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Patient Care

The Top 5 Papers of 2016: #4

Every year, three EMS experts take to the stage at the National Association of EMS Physicians annual conference to sum up the top five research articles of the previous year. Their goal? Identify research that is relevant, counter-intuitive and practice changing—research that is important to the patients who call 9-1-1 with the expectation that they will be served with the best available care possible. This year, paramedic and emergency room resident Blair Bigham describes the articles he and co-experts Drs. Jon Rittenberger and Michael Millin selected.

The Case of the Infected Man

The Case: A 41-year-old man who is being treated with chemotherapy (Cisplatin, last received 8 days ago) for prostate cancer calls 9-1-1 because he has a fever of 102ºF. His heart rate is 122, his respiratory rate is 24, his oxygen saturation is 98% on room air, and his blood pressure is 100/40. He complains of dysuria (increased frequency, pain on urination, weak stream), but history and physical are otherwise unremarkable. Paramedics initiate transport to a local emergency department, where they are placed in a holding area because there are no available beds. Two hours later, paramedics recheck his vital signs. He is now difficult to rouse, has a respiratory rate of 40, heart rate of 145, and blood pressure of 80/30. The triage nurse is updated and he is placed in a resuscitation room. Despite receiving antibiotics and fluid, he dies five hours later.

The Evidence:

  • Smyth MA, Brace-McDonnell SJ, Perkins GD. Identification of adults with sepsis in the prehospital environment: A systematic review. BMJ Open 2016
  • Walchok JG, Pirrallo RG, Furmanek D, Lutz M, Shope C, Giles B, Gue G, Dix A. Paramedic-initiated CMS sepsis core measure bundle prior to hospital arrival: A stepwise approach. Prehosp Emerg Care, 2016 Dec 5:1–10.

There are more cases of sepsis attended to by paramedics than cardiac arrest. Seeing how sepsis care is time-sensitive, as are STEMI, stroke and trauma, it seems logical that paramedics play a larger role in sepsis care. A systematic review identified 9 low-quality studies and 0 high-quality studies that compared various tools to screen for and identify sepsis. The performance of the tools was highly variable:

  • Sensitivity (the ability of the tool to rule out sepsis): 0.2 to 0.93
  • Specificity (the ability of the tool to rule in sepsis): 0.14 to 0.94
  • Positive Predictive Value (the ability to the rule to predict people who are septic): 0.2 to 0.63

Two tools, the MEWS score and the PRESEP score, had the best performance and used variables entirely available to prehospital teams. qSOFA, a 3-component score recently shown to predict death in patients with septic shock, performed poorly in new research presented in January, as did traditional score SIRS. Mortality is estimated at 37% for those patients transported by ambulance who are diagnosed with sepsis in the emergency department.

In a second study, a retrospective case series study evaluated paramedic management of septic patients. Paramedics were trained to identify septic patients using a screening tool, and then complete four tasks if positive (sepsis bundle administered by paramedics):

  1. Alert the receiving hospital;
  2. Obtain IV access, draw blood cultures and lactate specimens;
  3. Administer IV antibiotics (ceftriaxone or piperacillin/tazobactam);
  4. Initiate a crystalloid fluid bolus of 30cc/kg to a max of 1000cc.

Results:

  • 2.05% of all EMS transports got “Sepsis Alert”
  • 1 in 3 from a healthcare facility
  • 74% admitted with sepsis
  • 94% treated as sepsis by ED physician
  • 13% had a prehospital lactate >4
  • Blood cultures were positive in 19%, contaminated in 5%
  • Antibiotics were effective against cultured organisms 72% of the time

The Bottom Line: Sepsis is a life-threatening inflammatory response to infection that requires rapid treatment. It is well known that meeting recommended timelines for the treatments of septic shock is difficult. Paramedics play a critical role in identifying patients with sepsis and seem capable of initiating time sensitive therapies like fluid boluses and antibiotic therapy. Large research trials are currently underway to better understand how best to improve paramedic recognition and treatment of sepsis.

After a decade working as a helicopter paramedic, Blair Bigham, MD, MSC, ACPF, completed medical school in Ontario, Canada, where he is now a resident physician in the emergency department. He has authored over 30 scientific articles, led major national projects to advance prehospital research and participated in multiple collaboratives, including the Resuscitation Outcomes Consortium. He has taught and mentored clinical and academic paramedics and loves his new role teaching medical students. He serves as a volunteer on the board of directors for the MedicAlert Foundation of Canada and is a task force member for the International Liaison Committee on Resuscitation. 

Michael Millin is a board certified EM and EMS physician from Baltimore, MD. He is a member of the faculty of the Johns Hopkins University School of Medicine and medical director of the Johns Hopkins Lifeline critical care transport program. He is also medical director for the BWI Airport Fire and Rescue Department, Maryland Search and Rescue, and associate medical dDirector for the Prince George’s County Fire/EMS Department.

Jon Rittenberger, MD, is an associate professor of emergency medicine and medical command physician for UPMC Prehospital Care. In addition to his emergency medicine practice, he is a founding member of the Post Cardiac Arrest Service at UPMC Presbyterian hospital. His research interest is in brain resuscitation during critical illness states. He brings over 20 years of EMS experience as a provider and researcher.

 

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