Five Research-Based EMS Practices for BLS Units
EMS providers do not generally consider themselves academic researchers. We take training classes, follow protocols, and in many cases do what we’ve always done. If we want to be considered clinicians and not just technicians, it behooves EMS providers, especially BLS providers, to stay current on research that provides evidence for new practices. In all cases, of course, follow your protocols and discuss any questions with your medical director.
Practice #1—Having patients with nausea sniff isopropyl (rubbing) alcohol is as effective as, or more effective than, giving them oral ondansetron (Zofran), according to a recent study.
Source—April MD, Oliver JJ, Davis WT, et al. Aromatherapy versus oral ondansetron for antiemetic therapy among adult emergency department patients: a randomized controlled trial. Ann Emerg Med, 2018 Aug; 72(2): 184–93.
Brief summary of the research—In a randomized, blinded, placebo-controlled trial, a sample of 122 adults presented to an urban tertiary care emergency department with chief complaints including nausea or vomiting. Forty received inhaled isopropyl alcohol and 4 mg oral ondansetron (Zofran); 41 received inhaled isopropyl alcohol and oral placebo; and 41 received inhaled saline solution placebo and 4 mg oral ondansetron The primary outcome was mean nausea reduction measured by a 0- to 100-mm visual analog scale from enrollment to 30 minutes postintervention. It was found that among ED patients with acute nausea and not requiring immediate intravenous access, aromatherapy with or without oral ondansetron provided greater nausea relief than oral ondansetron alone.
Practical BLS EMS tip—Either use alcohol prep pads or place a few alcohol prep pads in an emesis bag and have the patient with nausea inhale deeply for a minute.
Practice #2—Continuous compressions and a 30:2 compression-to-ventilation CPR ratio do not yield different survival rates for sudden cardiac arrest. “Push hard, push fast, more time on the chest” is still the gold standard for SCA.
Source—Ashoor HM, Lillie E, Zarin W, et al; ILCOR Basic Life Support Task Force. Effectiveness of different compression-to-ventilation methods for cardiopulmonary resuscitation: A systematic review. Resuscitation, 2017; 118: 112–25.
Brief summary of the research—In a review of several nonrandomized trials, authors of this study compared manual uninterrupted compressions to the standard American Heart Association-taught CPR practice of a 30:2 compression-to-ventilations ratio. The article shared that although bench research in cardiac arrest has suggested that even brief pauses in chest compressions are detrimental, clinical studies have not corroborated this widely held belief.
Practical BLS EMS tip—Minimize time off the chest while performing CPR, ventilating cardiac arrest patients between compressions, defibrillation, and patient movement. Perform high-quality pit-crew CPR for the most effective approach to maximize time on the patient’s chest.
Practice #3—Rather than just using a scored scale as part of stroke assessment, consider the VAN approach, which looks for visual disturbance, aphasia, and neglect.
Source—Ermak D. How to best detect large vessel occlusion. Neuro News, https://neuronewsinternational.com/detect-large-vessel-occlusion/.
Brief summary of the research—In 2015 five major studies showed the efficacy of endovascular thrombectomy for the treatment of large-vessel occlusion. Recognizing stroke symptoms, and more specifically LVO, has become crucial to the treatment of patients suffering from acute ischemic stroke.
Current national guidelines have not yet embraced a requirement for use of a prehospital LVO scale, but there are many tools designed for prehospital LVO detection. PASS, VAN, and C-STAT are among the most basic, simply requiring the EMS provider to determine the presence or absence of a given deficit rather than score its severity. LAMS, RACE, FAST-ED, PASS, and C-STAT all have numeric cutoffs to meet or exceed for LVO. The exception is VAN, which requires only the presence of weakness with one or more associated cortical signs (visual changes, aphasia, and neglect/gaze preference).
