cause of death and disability, so it is paramount for all prehospital providers to be proficient at recognizing and managing these patients. For any patient with concern for stroke or altered mental status, it is important to first assess for immediate life threats, including assessment of ABCs and vital signs. Blood glucose should also be part of your initial assessment for these patients. Don’t forget the basics.

When examining the patient, there are many validated prehospital screening tools used when assessing for stroke.  The Cincinnati Prehospital Stroke Scale is one of the most widely used scoring tools and part of the UH Protocol. During initial assessment for suspected stroke, it is very important to gather essential history, including symptom onset and last known normal, as this will help guide possible interventions. Other information like medical history, any baseline neurologic deficits, recent trauma or surgeries, or use of anticoagulation medications may also be crucial for stroke management.

For Cincinnati-positive patients, it is important to screen for a large vessel occlusion or LVO, which is a blockage of one of the large arteries of the brain. Identification of LVO is vital, as these patients may be candidates for mechanical thrombectomy. This procedure can be done up to 24 hours after the last known well, providing a valuable treatment option for LVO patients, who often would otherwise be left with severely disabling symptoms. Only certain hospitals have thrombectomy capabilities, so rapid identification is important for deciding the appropriate destination and helping the ED team decide on specific imaging tests and possible patient transfer.

For the UH protocol, we utilize the VAN assessment for this purpose: Vison, Aphasia, and Neglect, which are the three components of the test. First, assess for arm drift. If absent, the test is negative, and no further assessment is needed. If the patient does have unilateral arm drift, continue to the other parts of the VAN. Vision assessment will be positive if the patient has double vision, a field cut, or loss of vision. Aphasia exam includes either expressive or receptive aphasia. Neglect refers to forced gaze, ignoring one side of the body, or unable to feel both sides at the same time. If any of these three parts are positive, then the VAN exam is positive.2,3

One stroke type involving the posterior circulation presents differently and is commonly missed by most stroke assessment tools. The patient may complain of being unable to walk normally and falling to one side. Ataxia is the main sign of posterior stroke, which can be assessed by having the patient do the finger-to-nose and heel-to-shin testing for each side. If either of these cannot be done easily, then ataxia is likely concerning for posterior stroke.

In addition to ischemic strokes, both traumatic and atraumatic intracranial hemorrhage can present similarly. There are many other stroke mimics as well, the most common is hypoglycemia, so it is essential to check blood glucose on all patients with stroke-like symptoms or altered mental status.

In addition, patients may experience similar symptoms during a post-ictal phase after seizures. It is called Todd’s Paralysis, which is temporary and resolves along with the post-ictal period. Similarly, some patients with complex migraine headaches may experience transient neurologic deficits along with their migraines. Both situations can cause patients to experience symptoms like a stroke and are often clinically indistinguishable in the prehospital environment. It is always safest to assume it could be a stroke and act accordingly. Obtaining this additional history of seizure or history of similar symptoms with migraine headaches can be very important to pass on to the emergency department providers to aid in proper diagnosis. 

While stroke is a complex disease, recognition is the most important thing for prehospital care. Remember to assess for immediate life threats, look for hypoglycemia, and perform the Cincinnati Prehospital Stroke Scale. Then, if positive, assess VAN + ataxia. Additionally, the important history will assist the next providers in caring for the patient. By completing these steps effectively and efficiently, prehospital providers can provide excellent care for all stroke patients.

Frank Forde, MD

References:

“Stroke Facts”. Centers for Disease Control and Prevention. https://www.cdc.gov/stroke/facts.htm

Swaminathan, A. 17 May 2018. “The VAN Assessment to Identify Large Vessel Occlusion Stroke”. https://coreem.net/journal-reviews/the-van-assessment/

Teleb, M. https://strokevan.com/