Critical Transport Decisions

This CE activity is approved by EMS World Magazine, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS) for 1 CEU. To take the CE test that accompanies this article, go to www.rapidce.com to take the test and immediately receive your CE credit. Questions? E-mail editor@EMSWorld.com.

Over the past decade emergency medical services have experienced a complete paradigm change. There was a time when the paramedic classroom clearly instructed students to never diagnose and not overthink their patients. Since its infancy in the 1970s, prehospital care has shifted from a mentality of “you call, we haul” to one where prehospital staff are medical professionals whose critical decisions have a real and profound impact on patient outcomes.

There has been a shift in recent years toward early recognition and intervention in time-sensitive emergencies. During a time-sensitive emergency, every moment counts, and proper early interventions can make a real difference. This article explores five time-sensitive emergencies: ST-segment elevation myocardial infarction (STEMI), cardiac arrest, stroke, trauma and sepsis, and discusses how prehospital patient care decisions and transport destinations can improve outcomes and save lives.

STEMI

Critical questions to ask:

• Does this patient have symptoms and a 12-lead EKG that meet STEMI criteria?

• Where is the closest PCI center?

• Can I get the patient to PCI within 60 minutes by ground? What about with a helicopter?

• Do I need to transmit the 12-lead EKG to activate the cath lab?

When presented with patients experiencing cardiac-related complaints (weakness, chest pain, nausea, etc.), the first decision that must be made is when to perform a 12-lead EKG. The American Heart Association recommends a national standard of within five minutes of patient contact; that means the 12-lead should be completed on scene, not en route to a hospital.

Delaying acquisition of a 12-lead EKG could mean beginning transport to an incorrect hospital. Patients experiencing STEMIs need either percutaneous coronary intervention (PCI) or IV fibrinolytics, an alternative when rapid PCI is not an option. Chris Granger, MD, chair of the AHA Mission: Lifeline project, recommends that if you can get a prehospital patient from first medical contact to balloon (E2B) within 90 minutes (allowing the hospital 30 minutes for procedure setup and completion), then transport directly to a hospital that permits paramedic activation of its cath lab. If the E2B time will exceed 90 minutes, then take the patient to the closest hospital that can administer fibrinolytics.¹

Transporting to an emergency department with the intent of transfer to a PCI center has inherent delays and is not in the patient’s best interest. One study of 8,680 STEMI patients found that when EMS transported to a non-PCI center, only 24% of patients received PCI within 120 minutes, but with transport directly to a prehospital-activated PCI center, 53% got it within 90 minutes.² Extending transport times by taking patients directly for PCI is not dangerous. Clear evidence shows that patients with suspected STEMI can safely bypass non-PCI centers. One study monitored 134 STEMI patients who were diverted past local EDs for PCI, their total transport time ranging from 36–57 minutes; only one patient developed complications (atrial flutter requiring intervention).³

We’ve learned that the hospital and prehospital sides of care cannot work independently on this. A 2013 study on door-to-balloon (D2B) times and hospital mortality found that despite a reduction in D2B time from 83 to 67 minutes, mortality only decreased from 4.8% to 4.7%.⁴ The commentary following this trial revealed that prehospital patient care times were not monitored and that time savings cannot happen solely in the hospital or outside it; rather, a joint effort is required to streamline times from first medical contact to balloon.

In recent years the measure of STEMI care has shifted from beginning at the hospital door to first medical contact. First medical contact is often prehospital providers. EMS (first medical contact)-to-balloon time has become the true measure of high-performing EMS systems. Comprehensive and integrated systems that promote rapid 12-lead EKGs and prehospital cath lab activation can consistently achieve E2B times of less than 90 minutes and D2B times under 30.⁵

Plan ahead to best manage the decisions surrounding STEMI care. Establish standard practices within the EMS system for when to perform 12-leads and to which PCI centers you’ll transport patients. Currently the largest debate around prehospital STEMI care is whether to have the prehospital 12-lead transmitted to the ED for physician review prior to cath lab activation. There is a true trade-off here; transmission will reduce false activations of the cath lab team; however, there can also be a delay in the team’s activation when the transmitted EKG is not immediately reviewed. Depending on how quickly a 12-lead is obtained by the physician, this delay could exceed 5–10 minutes. Currently most systems transmit 12-leads for confirmation, but several studies show paramedics can accurately interpret 12-leads up to 95% of the time.⁶ Further studies suggest that when blinded, paramedics and emergency physicians have similar accuracy.⁷ The question is ripe for further discussion and research.

