Transcript EMS/Nursing 81711 - Texas Tech University Health Sciences Center

This PowerPoint file is a supplement to the video
presentation. Some of the educational content of
this program is not available solely through the
PowerPoint file. Participants should use all
materials to enhance the value of this continuing
education program.
EMS/Nursing
81711/
316011
Healthcare
Research/Sepsis
T. Ryan Mayfield, MS, EMT-P EMS
Educator, Centura Health
Lab Instructor
Arapahoe Community College
Littleton, Colorado
EMS/Nursing
81711/
316011
Objectives
1. Identify components of
the scientific method.
EMS/Nursing
81711/
316011
Objectives
2. Differentiate between
various types of
research studies/methods.
EMS/Nursing
81711/
316011
Objectives
3. Identify patients at high
risk for developing
sepsis.
EMS/Nursing
81711/
316011
Objectives
4. Indicate appropriate
prehospital treatment for
a septic patient.
Scientific Method
 Make
observations/ask
questions
how, what, when,
where, who, which
 WHY??

Scientific Method
Observation:
There are more
psychiatric emergencies
when the moon is full.
Scientific Method
 Do
background research
(borrow from other
people)
Scientific Method
 Construct
hypothesis:
statement of believed
outcome
Scientific Method
 Hypothesis:
psychiatric
emergencies are more
common when the
lunar cycle is in the full
moon phase
Scientific Method
 Test
hypothesis
Scientific Method
 Analyze
data/draw
conclusions
full moon – 13.31
psychiatric patients
per day

Scientific Method

non full moon – 13.32
psychiatric patients
per day
Scientific Method
 Hypothesis
disproved
Scientific Method
 Communicate
(good or bad)
results
Research Bias
 Bias:
a mental leaning,
inclination, partiality, or
prejudice
All graphics can
also be found
under “Course
Resources” online.
Levels of Evidence
Randomized
Controlled Double
Blind Studies
Systematic Reviews
and Meta-analysis
Animal Studies
 Provide
insight into
biology
 For ethical reasons,
some studies cannot be
carried out on humans
Animal Studies
 Computer
modeling is
replacing many animal
studies
Expert Opinion/
Rational Conjecture
 Expert
opinions can
take various forms:
systematic reviews
 pure opinion pieces

Expert Opinion/
Rational Conjecture
 Rational
conjecture
lowest level of
scientific validity
 overall very important

Case
Report/Series
 Case
report: narrative
of an interesting case
Case
Report/Series
 Case
series: report on
a series of patients with
an outcome of interest
Case-Control
Studies
 Patients
who already
have a certain condition
are compared with
people who do not
Group of interest
(e.g. , cancer patients)
Take histories
Compare
histories
Draw
conclusions
Take histories
Comparison group
(e.g., non-cancer
patients)
Cohort Studies
 Patients
who presently
have a certain condition
and/or receive a
particular treatment are
followed over time
Group of interest
(e.g., smokers)
Follow
over time
Comparison group
(e.g., non-smokers)
Follow
over time
Compare
outcomes
Randomized
Controlled Trial
 Patients are
randomized into an
experimental group
and a control group
Patients
Treatment group
Follow-up
Control group
Follow-up
Random
assignment
Compare
results
Double-Blind Study
 Neither
the patient nor
the researcher knows
whether the patient is
receiving the treatment
of interest or the control
treatment
Please take
these pills
These are
Pill A
These are
Pill B
Please take
these pills
(Study Manager)
Patients
Meta-Analysis
 High-level
overview
 A systematic review
that uses quantitative
methods to summarize
the results
Study 1
Study 2
Combined
Results
Study 3
Study 4
Meta-Analysis
Group Problem
 Best
pain relief
PAIN
Scientific Method
 Research
question
What is a better pain reliever
in the prehospital setting,
fentanyl or morphine?
Scientific Method
 Background
studies on pain relief
are hard to do because
very subjective
 lot of expert opinion

Scientific Method
 Hypothesis
“Fentanyl will work better
than morphine.”
Scientific Method
 Test
(fairly easy to do)
Don’t you have to
establish a level of pain
you’re working with?
Scientific Method
 Test
 Analyze
Scientific Method
 Test
 Analyze
 Communicate
results
Evaluate
Published Studies
 Evaluate
stakeholders
Who did the research?
 Who paid for the
research?

