Prehospital Point of Care Testing Paul A. Berlin, MS, NREMT-P

1. Prehospital Point of Care TestingPaul A. Berlin, MS, NREMT-P • EMS POC is here today • Provides EMS providers with valuable information leading to better treatment plans • Can help direct patients to appropriate receiving centers • Increases capability and professionalism of EMS providers

2. Point-of-Care Testing • POC devices fall into two general categories: • QUANTITATIVE devices which are normally an electronic instrument that measures the quantity of whatever substance is being tested for in a blood sample (an example of which would be an electronic glucometer which shows the blood sugar in mg/dL) • QUALITATIVE devices which usually contain chemically treated paper that changes color to indicate the presence of the specific substance being tested for (an example of which would be a colormetric CO2 detector)

3. Measure What? • Electrolytes: Sodium, potassium, chloride, BUN, anion gap, base excess, bicarbonate, glucose levels • Blood: Hematocrit, hemoglobin • Blood Gas: pH, CO2, PO2 • Coagulation: Prothrombin time • Cardiac enzymes: Cardiac troponin-I, BNP, CK-MB, myogloblin and H-FABP • And More

4. Getting POC • Costs: $--$$$$ • Cartridges • Analyzers • Accessories • Service Contract • Regulations: • Clinical Laboratory Improvement Amendments (CLIA) • CMS

5. 80 Year Old Female • Decreased LOC • Likely been on the floor for days • Her BP is 70/50 mm/Hg, pulse is 60 bpm, respirations are 8/min and she only responds to deep pain POC test shows potassium (K+) of 9.2 mEq/L (3.5-5.5 mEq/L). • Treatment plan now includes giving CaCl2, Bicarbonate and Albuterol.

6. 56 Year Old Female • Reports intermittent, “funny feeling” in her right arm and neck for the past four days. She has a history of hypertension and takes medication. She is diabetic. She wants to stay home. Troponin I on this patient is 8.5

7. 37 Year Old Marathon Runner • Complains of headache and confusion 30 minutes after finishing. • Suddenly has tonic-clonic seizure lasting 90 seconds. • Electrolytes: • Sodium 112 mEq/L (135-148 mEq/L) • Potassium 3.5 mEq/L (3.5-5.5 mEq/L) • Glucose: • 90 mg/dL (60-99 mg/dL) • Dx: Dilutional Hyponatremia

8. Respiratory Distress • Elderly patient with a recent strokeand a history of coronary artery disease calls 911 for help • On examination, he has expiratory wheezing, tachypnea and is nowstuporous • Oximetry reads 96% on 6 L oxygen flow by nasal cannula • Temperature is 96.7° F orally • An ECG shows a left bundle branch block • B-type natriuretic peptide (BNP) is 1100 pg/ml indicating heart failure.

9. Getting POC • Training: • Sample handling • Unit operations • Annual refresher • QA: • Testing the test • Oversight • Expectations of ED • Will the except your test • Getting “buy-in”

10. References • 1. Part 10.1: Life-Threatening Electrolyte Abnormalities. Circulation. 2005;112:IV-121-IV-125. • 2. Part 8: Stabilization of the Patient With Acute Coronary Syndromes. Circulation. 2005;112:IV-89-IV-110 • 3. Part 10.1: Life-Threatening Electrolyte Abnormalities. Circulation. 2005;112:IV-121-IV-125. • 4. Differentiating the Causes of Metabolic Acidosis in the Poisoned Patient. Clinics in Laboratory Medicine - Volume 26, Issue 1 (March 2006) • 5. Modern Management of Cardiogenic Pulmonary Edema. Emergency Medicine Clinics of North America; Volume 23, Issue 4 (November 2005). • 6. Part 9: Adult Stroke. Circulation. 2005;112:IV-111-IV-120 • 7. Point-of-Care Testing and Cardiac Biomarkers: The Standard of Care and Vision for Chest Pain Centers. Cardiology Clinics - Volume 23, Issue 4 (November 2005) • 8. Point-of-Care Testing Reduces Length of Stay in Emergency Department Chest Pain Patients. Annals of Emergency Medicine - Volume 45, Issue 6 (June 2005) • 9. Patient safety in point-of-care testing. Clinics in Laboratory Medicine - Volume 24, Issue 4 (December 2004)