Cardiac Arrest

Critical questions to ask:

• Do we resuscitate this patient on scene? Is there a good reason not to?

• Following ROSC, do we initiate cooling?

• Where is the closest cardiac arrest center with PCI capability?

The standard of cardiac arrest care no longer accepts routinely transporting patients while performing chest compressions. In January a presentation at the NAEMSP annual meeting highlighted the need for on-scene cardiac arrest care with data that showed that moving patients during cardiac arrest worsened CPR quality and the frequency of chest compressions.⁸ And data from North Carolina’s RACE CARS (Regional Approach to Cardiovascular Emergencies Cardiac Arrest Resuscitation System; https://racecars.dcri.duke.edu/) effort showed the use of on-scene “pit crew” approaches to CPR yielded a fivefold increase in ROSC and patients with meaningful neurologic discharge.

The decision to delay transport and try to resuscitate a patient on scene cannot be made by a single provider. Rather this process needs to be planned by the entire system so that all involved agencies, including the hospitals, are prepared to manage this change. Performing pit-crew cardiac arrest care can commit 5–7 providers to a single scene for 30–45 minutes or more. During a pit-crew resuscitation, every provider has their dedicated role. For example, two providers alternate chest compressions every two minutes, one person focuses on airway, one on the monitor, one prepares and administers drugs, and one records events and manages the family. The trick to a good pit-crew resuscitation is planning who will have each assigned role.

Once a patient is resuscitated, there are two critical decisions prehospital providers must make: if and when to begin therapeutic hypothermia, and to which hospital to transport. These decisions are made in conjunction. Beginning TH without a plan to move the patient to a hospital with hypothermia capability is dangerous. Cooling followed by uncontrolled rewarming can be detrimental. Planning a cardiac arrest destination coincides with the decision to initiate TH. It is imperative that the prehospital and hospital systems agree on which patients should receive cooling and how, because a hospital’s commitment to maintain TH is significant, with both staffing and equipment requirements.  

Optimized prehospital resuscitation is a key to ROSC as well as meaningful neurological outcomes. However, coordinated and well prepared in-hospital care is at least as important.⁹ A patient’s best opportunity for survival requires management by a multidisciplinary team including intensivists, neurologists, cardiologists and rehabilitation specialists. Developing a systems approach where survivors of out-of-hospital cardiac arrest are transported only to comprehensive cardiac arrest centers has been shown to improve patient outcomes.¹⁰

Often the cardiac arrest and STEMI receiving centers are one and the same. This isn’t by accident. Patients experiencing a ventricular fibrillation or pulseless ventricular tachycardia cardiac arrest may require cardiac catheterization, as coronary artery disease and STEMI are both common causes of these lethal dysrhythmias.

Stroke

Critical questions to ask:

• Does my patient have symptoms consistent with stroke?

• When were they last seen normal?

• Are they a candidate for fibrinolytics?

• Do I transport to the closest CT scan or go directly to a stroke center?

Each year nearly 800,000 U.S. citizens experience stroke, and the vast majority do not receive medical attention in time for early fibrinolytics to be considered. The symptoms of stroke are poorly communicated and often missed, even by prehospital professionals. A January 2014 study found that 50% of strokes are missed when prehospital professionals fail to perform a validated stroke scale.¹¹ While this study was of an EMS system that used the Cincinnati Prehospital Stroke Screen (CPSS), other validated stroke scales include the Los Angeles Prehospital Stroke Screen, the Miami Emergency Neurologic Deficit (MEND) exam and the gold standard, the National Institute of Health Stroke Scale (NIHSS).

Regardless of the stroke exam used, this study demonstrates that prehospital systems can do a better job screening for potential stroke patients. While the CPSS provides the most false-positive results, it is the easiest to perform. The MEND exam has a few more steps than the CPSS, which helps reduce false positives, and remains easier than the comprehensive NIHSS, which is often too difficult to perform in the prehospital setting.

