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We'll have several different sections reporting in - recent research, local topics, or highlighting areas of the Sponsor Hospital Council of Greater Bridgeport protocols.

*** Keep in mind - this website does not replace your protocols, and these posts do not reflect SHCGB or Bridgeport Hospital policies. This is a place to discuss research, controversies, or discuss possible future protocols. When in doubt, check your current protocols through the official source.

Wednesday, September 28, 2011

Prehospital sepsis - new research

Sometimes, it can be pretty discouraging to keep up on the EMS literature. Seems like everytime you hear of a new study, it’s showing that something that EMS does is either harmful, or just doesn’t matter. 

MAST, pediatric intubation, ACLS drugs, IV fluids for penetrating trauma – it’s enough to make a proud medic hang up her laryngoscope. 

This is no longer the standard of care?!
In a nice change of pace, a couple recent studies point out the value of EMS in treating sepsis, an area that hasn’t had much emphasis in EMS education and protocols in the past. Even better – the results show that EMS is probably making a difference, even without trying!

These recent publications tie in with a patient that AMR brought us in Bridgeport recently. The paramedic called med control, looking for some advice. He was bringing in an older gentleman from an ECF, and he was reasoning out some antiarrhythmic therapy. We talked on the radio some about the rhythm, but the most important thing he got across to me was that this guy was sick looking. That’s enough for me, and I met them at the door and we got things rolling. Fever, hypoxia, altered mental status, nonsustained VT – yep, he was sick! Three liters of NS and 3 antibiotics later, the ICU team was wondering what all the fuss was about.

Of course, if EMS hadn’t identified this guy, he might have slipped through triage, as his vital signs looked OK at the moment he came through there. We would have noticed when his pressure or sat dropped, but we would have been behind at that point, delaying his antibiotics and fluids for some time. 

One recent paper, hot off the presses, may illustrate the benefit of EMS in cases like this. 

The folks at U Penn wanted to see how EMS was affecting the care of these kinds of patients. They already had a bunch of data on the severe septic patients they were treating in their ED, and so they examined the records to see which of them were brought in by EMS.

What they found was that EMS only brought in 41% of the bad sepsis players. Of course, they were sicker than the 59% that came in by other means. The EMS patients were older, had higher initial lactate levels, and higher APACHE II score (rating system for critical illness). The EMS patients were also far more likely to be African-American, which usually predicts worse outcomes, no matter what ailment you’re talking about.

The two critical interventions in the treatment of sepsis are IV fluids and antibiotics, and the EMS patients got these in the ED about 40 minutes sooner than the “walk-ins.” That’s pretty big, considering that, in the ED, we're scrambling to get the antibiotics in within the first hour! 

No, they couldn’t show that EMS was saving any lives, but this study wasn’t designed to show that. But that really isn't the point either. Nowhere in the paper do they describe any specific education that EMS had, any QI process, or any change in protocols. EMS was just doin' what they was doin'.

Well, okay, maybe this isn't a big deal. We all know that using EMS is a great way to skip the line at triage if the long wait at the ED bothers you. Heck, maybe toe pain gets seen faster if it comes in by EMS. Is there any evidence that having a conscious EMT in the back of the rig changes anything?

In 2010 year there was another paper that showed similar findings, and added some others. 

The first author is hiding his paramedic roots.
The ED at Carolinas Medical Center looked at a similar group of ED patients, bad sepsis, and wanted to see if the people who came in by EMS got fluids and bug juice sooner than non-EMS arrivals. 

Just like the first paper, the EMS patients were a sicker bunch, but they got treated sooner. Interestingly, they had the same approximate differences in time to treatment – 40 minutes – that the U Penn group found.

The really neat thing about Studnek's paper was that the researchers also checked to see what the prehospital providers had written on their run-sheets. If the medics wrote the word “sepsis” somewhere in their impression, it turns out that the times in the ED for those patients were even better. Those EMS-identified patients got their antibiotics about 50 minutes earlier, and had resuscitation started an hour earlier! Again, just as in the preceding study, the researchers made no mention of any specific EMS sepsis protocol or pre-arrival alerts.