Stakeholders
Reduced Mortality at a
Community Hospital Trauma
Center: The Impact of
Changing Trauma Level
Designation from II to I. Arch
Surg. 2008 Jan;143(1):22-7;
discussion 27-8.
Funding
Measurement of
Carboxyhemoglobin and
Methemoglobin by Pulse
Oximetry: A Human Volunteer
Study. Anesthesiology 2006;
105:892-7
Funding
Partial support for
laboratory expenses
incurred during this study
was provided by Masimo
Inc.
Evaluate
Population
 Age
Evaluate
Population
 Age
 Gender
Evaluate
Population
 Age
 Gender
 Comorbidities
Evaluate
Population
 Age
 Gender
 Comorbidities
 Numbers
Evaluate
Population
 Age
 Gender
 Comorbidities
 Numbers
 Selection process
Evaluate Study Design
Systematic Reviews
and Meta-Analysis
Randomized
Controlled
Double-Blind
Studies
Evaluate Statistics
 Good
Luck!
Going Forward
 Research
does not
have to be a grandiose
adventure
Going Forward
 Someone
will do
Emergency Medical
Services (EMS) research
 If EMS providers don’t
do it, they will not like
the results
SEPSIS
Why is this
Important?
 Sepsis
estimated 750,000
cases per year
 estimated 215,000
deaths per year

Why is this
Important?

during this
presentation:
● 84 cases will develop
● 24 people will die in the
United States
Why is this
Important?
 CDC death rates (2007)
- 132,968 deaths from
acute myocardial
infarction
SIRS-Systemic
Inflammatory
Response
Syndrome
 Causes
trauma
 severe burns

SIRS
infection
 pancreatitis
 ischemia

SIRS - Signs and
Symptoms
 Two
or more:
temperature: >38° C
°
(100.4 F) or <36 C
(96.8 F)

SIRS - Signs and
Symptoms
 heart rate: >90
beats/minute (outside
factors?)
SIRS - Signs and
Symptoms
 respiratory rate: >20
breaths/minute or
mechanically
ventilated
SIRS - Signs and
Symptoms
 white blood cell (WBC)
leukocyte count:
>12,000 or <4,000 or
>10% immature
Sepsis
 SIRS
with documented
or suspected infection
bacterial
 viral
 fungal
 protozoan

Sepsis
 Common
causes:
pneumonia
 urinary tract infections

Sepsis
abdominal surgery
 cellulitis
 intravenous (IV) drug
use
 ear infections

Sepsis - High
Risk Factors
 Higher risk
 extremes of age
 multiple comorbidities
Sepsis - High
Risk Factors
 recent hospitalization
(2 million hospitalacquired infections
per year)
Sepsis - High
Risk Factors
 Cough present
 Indwelling Foley
catheter
 Wounds/injuries
Sepsis - High
Risk Factors
 Para-/quadriplegic
 Bedridden
 Recent antibiotic use
Sepsis - High
Risk Factors
 Immune compromised
 diabetic
 cancer
Sepsis - High
Risk Factors
 human
immunodeficiency
virus (HIV)
 systemic steroids
Sepsis - High
Risk Factors
 anti-rejection
medications
 powerful
anti-inflammatory
medications
Septic Shock
 Two
of the four SIRS
criteria
 Infection
 Hypoperfusion
Septic Shock
 Define
shock = systolic
less than 90 mmHg
Septic Shock
 Systolic
= pressure
when your heart is
beating (1/3 of the
cardiac cycle)
Septic Shock
 Diastolic
= pressure
when heart is at rest
(approximately 2/3 of
the cycle)
Septic Shock
 Mean
arterial pressure
(MAP)

<65 mmHg considered
shock
Septic Shock
MAP =
(2 x diastolic) + systolic

3
Lactates
Infection
MODS
Lactates
 Cells
usually use
oxygen to make energy
Lactates

when cells do NOT get
the oxygen they need,
anaerobic metabolism
occurs (make energy
without oxygen)
Lactates

by-product: lactic acid
(toxin)
Lactates
A
measure of cellular
profusion NOT blood
pressure
EMS Lactate
Levels
 Prehospital
lactate
meters
look/work like a
glucometer

EMS Lactate
Levels
takes 60 seconds
 developed for
endurance athletes
 lactate ≥4 (shock)

