EMS World

FEB 2017

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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Page 42 of 51

42 FEBRUARY 2017 | EMSWORLD.com as well. As the RV struggles to overcome the pressure in the pulmonary vasculature, the right atrium will overfill too, limiting incoming flow from the IVC. This causes the IVC to become distended, with little to no variation in diameter on respiration. If these findings weren't enough on their own, an embolus may even be found float- ing in the RV. While there are no readily available field treatments for pulmonary embolism, obtain- ing this information can help with transport decisions. This is a case where rapid trans- port to a hospital would be appropriate, as you know no field treatment will fix this patient. Better yet, the ability to reliably diagnose pulmonary embolism may lead to the adoption of better field treatments, such as tPA. A recent study administered a small dose of tPA to patients in cardiac arrest sec- ondary to pulmonary embolism. No bleeding complications were noted, and 87% of these patients were alive two years later and had returned to their normal lifestyle with no disability. 6 Though this was only one study and more investigation is needed, low-dose tPA shows enormous potential for this typi- cally lethal condition. Rhythm Confirmation In addition to pathology, POCUS can be used to verify rhythms. This may seem like a party trick—after all, asystole is asystole, right? In the age of POCUS, it may not be quite that simple. Multiple trials and case studies have discovered a new phenomenon: cardiac wall motion during apparent elec- trical asystole. This is such a new discov- ery that the publication of a recent study identifying this phenomenon was delayed, as reviewers did not believe the data could be correct. Studies have revealed a 10%–35% occur- rence of cardiac motion in asystole. 4,7 It is not unreasonable to suspect many of our asystolic patients are not receiving indicated treatments, including defibrillation. Conclusion Point-of-care ultrasound represents the next frontier in improving prehospital care in many ways, but the treatment of cardiac arrest perhaps has the most to gain from its adoption. We are rapidly approaching the point where we are maximizing our exist- ing resources and methods. To continue to improve, we must be open-minded and willing to examine new diagnostics and treatments so we can give our patients the care they deserve. R E F E R E N C E S 1. Argula RG, Negi SI, Banchs J, Yusuf SW. Role of a 12-lead electrocardiogram in the diagnosis of cardiac tamponade as diagnosed by transthoracic echocardiography in patients with malignant pericardial ef fusion. Clin Cardiol, 2015 Mar; 38(3): 139–44. 2. Tasci O, Hatipoglu ON, Cagli B, Ermis V. Sonography of the chest using linear-array versus sector transducers: Correlation with auscultation, chest radiography, and computed tomography. J Clin Ultrasound, 2016 Jul 8; 44(6): 383–9. 3. American Heart Association. 2015 Guidelines for CPR & ECC, https://eccguidelines.heart.org. 4. Breitkreutz R, Price S, Steiger HV, et al.; Emergency Ultrasound Working Group of the Johann Wolfgang Goethe-University Hospital, Frankfurt am Main. Focused echocardiographic evaluation in life support and peri- resuscitation of emergency patients: a prospective trial. Resuscitation, 2010 Nov; 81(11): 1,527–33. 5. Hess EP, Campbell RL, White RD. Epidemiology, trends, and outcome of out-of-hospital cardiac arrest of non-cardiac origin. Resuscitation, 2007 Feb; 72(2): 200–6. 6. Sharifi M, Berger J, Beeston P, et al.; "PEAPET T" investigators. Pulseless electrical activity in pulmonary embolism treated with thrombolysis (from the "PEAPET T" study). Am J Emerg Med, 2016 Oct; 34(10): 1,963–7. 7. Gaspari R, Weekes A, Adhikari S, et al. Emergency department point-of-care ultrasound in out-of-hospital and in- ED cardiac arrest. Resuscitation, 2016 Dec; 109: 33–9. A B O U T T H E A U T H O R Branden Miesemer, NRP, FP-C, is a flight paramedic in the Midwestern United States and an adjunct paramedicine instructor for several local colleges. He is an advocate for leveraging technology and social media to provide low-cost, cutting-edge medical education and training. Follow him online at EMSPOCUS.com, Facebook.com/emspocus and on Twitter at @emspocus. Next month: Advanced applications for the future, including stroke diagnosis and treatment, noninvasive intracranial pressure monitoring and nerve blocks. Download a pdf of Prehospital Ultrasound in Action at EMSWorld.com/12251451. TABLE 1: CAUSES OF CARDIAC ARREST AND TYPICAL DIAGNOSTIC METHOD 3 H's Hypoxia—Treated by standard CPR/ ACLS treatment; Hypovolemia—Patient history; Hydrogen ion—Requires point-of-care testing; Hypo-/hyperkalemia—Requires history, point-of-care testing or EKG findings; Hypothermia—Body temperature. T's Toxins—Patient history; Tamponade, cardiac—Beck's triad, electrical alternans (sensitivity of 23%); 1 Tension pneumothorax—Absent lung sounds (sensitivity of 50%); 2 Thrombosis, pulmonary—History, low EtCO 2 ; Thrombosis, coronary—EKG findings.

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