I'm fascinated by the results of these investigations.

For example, why would a medic record an impression for “sepsis” if there weren’t a corresponding protocol or pre-arrival alert? I'm imagining an analogous study: picture a system where the EMTs received basically no education on heart problems, angina, MIs - nothing.
As in, pre-Johnny and Roy
What if we then looked at the patients who had STEMIs, and then went to check if arriving by ambulance affected the door-to-ballon times? Furthermore, what if the patients who had a prehospital diagnosis of "heart trouble" got the cath lab even faster? That's kind of what is going on in these studies.

This is the benefit, I believe, of having educated and aggresive prehospital providers. The results above don't seem to reflect any new QI project or protocols. However, I think that Basics and medics are often at their best when they are “off protocol.” The medic who brought in my septic patient was calling med control to discuss treatment for salvos and runs of VT, but he was really calling in to tell me he had a “sick-as-something” patient.

Of course, we don’t have a “SAS alert,” but he was doing what he could with the system we’ve set up. When I was a resident up in New Haven, I had a medic call in a STEMI alert. When we looked at the ECG, however, it certainly did not meet any of the standard criteria for an activation. Looking at the patient, however, he certainly met classic SAS definitions – sweating, pale, cold, screaming in pain. A closer look at the ECG showed a classic left-main occlusion pattern. The medic had never heard of this rare pattern, but he knew that the ECG had some ugly things on it, and that the guy was circling the drain.
Bridgeport, I'm calling in with a CTD alert.
The potential for EMS to be involved in the care of sepsis is huge. Jeez, look at how much effort we’ve put into cardiac arrest, and for what? We might be just as well off with taxis and AEDs! (Insert a winking emoticon here…) 

Sepsis is a whole new area for EMS to show its worth, to make a difference. There is going to be more research on this; findings ways to identify septic patients in the field, start interventions, calling alerts.

One request in the meantime, though: Just don’t call in any SAS alerts for now!

***Late breaking*** 
Dug up this study, buried deep in the JEMS website:
 Decreasing Blood Lactate Levels in EMS Patients
By T. Ryan Mayfield, MS, NREMT-P; & Mary Meyers, MHA, EMT-P

Research has shown that clearance of blood lactate is associated with better outcomes in patients with severe sepsis and septic shock. One of the primary treatments of these patients is administration of IV fluids. This study looked at blood lactate levels before and after EMS treatment to determine if there was a significant change.
There will be a change in blood lactate levels between EMS and hospital lactate levels.
Paramedics were provided with and given training on the Lactate Pro blood lactate meter by Arkray Inc. This meter is FDA-approved and CLIA waived, and has shown a good correlation to hospital lactate tests. Between May 1, 2009, and Sept. 15, 2010, 134 patients with suspected severe sepsis or septic shock underwent blood lactate readings by EMS. Patients with a lactate reading of ≥ 4.0 mg/dL were considered to be in shock regardless of their corresponding blood pressure. Treatment was not dictated by this study and was administered according to EMS protocols.
: Of the 134 patients, 120 had hospital lactate levels available for comparison. Overall, hospital lactate levels were lower after EMS treatment. EMS patients were divided into groups that received greater than 1000 mL of fluid between readings (Group A), and patients who received between 250 mL and 1000 mL (Group B). Group A had a median decrease of 2.25 mg/dL (p = 0.0003) while Group B had a decrease of 1.1 mg/dL (p < 0.0001). Analysis used the Wilcoxon-Rank Sum Test.
There was a significant decrease in lactate levels associated with EMS treatment. Further, the group that received greater amounts of IV fluids had an even larger drop in lactate levels. These results illustrate the importance of EMS treatment and how it might impact patient outcomes. Further research and training needs to be done to expand the role of lactate in EMS, as well as reinforcing the importance of fluid administration to these patients.

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