When patients have a positive validated stroke exam, an immediate transport decision must be made. The most significant factor in determining an appropriate destination is establishing the time the patient was last seen normal. When this can’t be established or is known to exceed 4.5 hours, patients are unlikely to be candidates for rapid intervention, and initial transport to a local emergency department may be warranted. Time is brain when a patient is a potential candidate for fibronlytics; for every minute delay that occurs prior to tPA administration for ischemic stroke, up to two million neurons die.

Transport of the patient thought to be a candidate for fibrinolysis with tPA is a bit more controversial. Ultimately these patients have the best outcomes with care at a Joint Commission-accredited primary (or comprehensive) stroke center. However, the two most important interventions stroke patients require are a rapid CT scan followed by immediate tPA administration when it is indicated. The window for tPA administration is ideally within three hours of symptom onset but can be extended to 4.5 hours with some restrictions. The American Stroke Association recommends tPA administration within 60 minutes of arrival at the emergency department. When EMS systems and hospitals work together, plans can be established to alert EDs of stroke patients. With proper alerts, some systems have transporting EMS teams take stroke patients directly to CT scan prior to their ED bed. This rapid access helps save the patient time and neurons.

When transport to a primary stroke center is extended beyond 30 minutes, it may be reasonable to transport a patient to the closest CT-capable hospital that will administer tPA. Patients can then be transferred to a primary stroke center following tPA administration. The exact timing of when to divert for tPA versus transport directly to a primary stroke center has not been established. To help determine this in your system, work with your closest primary stroke center to develop a plan.

Trauma

Critical questions to ask:

• Does my patient have physiologic or anatomic injuries that require a trauma center?

• Does the mechanism of injury suggest I divert past the local hospital?

• Is there a special consideration indicating trauma center care?

• What is the best transport method to move the patient to definitive care?

Trauma is a significant cause of morbidity and mortality; more than 5.4 million injured people were transported via EMS in 2008 alone.¹² Once prehospital providers arrive on the scene of an accident, a lot is expected in a very short time. In addition to securing the scene and stabilizing the patient, providers must rapidly determine injury severity and determine whether to transport to a local emergency department or directly to a trauma center. Treating severely injured patients at a level 1 or 2 trauma center reduces mortality by 25%. Proper triage helps guide transport to an appropriate destination and saves the healthcare system money. The CDC’s 2006 field triage guidelines were shown to reduce overtriage and cut the costs of trauma center patient care by an average of $7,274, for an annual savings of $568 million.¹³

The field triage guidelines were last updated in 2011 and currently base the decision to transport directly to a trauma center on four criteria: physiologic, anatomic injury, mechanism of injury, and special considerations (Figure 1).¹⁴ The goal of the field triage criteria is to direct the more severely injured patients to a trauma center while referring the lesser-injured individuals to a community emergency department.

What exactly changed in 2011? There was an addition of the phrase need for ventilatory support to the respiratory rate of less than 10 or greater than 29 in the physiologic criteria. Three studies found patients with otherwise normal respiratory rates still required advanced airway management; these studies demonstrated the need for advanced airway placement was the strongest predictor of death or prolonged hospital stay.¹²

Two modifications occurred within the anatomical injury criteria. Pulseless extremities were added to the list of crushed, degloved or mangled extremities, as the loss of pulses in a single extremity indicates severe vascular injury, and circulation must be rapidly restored. Additionally, flail chest was modified to read chest wall instability or deformity (e.g., flail chest), as flail chest occurs in less than 1% of chest injuries. However, many chest injuries can cause instability likely to require trauma center care.¹²

One addition was made to the list of mechanisms of injury. Roof intrusion was added based on a study of pediatric trauma patients that found that each centimeter of roof intrusion increased the odds of major injury by 2.9%.¹²

For older adults a special statement was added to indicate that a systolic blood pressure less than 110 often represents shock in those 65 and older, and that ground-level falls can cause severe injury.

Two new emphases were placed on special populations. Patients with known or suspected head injuries who are taking anticoagulants or have known bleeding disorders benefit from direct transport to trauma centers, as they have a higher risk of intracranial hemorrhage and increased mortality rates.¹² Additionally special consideration should be given those over age 65, as they are prone to an undertriage rate of nearly 50%. As they age, less-severe mechanisms can cause these patients major injury, and a lower threshold for transporting the elderly to trauma centers is warranted.