EMS Lactate
Levels
 Three
measures used
for hypoperfusion:
systolic (least effective)
 MAP
 lactate levels

Septic Shock
 Classic
shock
distributive
Septic Shock
cardiac function
compromised
(cardiogenic shock)
 massive fluid shift
(hypovolemic shock)

Multiple Organ
Dysfunction
Syndrome (MODS)
 Last
stop before death
 80 - 100% mortality rate
Multiple Organ
Dysfunction
Syndrome (MODS)
 Presence
of altered
organ dysfunction in
the septic patient
Infection
MODS
Pathophysiology
 Bacterial infection
 chemotaxis
 secreted chemical
signal
Pathophysiology
 capillary vasodilation
and increased vascular
permeability
 leukocytes (WBCs)
combat infection
Pathophysiology
 Systemic infection
(can’t maintain
perfusion pressures)
Pathophysiology
 blood vessels dilate
and attack, damaging
tissue simultaneously
Pathophysiology
 more damage to tissue,
tissue sends out signal
needing help
● more vasodilation
● more capillary leaking
● more damage occurs
Pathophysiology
 more damage occurs,
more of the signal gets
sent out
● more capillary dilation
● more leaking
Early
intervention,
early treatment!
Pathophysiology
 Release of
proinflammatory
cytokines (powerful
vasodilators)
Pathophysiology
 Release of
anti-inflammatory
mediators
(inhibit production of
inflammatory components)
Pathophysiology
 Coagulation
 proinflammatory
cytokines cause
endothelium to loosen
anticoagulation
properties
Pathophysiology
exacerbated by venous
blood pooling (takes
blood out of circulation)
 microthrombi form
(organ system
dysfunction/failure)

Pathophysiology
 Remaining blood
 no coagulation
properties
 flows sluggishly
 vessels permeated and
dilated (leaks out)
Pathophysiology
 Respiratory system
 acute respiratory
distress syndrome
(ARDS) - 40% mortality
rate
Pathophysiology
 surfactant production
decreases
● maintains alveolar
tension
Pathophysiology
● lungs are extremely
susceptible to
ventilation-induced
injury
EMS Treatment
 Early

recognition key
history
EMS Treatment
 Early
recognition key
history
 physical exam (look
for infection)

EMS Treatment

strict aseptic practices
(patient already
compromised)
EMS Treatment

fluid resuscitation
● large bore IVs
● 20 mL/Kg bolus
(500 mL increments)
● follow local protocol
for maximum dose
EMS Treatment

every 500ccs listen to
breath sounds in case
they go into pulmonary
edema
EMS Treatment

pulmonary edema
(move to
vasopressors)
EMS Treatment

increased oxygen
demand
● hypermetabolism
● impaired oxygen
extraction
EMS Treatment
respiratory failure
occurs rapidly
 lung-protective
ventilation

EMS Treatment
● slightly increased rate
● slightly lower tidal
volumes
EMS Treatment
● slightly increased rate
● slightly lower tidal
volumes
● oxygen saturation
between 88% and 92%
EMS Treatment
 Pharmacological
support
dopamine 2 - 20 μg/kg
per minute

EMS Treatment
maintain systolic of
90 mmHg or MAP of
65 - 70 mmHg
 may need higher doses

EMS Treatment
 Place
supine with feet
elevated
 NOT Trendelenburg
 may impede breathing
EMS Treatment
 Rapid
transport to the
closest, appropriate
facility
What Can I Do?
“I’m just a lowly EMS
provider.”
EMS Sepsis
Alert
 Goal
identify septic shock
patients
 alert hospital
 start fluid resuscitation

EMS Sepsis
Alert
start vasopressors
(if needed)
 transfer to closest
appropriate facility

EMS Sepsis
Alert

consider emergent
transport
EMS Sepsis
Alert Criteria
 Initiate
sepsis alert for
patients
18 years and older
 NOT pregnant

EMS Sepsis
Alert Criteria
 Two
or more of the
below SIRS criteria:
EMS Sepsis
Alert Criteria
temperature >38 C
(100.4 F) or <36 C
(96.8 F)
 pulse >90
 respiratory rate >20