Practical BLS EMS tip—How to assess using VAN:
If patient has any degree of weakness plus any one of the below, consider transport to a stroke center and a stroke alert:
- Visual disturbance (assess in the field by testing both sides—two fingers to the right, one to the left);
- Aphasia (inability to speak or understand—have the patient repeat and name two objects, close their eyes independently, and make fists independently);
- Neglect (observe the patient for a forced gaze to one side or ignoring one side, touching both sides, or a facial droop)—this is likely a large artery clot (cortical symptoms).
The advantage here is that VAN only requires the EMS provider to determine the presence or absence of a given deficit to indicate large-vessel occlusion, rather than score severity. While there is limited data backing its use, the VAN scale is easy to use for BLS EMS providers.
Practice #4—Well-equipped BLS units should carry continuous positive airway pressure equipment and use pulse oximetry for hypoxic breathing patients who meet CPAP criteria.
Source—Sahu N, Matthews P, Groner K, Papas MA, Megargel R. Observational study on safety of prehospital BLS CPAP in dyspnea. Prehosp Disaster Med, 2017; 32(6): 610–4.
Brief summary of the research—Seventy-four patients in this study received prehospital CPAP treatment by BLS crews. Their respiratory status and CPAP were appropriately monitored and documented in the majority of cases (98.6%). A total of 89.2% of patients improved, and 4.1% worsened; CPAP significantly reduced the proportion of patients with poor SpO2 and cyanosis (p < .01). The BLS providers were able to determine patients for whom CPAP was indicated, apply it correctly, and appropriately monitor the patients’ status. The majority of patients who received CPAP by BLS providers had improvement in their clinical status and vital signs. The findings suggest that CPAP can be safely used by BLS providers with appropriate training.
Practical BLS EMS tip—Work with your local protocols and medical director to get training and supplies for CPAP. Disposable single-use CPAP systems (e.g., Flow-Safe) are recommended and should be kept in your first-in bag. Practice with your equipment often.
Practice #5—Longboards and full c-spine restriction should not be used for treatment of spinal injury, only to facilitate extrication. Patients should not be transported on a longboard.
Source—Swartz EE, Tucker WS, Nowak M, Roberto J, et al. Prehospital cervical spine motion: Immobilization versus spine motion restriction. Prehosp Emerg Care, 2018 Feb 16.
Brief summary of the research—Spinal motion restriction is not a new idea in EMS. In fact, it has been more than five years since the NAEMSP and American College of Surgeons Committee on Trauma published findings that the longboard was neither a treatment for spinal injury nor a therapeutic modality. The research then showed longboards are not benign and can increase the risk of pressure ulcers and decreased respiratory function in transports as short as 20 minutes. They can also cause false positives for spine tenderness and injury.
This study, completed in 2017, had 20 healthy male volunteers in their 20s undergo ambulance transport from a simulated scene to a simulated emergency department in two separate conditions: utilizing traditional spinal immobilization and spinal motion restriction. The scenarios were otherwise identical. The main outcome measures were cervical spine motion, basic vital signs (heart rate, blood pressure, oxygen saturation), and self-reported pain. Vital signs and pain reports were collected at six consistent points throughout each scenario. The results showed that participants experienced greater transverse plane cumulative integrated motion and greater transverse peak range of motion during longboard use compared to spinal motion restriction. Further, pain was reported by 40% of the participants on a longboard compared to 25% of participants not on a board.
Practical BLS EMS tip—Full c-spine precautions using a longboard is not a treatment for possible spinal injury. Further, its use can cause harm to patients. A longboard can be used to facilitate removal from a vehicle or the ground to a stretcher. Once the patient is on the stretcher, the longboard should be removed, and the patient not transported on it.
These are just five examples of the plethora of current EMS research. The studies are out there. All you need to do is look, read, or talk to your medical director! Effective research helps improve our skills and supplies evidence-based reinforcement for our clinical EMS practice.
Barry A. Bachenheimer, EdD, FF/EMT, is a career educator and university professor. He is also a firefighter and member of the technical-rescue team with the Roseland (N.J.) Fire Department and an EMT with the South Orange (N.J.) Rescue Squad. With an emergency services career of more than 30 years, he frequently serves as an instructor for both departments. Reach him at firstname.lastname@example.org.