When selecting a destination facility for trauma patients, the CDC guidelines are the gold standard. Use of these guidelines has been shown to reduce the burden of overtriage at trauma centers by 12% while reducing undertriage to 6%.¹⁵

Severe Sepsis

Critical questions to ask:

• Does my patient have an infection plus SIRS?

• Do they have hypotension or an elevated lactate level?

• How can I get antibiotics initiated within the next hour?

Severe sepsis is a time-sensitive emergency that kills more patients than stroke, STEMI or cancer and annually costs the U.S. healthcare system over $16 billlion.¹⁶ Unfortunately severe sepsis remains frequently unrecognized and poorly treated. Patients are diagnosed with sepsis when they have a known or strongly suspected infection plus any two criteria for systemic inflammatory response syndrome (SIRS):

• Heart rate greater than 90 bpm;

• Respiratory rate greater than 20 or pCO₂ less than 32 mmHg;

• White blood cell count greater than 12,000/mm³ or less than 4,000/mm³;

• Temperature greater than 100.4°F or less than 96.8°F.

When sepsis patients enter the hospital via EMS systems, prehospital providers have a true opportunity to improve both morbidity and mortality. You can read about about sepsis recognition and management in the May 2012 EMS World CE article “Managing Sepsis in the Adult Patient.” [www.emsworld.com/article/10685110] When you’re managing a patient you suspect to have sepsis or severe sepsis (Figure 2), consider transporting directly to a hospital with a Code Sepsis program that allows prehospital providers to provide a sepsis alert. Patients are diagnosed with severe sepsis when they meet the sepsis criteria and have either hypotension (SBP less than 100 mmHg) after 30 mL/kg of a crystalloid or a known venous lactate greater than 4 mmol/L.

Hospitals with a Code Sepsis program adhere to the Society of Critical Care Medicine’s Surviving Sepsis Campaign’s three- and six-hour sepsis treatment bundles and utilize a multidisciplinary team to manage patients with sepsis. Within the first three hours, a sepsis patient’s interventions are:

• Determine a baseline serum lactate;

• Obtain blood cultures;

• Administer broad-spectrum antibiotics (first hour);

• Administer 30 mL/kg crystalloid for hypotension (BP less than 100 systolic) or a serum venous lactate greater than 4 mmol/L.

Within the six hours patients should have:

• Vasopressors for hypotension unresponsive to fluids (Levophed is the drug of choice);

• ?Measured central venous pressure;

• Repeated venous lactate when baseline is greater than 4 mmol/L.

Work with a hospital that has a Code Sepsis program to permit prehospital notification of severe sepsis. If your patient has a suspected or known infection with SIRS, they have sepsis. If their blood pressure remains less than 100 systolic after fluids or you can determine they have a serum lactate greater than 4 mmol/L, you can diagnose them with severe sepsis. By alerting emergency departments of these patients, the EDs can rapidly obtain blood cultures and administer the first antibiotic. A one-hour delay in antibiotic administration decreases survival by 7%, and up to 50% of septic shock patients do not receive timely antibiotic administration.¹⁷

Several high-performing EMS systems (e.g., Denver’s HealthONE EMS and the Christiana Care Health System in Wilmington, DE) have implemented sepsis alert/Code Sepsis programs where local EDs are bypassed and patients are taken directly to hospitals prepared accept severe sepsis patients with immediate interventions. Only one program is known to have taken the step to bring antibiotics into the field. Within the next several years, prehospital antibiotic administration for severe sepsis patients may become more common; however, there are many hurdles to overcome before this can become a reality.

Summary

Time-sensitive emergencies require early recognition and rapid transport to a facility properly equipped to manage the patient’s needs. When managing STEMI, cardiac arrest, suspected stroke, trauma or a severe sepsis patient, use your resources smartly. Manage the patient using all of your capabilities on scene and know the destination best prepared to manage the patient upon ED arrival. When it makes sense to extend transport time to take a patient to a proper facility, it is OK to do so. Considering air medical transport for patients as ground transports exceed 30 minutes is reasonable as long as the flight team provides transport more rapidly or brings additional care that will improve patient outcomes.

