EMS World

AUG 2018

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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EMSWORLD.com | AUGUST 2018 33 paramedics to truly dif ferentiate many patients' shock states in the prehospital environment. In the past the ability of paramedics to dif ferentiate shocked patients wa s deemed less important than simply rap- idly transpor ting them to a hospital for resuscitation. Today we know that even transient episodes of severe hypoten- sion lead to a significantly increa sed risk of end-organ damage and resultant morbidit y. 1 These patients require and deser ve aggressive resuscitation in the field from astute clinician paramedics to optimize their hemodynamics—not just large fluid boluses and a fast ride to a hospital. Our ability to provide that level of care requires more than a good histor y and physical and knowledge of shock physiol- ogy. It requires a special set of skills and tools to uncover the underlying cause of the patient's shock and develop an effec- tive resuscitation plan to address it. The Role of POCUS P o i n t- o f- c a r e u l t r a s o n o g r a p h y, o r POCUS, ha s evolved over the la st 20 years to become a mainstay of emergen- cy department diagnosis and treatment. Whether assessing obstetric patients, visualizing abdominal bleeding, or guid- ing invasive procedures, the practice of emergency medicine continues to find new, innovati ve applications for this technology. A more recent development, however, is the migration of POCUS from the emer- gency depar tment into the prehospital setting. While as of 2014 North American EMS agencies had an ultrasound adop- tion rate of only 4%, 2 there are indica- tions that many progressive EMS agen- cies are rapidly coming to use POCUS as par t of their standard practice. This change has been so rapid that just this year, the nation's first universit y-level POCUS course designed specifically for prehospital providers debuted at the Vir- ginia Commonwealth University School of Medicine. 3 What makes POCUS such an attractive technology for agencies, and how could it be useful in the hands of paramedics? What a RUSH To u n d e r s t a n d t h e a p p l i c at i o n s o f POCUS in shock, let's revisit the patient we discussed earlier. This is a patient in undif ferentiated shock; she ha s no obvious trauma, she's afebrile and has no obvious por tal of infection, and the husband doesn't articulate any thing that sounds like a cardiac histor y. We know she is hemodynamically unstable and near-arrest, but we have no idea why. While ever y area and agency has its own set of treatment guidelines and pro- tocols, without a true differentiation of the patient's shock, most would direct the provider to initially give a sizable fluid challenge and reassess. And while this strategy is safe for many patients, it may cause deleterious effects in many others. The safest way to approach resuscitat- ing the undifferentiated patient is to first correct, or attempt to correct, immediate life threats, then deploy POCUS to guide medical decision-making. While there are many published tech- niques and exam protocols to a ssess critically ill patient s, the most preva- le nt p roto co l is k n ow n a s th e rapid ultrasound in shock and hypotension, or ISSUE FOCUS: ADVANCED CARE EMS agencies are rapidly embracing the use of ultrasound. (Photos: Thomas Hudson)

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