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PERFORMANCE BENCHMARKS EMS Sepsis Alert At Christiana Care Health Systems in New Castle County, DE, mortality from severe sepsis dropped from 61.7% to 30.2% after institution of an in-hospital sepsis alert program.1 Patients who arrived at Christiana with ALS ambulances met early goal-directed therapy (EGDT) objectives faster than patients who arrived on their own. Interestingly, it took more time to meet treatment goals in patients transported by BLS ambulances.2 Now New Castle County paramedics have a sepsis protocol and are equipped with lactate meters. A venous lactate test is indicated for patients who have a suspected infection, high or low temperature, pulse above 90 or respiratory rate above 20. This covers a large number of patients, and the lactate reading helps identify which of them are likely to decompensate before they start to look sick. Based on this information, paramedics now request a sepsis alert, which triggers a hospital response similar to ones for STEMIs and strokes. For sepsis patients, early recognition, antibiotics and aggressive fluid resuscitation save lives. Preliminary data shows the estimated time saved from prehospital lactate is 98 minutes, and that prehospital sepsis alerts have cut the time to antibiotics in half. REFERENCES 1. Whitehead S. Sepsis alert: recognition and treatment of a common killer. EMS World, www.emsworld.com/ article/10319536. 2. Shiuh T, Sweeney T, Reed J. Effect of arrival mode to the emergency department on time to early goal-directed therapy of the septic patient. Prehosp Emerg Care, 2010 Jan; 14(Suppl1): 5. the benefts of this are not seen while EMS has contact with patients, its impact on their hospital course is signifcant. If someone feels like they are breathing through a straw, supplemental oxygen alone does not make it easier. Nebulized bronchodilators and/or CPAP are needed for this. Knowing how common respiratory distress is, and how much of an impact early EMS care has on its outcome, patients deserve an EMS system that can deliver those treatments when needed. Seizures Seizures are another common problem encountered by EMS. Status epilepticus, which is a seizure lasting more than 30 minutes or multiple seizures without a lucid interval in between, has been shown to cause permanent brain damage and increased mortality. There has been a recent push to change that defnition to any seizure lasting longer than fve minutes.16 Up to one third of these patients are either actively seizing on EMS arrival or have a seizure in the presence of EMS.1 In addition to checking seizing patients' blood sugar, the 2008 Eagles benchmark paper recommends giving them a benzodiazepine medication. Of every four patients given lorazepam or diazepam, one will have their seizure terminated.1 Since that report, 40 JUNE 2013 | EMSWORLD.com midazolam delivered with an intramuscular auto injector has also been shown to be effective at stopping seizures.17 This may make seizure medication available to more responder levels. Although most seizure patients do not require medication from EMS, the Medical Priority Dispatch System has not been shown to reliably determine which ones do. Under the telephone triage system, a BLS response is indicated for patients whose seizure has stopped and breathing is verifed.18 In one study, this group of patients received an ALS medication just as often as others who were believed to have prolonged seizures. Based on this data, and with seizure medication only available from ALS units, the authors recommended that ALS be sent on all seizure calls.18 Knowing how dangerous prolonged seizures are and how effective EMS treatment is for them, shouldn't at least one person on scene be capable of delivering medication to stop them on every seizure call? If a patient remains actively seizing during transport and does not receive medication, no matter how close the hospital is, his or her EMS system has failed. Sedation Combative patients present a threat to themselves, bystanders and the people who respond to help them. Causes include drug overdoses, alcohol intoxication and psychiatric conditions. Sometimes combativeness is caused by excited delirium, a life-threatening condition in which agitated patients are irrational, violent and immune to pain. Patients who do not respond to verbal de-escalation techniques or whose combativeness is not caused by a correctable medical condition need to be restrained before transport. A number of problems have been found with physical restraint. It can worsen agitation, and patients risk injury from fghting against it. In cases of excited delirium, sudden death can occur during physical control measures. To reduce the risk of sudden death, a white paper published by the American College of Emergency Physicians recommends physical restraint from law enforcement be combined with immediate sedative medical interventions by EMS.19 Agitated patients may also display unusual physical strength and be immune to pain, so providers risk being injured if they break free. Chemical restraint, used with or instead of physical restraint, can mitigate these problems. The same benzodiazepines used for seizures can be used for chemical restraint, along with antipsychotic medications such as haloperidol (Haldol), droperidol (Inapsine) and ziprasidone (Geodon). The dissociative agent ketamine is also effective for agitated patients, has a faster onset than other agents when given intramuscularly and has the fewest side effects.19 Why do we fght with people when safe chemicals are so readily available to sedate them? Soft restraints can be found on every ambulance, but medications for sedation are restricted to ALS units. Why do we place ourselves in enclosed spaces with violent patients who resist physical restraints? Since any patient has the potential to become combative, shouldn't at least one provider be capable of administering these medications on every call? When something bad happens with a combative patient, to us or to them, is there any excuse for not having sedatives available? For everyone's safety, medications for sedation should be given to any patient who requires physical restraint.