CPR for Trauma Victims; Reporting Errors; Appropriate Furosemide

Prehospital CPR for Trauma Victims

Willis CD, Cameron PA, Bernard SA, Fitzgerald M. Cardiopulmonary resuscitation after traumatic cardiac arrest is not always futile. Injury, Jan 19, 2006.

Abstract: The use of guidelines regarding the termination or withholding of cardiopulmonary resuscitation (CPR) in traumatic cardiac arrest patients remains controversial. This study aimed to describe the outcomes for victims of penetrating and blunt trauma who received prehospital CPR. Methods-Authors conducted a retrospective review of a statewide major trauma registry using data from 2001-04. Subjects suffered penetrating or blunt trauma, received CPR in the field by paramedics and were transported to the hospital. Demographics, vital signs, injury severity, prehospital time, length of stay and mortality data were collected and analyzed. Results-Eighty-nine patients met inclusion criteria. Eighty percent of these were blunt-trauma victims, with a mortality rate of 97%, while penetrating-trauma patients had a mortality rate of 89%. The overall mortality rate was 95%. Sixty-six percent of patients had a length of stay less than one day. Four patients survived to discharge, of whom two had penetrating and two had blunt injuries. Hypoxia and electrical injury were probable associated causes of two cardiac arrests seen in survivors of blunt injury. Conclusions-While only a small number of penetrating- and blunt-trauma patients receiving CPR survived to discharge, this therapy is not always futile. Prehospital emergency personnel need to be aware of possible hypoxic and electrical causes for cardiac arrest appearing in combination with traumatic injuries.

Comment: Most of us who have been in EMS awhile begin to wonder if performing CPR on patients after traumatic cardiac arrest is at all useful. This study shows us that a few of these patients do survive. Penetrating-trauma patients were more likely to do so, but even blunt-injury patients could survive. EMS systems should examine their field determination-of-death policies and improve education to be certain these patients get resuscitation efforts.

Identification and Reporting of Errors
Hobgood C, Bowen JB, Brice JH, et al. Do EMS personnel identify, report and disclose medical errors? Prehosp Emerg Care 10(1):21-7, Jan-Mar 2006.

Abstract: Using a two-part instrument, the authors surveyed a convenience sample of prehospital providers attending a statewide emergency medical services conference. Part 1 evaluated respondent demographics and actual practice patterns. Part 2 used hypothetic scenarios to assess error identification, disclosure and reporting patterns. Descriptive statistics and Fisher's exact tests (to determine nonrandom associations between variables) were used to characterize demographics and practice patterns. For hypothetical scenarios, the authors calculated mean responses with 95% confidence intervals (CIs) to assess error identification, and anticipated disclosure and reporting patterns. Results-The response rate was 88% (372/425). Analysis was limited to 283 (75% of 372) respondents who were emergency medical technicians and had complete data. In the previous year, 157 providers (55%) identified no errors in practice, 100 (35%) reported one or two errors, and 26 (9%) identified more than two errors. In approximately half of cases, identified errors were reported to the receiving provider or supervisor. In hypothetical cases, severe errors were identified 93% of the time (95% CI, 92-94), but the ability of providers to identify mild errors significantly varied. In all scenarios, respondents were much more likely to report errors to the receiving hospital, their supervisor and their medical director than to patients. Conclusions-Prehospital providers demonstrate the capacity to identify, report and, to a lesser extent, disclose errors in hypothetical scenarios, but may not apply these skills uniformly in their own practices. Enhancing error-management skills in prehospital clinical practice will require focused education and training.

Comment: Quality improvement systems rely upon the accurate and complete reporting of errors to be effective. By carefully examining error rates, types and consequences, we can design training, systems and safeguards to reduce them. Many industries, from auto manufacturers to aircraft pilots, have designed processes that encourage the reporting of errors. Hospitals and emergency departments are beginning to improve their mechanisms and procedures as well. This article accurately points out that there is room for improvement in EMS. It is only by recognizing the value of and actively participating in the process that EMS QI systems will be able to reduce medical errors and improve patient safety and outcomes.

Appropriate Use of Furosemide
Jaronik J, Mikkelson P, Fales W, Overton DT. Evaluation of prehospital use of furosemide in patients with respiratory distress. Prehosp Emerg Care 10(2):194-7, Apr-Jun 2006.

Abstract: All patients over 18 years old receiving prehospital furosemide were retrospectively identified, and cases were matched to subsequent hospital records. Data collected included ED and hospital primary and secondary diagnoses, brain-type natriuretic peptide (BNP) levels and final disposition. Furosemide was considered appropriate when the primary or secondary ED or hospital diagnoses included congestive heart failure (CHF) or pulmonary edema, or the BNP was greater than 400. Furosemide was considered inappropriate when none of the diagnoses included CHF, when the BNP was less than 200 or when an order for IV fluid hydration was given. Furosemide was considered potentially harmful when the diagnoses included sepsis, dehydration or pneumonia without a diagnosis of CHF or BNP greater than 400. Results-Of the 144 included patients, a primary or secondary diagnosis of CHF was reported in 42% and 17%, respectively. The initial BNP was greater than 400 in 44% of the 120 patients for whom this lab test was obtained. Sixty patients (42%) did not receive a diagnosis of CHF, 30 patients (25%) had BNPs less than 200, and 33 (23%) had orders for IV fluid hydration. A diagnosis of sepsis, dehydration or pneumonia without a diagnosis of CHF or a BNP greater than 400 occurred in 17% of patients. Seven of the nine deaths did not receive a diagnosis of CHF. Furosemide was considered appropriate in 58%, inappropriate in 42% and potentially harmful in 17% of patients. Conclusions-In this EMS system, prehospital furosemide was frequently administered to patients in whom its use was considered inappropriate, and not uncommonly to patients when it was considered potentially harmful. EMS systems should reconsider the appropriateness of prehospital diuretic use.

Comment: Furosemide (Lasix) was at one time considered an essential part of the treatment of congestive heart failure with pulmonary edema, and was routinely given in high doses as the primary treatment. More recently it has become less important, and in many EMS systems it is used rarely, if at all. CPAP and nitroglycerin are now emphasized, and have largely replaced Lasix and morphine. The field diagnosis of CHF is often difficult and, with limited history and no x-ray or lab capability, can often be impossible. This study is consistent with previous ones: Lasix is given inappropriately in a large percentage of patients. With its high likelihood of potential harm and limited benefit even when given correctly, EMS systems should consider restricting the use of Lasix to very select patients.