Adrie C, Adib‐Conquy M, Laurent I, et al. Successful cardiopulmonary resuscitation after cardiac arrest as a “sepsis‐like” syndrome. Circulation. 2002; 106:562–8.106 106 Kern KB, Hilwig RW, Rhee KH, Berg RA. Myocardial dysfunction after resuscitation from cardiac arrest: an example of global myocardial stunning. J Am Coll Cardiol. 1996; 28:232–40.
107 107 Tennyson H, Kern KB, Hilwig RW, Berg RA, Ewy GA. Treatment of post resuscitation myocardial dysfunction: aortic counterpulsation versus dobutamine. Resuscitation. 2002; 54:69–75.
108 108 Vasquez A, Kern KB, Hilwig RW, Heidenreich J, Berg RA, Ewy GA. Optimal dosing of dobutamine for treating post‐resuscitation left ventricular dysfunction. Resuscitation. 2004; 61:199–207.
109 109 Guyette FX, Martin‐Gill C, Galli G, McQuaid N, Elmer J. Bolus dose epinephrine improves blood pressure but is associated with increased mortality in critical care transport. Prehosp Emerg Care. 2019; 23:764–71.
110 110 Reynolds JC, Callaway CW, El Khoudary SR, Moore CG, Alvarez RJ, Rittenberger JC. Coronary angiography predicts improved outcome following cardiac arrest: propensity‐adjusted analysis. J Intensive Care Med. 2009; 24:179–86.
111 111 Dumas F, Cariou A, Manzo‐Silberman S,. Immediate percutaneous coronary intervention is associated with better survival after out‐of‐hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry. Cardiovasc Interv. 2010; 3:200–7.
112 112 Lemkes JS, Janssens GN, van der Hoeven NW, et al. Coronary angiography after cardiac arrest without ST‐segment elevation. N Engl J Med. 2019; 380:1397–1407.
113 113 Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002; 346:549–56.
114 114 Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out‐of‐hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002; 346:557–63.
115 115 Nielsen N, Wettersleve J, Cronbert T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013; 369:2197–206.
116 116 Lindsay PJ, Buell D, Scales DC. The efficacy and safety of pre‐hospital cooling after out‐of‐hospital cardiac arrest: a systematic review and meta‐analysis. Crit Care. 2018; 22:66.
117 117 Castren M, Nordberg P, Svensson L, et al. Intra‐arrest transnasal evaporative cooling: a randomized, prehospital, multicenter study (PRINCE: Pre‐ROSC IntraNasal Cooling Effectiveness). Circulation. 2010; 122:729–36.
118 118 Nordberg P, Taccone FS, Truhlar A, et al. Effect of trans‐nasal evaporative intra‐arrest cooling on functional neurologic outcome in out‐of‐hospital cardiac arrest: the PRINCESS randomized clinical trial. JAMA. 2019; 321:1677–85.
119 119 Langhelle A, Tyvold SS, Lexow K, Hapnes SA, Sunde K, Steen PA. In‐hospital factors associated with improved outcome after out‐of‐hospital cardiac arrest. A comparison between four regions in Norway. Resuscitation. 2003; 56:247–63.
120 120 Sunde K, Pytte M, Jacobsen D, et al. Implementation of a standardised treatment protocol for post resuscitation care after out‐of‐hospital cardiac arrest. Resuscitation. 2007; 73:29–39.
121 121 Rittenberger JC, Guyette FX, Tisherman SA, DeVita MA, Alvarez RJ, Callaway CW. Outcomes of a hospital‐wide plan to improve care of comatose survivors of cardiac arrest. Resuscitation. 2008; 79:198–204.
122 122 Werling M, Thoren AB, Axelsson C, Herlitz J. Treatment and outcome in post‐resuscitation care after out‐of‐hospital cardiac arrest when a modern therapeutic approach was introduced. Resuscitation. 2007; 73:40–45.
123 123 Hartke A, Mumma BE, Rittenberger JC, Callaway CW, Guyette FX. Incidence of re‐arrest and critical events during prolonged transport of post‐cardiac arrest patients. Resuscitation. 2010; 81:938–42.
124 124 Davis DP, Fisher R, Aguilar S, et al. The feasibility of a regional cardiac arrest receiving system. Resuscitation. 2007; 74:44–51.
125 125 Elmer J, Callaway CW, Chang CH, et al. Long‐term outcomes of out‐of‐hospital cardiac arrest care at regionalized centers. Ann Emerg Med. 2019; 73:29–39.
CHAPTER 14 The challenge of the undifferentiated patient
Andrew Travers
Introduction
The Call‐Taking Process
When a patient calls 9‐1‐1 and speaks with an emergency medical dispatcher, the complex process of providing optimal care has been initiated. This first point of medical contact, the interaction between the patient and telecommunicator, can influence every subsequent experience of patients during their prehospital and even in‐hospital care. Consequently, it is essential for the telecommunicator to initiate and optimize clinician–patient contact for the subsequent emergency medical services (EMS). The EMS clinician, in turn, optimizes contact with the emergency department (ED) or other destination.
Although many consider that the 9‐1‐1 public safety answering point is involved only in resource allocation such as dispatching ambulances, it also has a pivotal role in the provision of patient care [1]. The accurate identification of the chief complaint by the telecommunicator serves as an adjunct to the field personnel by allowing them to incrementally build on the dispatch “diagnosis” and initiate the appropriate therapy. If the telecommunicator incorrectly identifies the chief complaint, this may result in ineffective or inappropriate prehospital therapies, and even worse, it may introduce systematic biases that affect provision of patient care from the EMS clinician–patient contact onward [2, 3].
During the initial steps in the telecommunicator–patient interview, for example, if the chief complaint includes scene safety issues (e.g., drowning or electrocution), the telecommunicator decides on the protocol that best addresses the situation [3]. If the chief complaint involves trauma, the telecommunicator decides on the protocol that best addresses the mechanism of injury (e.g., fall, motor vehicle crash). When the chief complaint appears to be medical in nature, the telecommunicator chooses the protocol that best fits the patient’s foremost symptom, with the priority symptoms taking precedence. Regardless of which call is assessed, the subsequent dispatch information can influence the thought processes of the responding EMS clinicians and potentially influence how they approach the patient [4].In the case of drowning or electrocution calls, for instance, the responders are preparing themselves for the type of call, essentially reviewing in their minds the protocols and procedures to use when approaching the patient. For all calls, the EMS personnel consider their previous experiences to determine how to proceed when they initiate their own first medical contact.
En Route to the Patient
Just as emergency physicians do when they pick up a medical chart, view the chief complaint, and begin their approach to the patient with some element of preconceived notions based on the recorded chief complaint, so do field personnel when they are approaching the patient after being dispatched with some form of information. This can be beneficial in that it may immediately confer some sense that the patient has no high‐priority symptoms, thereby compelling the EMS clinician
