Are Prehospital EKGs Worthwhile? Who Knows, but We Wonʼt Let That Stop Us

FigureIt seems that more and more paramedic programs are performing prehospital EKGs. The theory is that this practice will result in faster ED treatment if, on the patient's arrival at the ED, the physician can be handed an EKG showing the ST elevation. Makes sense. But how many definitive AMIs (ST elevation EKGs) will there be for every person who gets an EKG in the field, and how much time will be added to the patient's prehospital care? Given the costs associated with equipping tens of thousands of ambulances with EKG equipment, teaching paramedics how to perform EKGs, and considering the potential grief of undressing patients in the back of a rig, the data to support this practice need to be compelling. But in view of the long history of prehospital care in which procedures and policies are often broadly adopted well before they are proven (the ready-fire-aim approach), I would expect no less with the issue of prehospital EKGs. The following paper reviews the world's literature on the subject — five studies. The mean methodologic quality of the studies was considered very poor, and there were no data to assess clinical outcomes resulting from the performance of prehospital EKGs. So, maybe prehospital EKGs are a good thing, maybe not. It would appear that no one really knows. But don't let that stop us. There is, however, another aspect to prehospital EKGs — the potential ability to divert AMI patients to hospitals that have 24-hour interventional capabilities rather than transporting them to hospitals that don't. This makes a lot of sense to me. All things being equal, I don't want to be taken to a hospital that only can provide thrombolytic therapy. I would rather take a little longer ride in the ambulance, assuming I'm more or less stable, to go to the hospital that has the capability to provide state-of-the-art care (and thrombolysis is not it). Prehospital 12-Lead Electrocardiography Impact on Acute Myocardial Infarction Treatment Times and Mortality: A Systematic Review, Morrison LJ, et al, Acad Emerg Med, 2006;13(1):84 BACKGROUND: Early diagnosis of acute myocardial infarction (AMI) can reduce the time to definitive treatment, possibly increasing the likelihood of myocardial salvage in some cases. Studies comparing prehospital electrocardiography with ED notification and standard EMS care, however, have yielded conflicting results about intervals to treatment and mortality. METHODS: The authors from the universities of Toronto and British Columbia performed a systematic review of five available studies that compare performance of prehospital EKGs and advance notification of the ED, with standard EMS care, and which specifically addressed scene times, time to fibrinolysis, and mortality in patients with suspected AMI. RESULTS: The mean methodologic quality of the studies was very poor. There were no differences between the two strategies in prehospital scene times among 519 patients with available information (weighted mean difference 1.2 minutes), but for the 181 patients with relevant data, prehospital EKG performance with advance ED notification was associated with a weighted mean decrease of 36.1 minutes in door-to-needle times for in-hospital fibrinolysis. A decreased mortality among patients having a prehospital EKG, reported in only one small study, did not achieve statistical significance. CONCLUSIONS: A limited series of methodologically flawed papers suggests that prehospital performance of an EKG in patients with suspected AMI, with advance notification of the receiving ED, may reduce the interval from ED arrival to fibrinolysis without significantly increasing scene time. There are insufficient data to speculate about any impact on patient-oriented outcomes. If EKGs are done in the field, how much time will be added to the patient's prehospital care? Hypothermia Using Cold IV Fluids Here's another paper that says patients can be cooled by giving them cold IV fluids. As more and more hospitals gear up to follow the 2005 AHA guidelines regarding cooling of cardiac arrest patients who have return of spontaneous circulation but who remain comatose, the provision of cold IV fluids may be an option. Surprisingly, as demonstrated by a prior paper as well, patients tolerated large quantities of fluid administered quickly (2 liters in the prior study and an average of 2.3 liters in the current study over 50 minutes) without developing complications. Induction of Hypothermia in Patients with Various Types of Neurologic Injury with Use of Large Volumes of Ice-Cold Intravenous Fluid, Polderman KH, et al, Crit Care Med, 2005;33(12):2744 BACKGROUND: It has been suggested that the time window for initiation of therapeutic hypothermia in patients with various types of neurologic insult is limited. The average time required to achieve a target temperature of 32–34°C with surface cooling techniques is about two to three hours. METHODS: This Dutch study examined the safety and effectiveness of infusion of large volumes of refrigerated saline (4°C), with or without Geloplasma, combined with surface cooling in achieving therapeutic hypothermia in 134 patients with differing types of neurologic injury. In addition to using a cooling blanket, patients without cardiogenic shock were treated with 1000 ml of refrigerated saline and 500 ml of Geloplasma infused over 30 minutes, with infusion of an additional 500 ml of refrigerated saline every 10 minutes as required to achieve a body temperature of 33.5°C or lower. The fluid protocol was modified for patients with cardiogenic shock. Target temperatures were maintained with a cooling blanket. Patients in one study tolerated large quantities of cold IV fluids administered quickly without developing complications RESULTS: An average volume of 2,340 ml of refrigerated fluids was administered over 50 minutes, and the core temperature decreased from 36.9°C at baseline to 34.6°C at 30 minutes and 32.9°C at 60 minutes. There was a 15 mmHg increase in mean arterial pressure, with the greatest increase being observed in hemodynamically unstable patients. There were no significant adverse effects on cardiac rhythm, central venous pressure, blood gases, serum electrolytes or glucose, or complete blood count, and no patient developed pulmonary edema. CONCLUSIONS: Rapid infusion of refrigerated fluids combined with application of a cooling blanket appears to be a safe method of inducing therapeutic hypothermia that is suitable for use in various clinical settings. Easing NG Tube Placement This paper reports results that seem too good to be true. Given that studies have indicated that NG tube placement is at the top of the list of unpleasant procedures for ED patients, it seems that it was worth bringing the results to your attention. I've never seen a similar paper, and it would be great if the results could be independently verified by other investigators. Effectiveness of Pre-Emptive Metoclopramide Infusion in Alleviating Pain, Discomfort, and Nausea Associated with Nasogastric Tube Insertion, Ozucelik DN, et al, Int J Clin Pract, 2005;59(12):1422 BACKGROUND: Insertion of a nasogastric (NG) tube can be associated with significant discomfort and pain, as well as nausea and vomiting. METHODS: In this prospective, controlled Turkish study, 100 ED patients 16 to 96 with indications for insertion of an NG tube (most for GI bleeding or gastric lavage after overdose) were randomized to pretreatment with IV saline placebo or the antiemetic and prokinetic agent, metoclopramide (10 mg), 15 minutes prior to the procedure. Pain, nausea and vomiting were graded using a 100 mm visual analogue scale (VAS) before and after NG tube placement. RESULTS: In a preliminary study phase involving 20 patients undergoing NG tube placement without pretreatment, pain and discomfort were reported by 20 percent and 30 percent, respectively, and nausea and vomiting occurred in 40 percent and five percent, respectively. In the active study phase, the baseline pain score was 0 in each of the two groups. The mean pain score with NG tube insertion was 2.55 in the active treatment group compared with 28.43 in controls. Mean nausea scores were about 14 in the two groups at baseline, decreasing to 1.53 in the metoclopramide treatment group but increasing to 51.27 in controls. Mean discomfort scores were about 13 in the two groups at baseline, decreasing to 2.65 in the metoclopramide group but increasing to 48.52 in controls. All five patients who developed complications with NG tube insertion were in the placebo control group. CONCLUSIONS: In this study, pretreatment with IV metoclopramide significantly decreased the pain, discomfort, and nausea associated with NG tube insertion.

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