Simon is a paramedic, crew chief, and public safety diver with the Pittsburgh Bureau of EMS. He also serves as a medical specialist on Pennsylvania USAR Strike Team 1, a contributing author for a variety of EMS platforms, a public speaker, and a harm reduction advocate.
The Pre-brief
A 56-year-old male called 911 and reported that he was experiencing shortness of breath. An EMS crew arrived on scene and found the male sitting in a recliner experiencing obvious respiratory distress. The patient was pale, diaphoretic, sitting in a tripod position, and was so dyspneic that he could barely speak. The patient said that he had been experiencing increasing shortness of breath throughout the day. He denied chest pain, fever, and cough. He had experienced similar symptoms previously but was unsure of the etiology. The patient’s heart rate was 135 beats per minute, his respiratory rate was 40 breaths per minute, his SaO2 was 73% on room air, and his blood pressure was 250/134 mmHg. There were audible rales present bilaterally upon auscultation of lung sounds. The treating crew suspected that the patient was likely suffering from acute pulmonary edema as a result of heart failure.
This patient is critically ill and common EMS practice would be to immediately place the patient on supplemental oxygen and then facilitate rapid transport to the hospital. In many cases when this occurs, aggressive medical intervention is deferred until the patient is secured in the back of the ambulance. Unfortunately, some patients experience cardiac arrest during that transition to transport phase. Research conducted by the Pittsburgh Bureau of EMS indicates that targeted intervention, known as a bundle of care, prior to patient movement substantially reduces the incidence of post-EMS contact cardiac arrest among a cohort of patients that include those who present with evidence of respiratory distress, medical shock, and altered mental status. Patients who have experienced a traumatic injury or other time-sensitive illnesses such as CVA or STEMI are excluded from this bundle. When the crashing patient’s bundle of care treatment paradigm was implemented throughout the system, the incidence of post-contact cardiac arrest was reduced from 12.1% to 5.8% (p = 0.025). In 2020 the bundle of care became a part of the Pennsylvania statewide ALS protocol.
The Crashing Patients Bundle of Care
The goal of the bundle of care is to prevent cardiorespiratory collapse and stabilize the patient prior to movement. It includes immediate application of supplemental oxygen, positive pressure ventilation, and BLS airway management as indicated. After that, all available monitoring should be applied including SaO2, waveform ETCO2, EKG, blood pressure, and blood glucose. IV access is a priority and for patients that are hypotensive, fluid resuscitation is prescient. For patients suffering from respiratory distress, early transition to CPAP is encouraged. Medications including epinephrine, albuterol, methylprednisolone, magnesium, and nitroglycerin should all be administered as indicated. If patients remain hypotensive after a 500cc fluid bolus then a vasopressor like an epinephrine or dopamine infusion should be administered. Patients that are experiencing clinically significant dysrhythmia, tachycardia, or bradycardia are treated using standard modalities prior to movement.
Case Conclusion
The patient was given sublingual nitroglycerin sprays (IV nitroglycerin was not available) and then placed on CPAP. IV access was established, all monitoring was applied, and a 12-lead EKG was obtained. Reassessment of the patient’s vitals showed a heart rate of 124 bpm (sinus tachycardia), a respiratory rate of 30 breaths per minute, an SPO2 of 94% on CPAP, an ETCO2 of 36 mmHg, a blood pressure of 230/130 mmHg, and the 12-lead EKG was non-diagnostic. The patient’s condition began to improve but he was still in distress. Additional sublingual nitroglycerin sprays were administered and then the patient was secured in a stairchair, extricated from the residence, placed on the waiting stretcher, and then placed in the ambulance. Throughout transport to the hospital, the CPAP and nitroglycerin therapy were continued, and the patient continued to improve. Shortly after arrival at the hospital, the patient was transitioned to low flow oxygen via nasal cannula as his respiratory distress had resolved. He was admitted to the hospital for observation and discharged home in good condition the following day.
The Debrief
- Rapid extrication and transport of critically ill medical patients are dogmatic in prehospital care. However, they are not supported by high-quality evidence.
- For some patients, rapid transport before stabilization may increase the likelihood of cardiac arrest and poor outcomes.
- A crashing patient bundle of care that prioritizes airway management, ventilation, and hemodynamic support prior to patient movement substantially reduces the incidence of post-EMS contact cardiac arrest.
- It may be challenging for clinicians, especially those who have been practicing for many years, to break old habits and make substantive changes to their practice. Successful implementation of a crashing patients bundle of care requires a great deal of simulation training as well as targeted education to increase knowledge and buy-in.
Reference
Pa ALS Protocol 3000. Available at http://pehsc.org/wp-content/uploads/2014/05/2020-PA-ALS-Protocols-Final_Updated_May-8-2020.pdf. Accessed: June 10, 2021.