References

1. Granger C. Presentation made at RACE CARS meeting, 10 April 2014, Lumberton NC.

2. Fosbol EL, Granger CB, Peterson ED, et al. Prehospital system delay in ST-segment elevation myocardial infarction care: a novel linkage of emergency medicine services and in hospital registry data. Am Heart J, 2013 Mar; 165(3): 363–70.

3. Cantor WJ, Hoogeveen P, Robert A, et al. Prehospital diagnosis and triage of ST-elevation myocardial infarction by paramedics without advanced care training. Am Heart J, 2012 Aug; 164(2): 201–6.

4. Menees DS, Peterson ED, Wang Y, et al. Door-to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med, 2013 Sep 5; 369(10): 901–9.

5. Rokos IC, French WJ, Koenig WJ, et al. Integration of pre-hospital electrocardiograms and ST-elevation myocardial infarction receiving center (SRC) networks: impact on door-to-balloon times across 10 independent regions. JACC Cardiovasc Interv, 2009 Apr; 2(4): 339–46.

6. Whitbread M, Leah V, Bell T, Coats TJ. Recognition of ST elevation by paramedics. Emerg Med J, 2002 Jan; 19(1): 66–7.

7. Feldman JA, Brinsfield K, Bernard S, White D, Maciejko T. Real-time paramedic compared with blinded physician identification of ST-segmentelevation myocardial infarction: results of an observational study. Am J Emerg Med, 2005 Jul; 23(4): 443–8.

8. Novak B. Preparing to move patients during resuscitation negatively impacts CPR quality. Reuters Health Information, 24 January 2014.

9. Nolan JP, Lyon RM, Sasson C, et al. Advances in the hospital management of patients following an out of hospital cardiac arrest. Heart, 2012 Aug; 98(16): 1,201–6.

10. Bosson N, Kaji AH, Niemann, JT, et al. Survival and neurologic outcome after out-of-hospital cardiac arrest: results one year after regionalization of post-cardiac arrest care in a large metropolitan area. Prehosp Emerg Care, 2014 Apr–Jun; 18(2): 217–23.

11. Gropen TI, Gokaldas R, Poleshuck R, et al. Factors related to the sensitivity of emergency medical service impression of stroke. Prehosp Emerg Care, 2014 Jan 24; e-pub ahead of print.

12. Sasser SM, Hunt RC, Faul M, et al. Guidelines for Field Triage of Injured Patients. MMWR, 2012 Jan 13; 61(RR01): 1–20.

13. Faul M, Wald MM, Sullivent EE, et al. Large cost savings realized from the 2006 Field Triage Guidelines: reduction in overtriage in U.S. trauma centers. Prehosp Emerg Care, 2012 Apr–Jun; 16(2): 222–9.

14. Centers for Disease Control and Prevention. Guidelines for the Field Triage of Injured Patients, www.cdc.gov/FieldTriage/.

15. Lerner EB, Shah MN, Swor RA, et al. Comparison of the 1999 and 2006 trauma triage guidelines: where do patients go? Prehosp Emerg Care, 2011 Jan–Mar; 15(1): 12–7.

16. Picard KM, O’Donoghue SC, Young-Kershaw DA, Russell KJ. Development and implementation of a multidisciplinary sepsis protocol. Crit Care Nurse, 2006 Jun; 26(3): 43–54.

17, Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med, 2006 Jun; 34(6): 1,589–96.

18. Mixon TA, Colato L. Impact of mode of transportation on time to treatment in patients transferred for primary percutaneous coronary intervention. J Emerg Med, 2014 Apr 16; e-pub ahead of print.

Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT, is performance improvement coordinator for AirLink/VitaLink in Wilmington, NC, and a lead instructor for Wilderness Medical Associates. E-mail kcollopy@colgatealumni.org.

Sean M. Kivlehan, MD, MPH, NREMT-P, is an emergency medicine resident at the University of California, San Francisco. E-mail sean.kivlehan@gmail.com.

Scott R. Snyder, BS, NREMT-P, is a faculty member at the Public Safety Training Center in the Emergency Care Program at Santa Rosa Junior College, CA. E-mail scottrsnyder@me.com.