EMS Sepsis
Alert Criteria
 Suspected
or
documented infection
AND
One of the following:
EMS Sepsis
Alert Criteria
 Hypoperfusion
evidenced by low
systolic <90 and/or MAP
<65
 Lactate ≥4
Thank You
T. Ryan Mayfield
[email protected]
www.ryanmayfield.com
(After December 1)
EMS/Nursing
81711/
316011
Healthcare
Research/Sepsis
If you have any questions about the program
you have just watched, you may call us at:
(800) 424-4888 or fax (806) 743-2233.
Direct your inquiries to Customer Service.
Be sure to include the program number, title
and speaker.
EMS/Nursing
81711/
316011
Release Date:
10/01/2011
The accreditation for this
program can be found by signing in
to
www.ttuhsc.edu/health.edu
EMS
81711
This continuing education activity is approved by the Continuing
Education Coordinating Board for Emergency Medical Services
for 1.5 Basic CEH. You have participated in a continuing
education program that has received CECBEMS approval for
continuing education credit. If you have any comments
regarding the quality of this program and/or your satisfaction
with it, please contact CECBEMS at: CECBEMS -12200 Ford Road,
Suite 478
Dallas, TX 75234 Phone: 972-247-4442
[email protected]
Nursing
316011
The Texas Tech University Health Sciences Center Continuing Nursing Education
Program is accredited as a provider of continuing nursing education by the
American Nurses Credentialing Center's Commission on Accreditation.
Provider approved by California Board of Registered Nursing, Provider #CEP11800,
for the designated number of contact hours for each program. Provider approved by
Florida Department of Health Board of Nursing, Provider #FBN2060. Provider
approved by West Virginia Board of Examiners for Registered Professional Nurses,
Provider #WV1998-0262RN. Iowa Board of Nursing approved provider #325.
Accepted by the North Carolina Board of Nursing. Reminder to all PARTICIPANTS,
certificates should be retained for a period of four (4) years.
Health.edu reports Florida Continuing Education (Contact Hours) to CE Broker. This
activity provides 1.5 contact hours.
Nursing
316011
This activity is presented for educational purposes only. Participants are
expected to utilize their own expertise and judgment while engaged in the
practice of nursing. The content of the presentations is provided solely by
presenters who have been selected for presentations because of recognized
expertise in their field.
Nursing
316011
DISCLOSURE TO PARTICIPANTS
Requirements of successful course completion:
•Complete the program via video presentation, PowerPoint slides, audio
presentation, and/or manuscript.
•Complete the course evaluation.
•Complete the posttest with a score of 80% or greater.
•Complete the time utilized in course completion including the posttest.
Nursing
316011
Conflicts of Interest:
T. Ryan Mayfield, MS, EMT-P has disclosed that no financial interests,
arrangements or affiliations with organization/s that could be perceived as a real
or apparent conflict of interest in employment, leadership positions, research
funding, paid consultants or member of an advisory board or review panel,
speaker’s bureau, major stock or investment holder, or other remuneration.
Commercial Support:
There is no commercial support and/or relevant financial relationships related to
this educational activity. Commercial support is defined as financial (or in-kind)
contributions given by a commercial interest, which is used to pay all or part of
the costs of a CNE activity. Relevant financial relationships are defined as
financial relationships of any amount, occurring within the past 12 months,
including financial relationships of a spouse or life partner that could create a
conflict of interest.
Nursing
316011
Non-endorsement of Products:
T. Ryan Mayfield, MS, EMT-P has disclosed that no significant relationships with
commercial companies whose products or services are discussed in educational
presentations. For speakers, significant relationships include receiving from a
commercial company research grants, consultancies, honoraria and travel, or
other benefits or having a self-managed equity interest in a company. Disclosure
of a relationship is not intended to suggest or condone bias in any presentation,
but is made to provide participants with information that might be of potential
importance to their evaluation of a presentation.
Off-label Use:
T. Ryan Mayfield, MS, EMT-P has disclosed that no products with off-label or
unapproved uses are discussed within this activity.
Nursing
316011
Individual programs are provided for a two (2) year period. Participants
should check with their site coordinator, sign in to Health.edu’s internet
site, http://www.ttuhsc.edu/health.edu or call Education Services at 1800-424-4888 for information on the date through which this learning
activity is provided. For questions or comments regarding accreditation,
please call Education Services at 1-800-424-4888.To speak to a Customer
Service representative, please call 1-800-424-4888.
Institutional refund is available to subscribing organizations according to
Health.edu’s tuition refund policy. See your site coordinator to view this
program.