What are some critical but easily missed conditions and interventions that an Advanced Care Paramedic (ACP) should be aware of?

From the Guidelines

Advanced Care Paramedics (ACPs) must be aware of several critical but easily missed conditions, including tension pneumothorax, posterior MI, Wolff-Parkinson-White syndrome with atrial fibrillation, hyperkalemia, adrenal crisis, and Wernicke's encephalopathy, which can have serious consequences if not promptly identified and treated. These conditions often present with subtle or atypical symptoms, making them challenging to diagnose. For instance, tension pneumothorax may present with decreasing oxygen saturation, absent breath sounds on the affected side, tracheal deviation, and hypotension, requiring immediate needle decompression using a 14G or 16G catheter in the second intercostal space, mid-clavicular line 1.

Some key considerations for ACPs include:

• Recognizing posterior MI, which often manifests with atypical symptoms like back pain or nausea rather than classic chest pain, and requiring a 15-lead ECG with posterior leads V7-V9 to detect ST elevation 1
• Identifying Wolff-Parkinson-White syndrome with atrial fibrillation, which is life-threatening and contraindicated for AV nodal blockers, and using procainamide 20-50 mg/min up to 17 mg/kg instead 1
• Detecting hyperkalemia, which may present subtly with peaked T-waves and widened QRS, and requiring immediate calcium chloride 1g IV (or calcium gluconate 3g), sodium bicarbonate 50-100 mEq, and albuterol 5-10 mg nebulized 1
• Diagnosing adrenal crisis, which presents with hypotension, weakness, and abdominal pain, and requiring prompt fluid resuscitation with normal saline boluses and hydrocortisone 100mg IV 1
• Identifying Wernicke's encephalopathy in malnourished or alcoholic patients, which needs immediate thiamine 100mg IV before glucose administration to prevent precipitating the condition 1

It is essential for ACPs to stay up-to-date with the latest guidelines and research, such as the 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1, to ensure they are equipped to recognize and manage these critical conditions effectively. Prompt recognition and intervention are crucial to prevent significant morbidity or mortality, and ACPs must be vigilant and proactive in their assessment and treatment of these conditions.

From the FDA Drug Label

5 WARNINGS AND PRECAUTIONS

5.1 Incorrect Locations of Injection Injection into the anterolateral aspect of the thigh (vastus lateralis muscle) is the most appropriate location for administration because of its location, size, and available blood flow. Do not administer repeated injections of epinephrine at the same site, as the resulting vasoconstriction may cause tissue necrosis. Do not inject into buttock. Injection into the buttock may not provide effective treatment of anaphylaxis and has been associated with the development of Clostridial infections (gas gangrene)

As an Advanced Care Paramedic (ACP), it's crucial to be aware of the following critical but easily missed conditions and interventions:

• Incorrect injection sites: Avoid injecting epinephrine into the buttock, digits, hands, or feet, as this can lead to serious complications such as tissue necrosis or Clostridial infections.
• Repeated injections at the same site: Do not administer repeated injections of epinephrine at the same site, as this can cause tissue necrosis due to vasoconstriction.
• Patients with certain medical conditions: Exercise caution when administering epinephrine to patients with heart disease, hyperthyroidism, Parkinson's disease, diabetes mellitus, pheochromocytoma, or pregnant women, as they may be at greater risk for developing adverse reactions.
• Allergic reactions to sulfite: Be aware that Adrenalin® contains sodium bisulfite, which may cause mild to severe allergic reactions, including anaphylaxis or asthmatic episodes, in susceptible individuals 2.

From the Research

Critical but Easily Missed Conditions

• Acute illness resulting in hospital admission can be an opportunity to engage in Advance Care Planning (ACP) conversations, but for some patients, ACP discussions may be antithetical to the goals of hospital care 3
• Lack of knowledge about patient preferences is a contributing factor for inappropriate therapy, highlighting the importance of ACP in critical care settings 4
• Patients with advanced illness presenting to the emergency department may benefit from ACP, but uptake of ACP discussions in this setting is limited 5

Easily Missed Interventions

• Advance Care Planning (ACP) is a process that guarantees the respect of the patient's values and priorities about their future care at the end of life, but its diffusion is accompanied by unforeseen limitations and issues 6
• Advanced paramedics (APs) can diagnose patients and predict hospital admission with a high degree of accuracy, but recognition of non-concordance case types may identify priorities for AP education and drive future AP practice 7
• ACP has potential due to the proven validity of advance directives and the prompt applicability of directives in an emergency, but prerequisites for ACP include the provision of resources and the implementation of counseling structures 4

Key Considerations for Advanced Care Paramedics (ACPs)

• ACPs should be aware of the importance of facilitated discussions with trained medical staff to lead to different ACP documents 4
• ACPs should recognize that acute illness can be an opportunity to engage in ACP conversations, but also be sensitive to patients who may find ACP discussions difficult or antithetical to their goals 3
• ACPs should be knowledgeable about the concept of ACP, its development, and implementation with respect to intensive care, as well as the potential and requirements for ACP in daily practice 4