EMS Protocol of the Week: Weapons of Mass Destruction - Nerve Agents

Hey all,

This week's protocol delves into the world of ⚠weapons of mass destruction⚠ with a focus on biochemical warfare -- specifically nerve agents that cause cholinergic toxicities. And I know you're all just foaming at the mouth waiting to hear about it 👅

This protocol can only be activated via a class order by an FDNY Medical Director from the Office of Medical Affairs. Pre-hospital providers must wear the appropriate chemical protective clothing and operate within the hot, warm, and cold zones as directed by the incident commander (throwback to your Orientation HazMat training).

Patients are tagged and triaged based on signs/symptoms of cholinergic toxicity. All "red" and yellow" patients who exhibit SLUDGEM symptoms (salivation, lacrimation, urination, diarrhea, GI upset, emesis, myosis), respiratory distress, or AMS should receive immediate treatment from the nerve agent antidote kit (see image):

• Atropine 2mg IM auto-injector

• Pralidoxime 600mg IM auto-injector 

Repeat doses of atropine can be given based on secretions and respiratory distress. Don't delay treatment in these patients for decontamination!

Paramedics can also give IM doses of Diazepam or Midazolam for actively seizing patients.

The role of OLMC is to provide additional doses of any of the standing order meds.

Hopefully, we never have to use this one, but if we do -- don't pee your pants -- just stay calm and follow the protocol!

More info at www.nycremsco.org

Best,

Chris Kuhner, MD

PGY-2 Emergency Medicine

EMS Protocol of the Week - Neonatal Care / Resuscitation

The prehospital protocol for neonatal resuscitation is dense, so it doesn't serve to reproduce it all within the email. Read through the attachment for details, and realize that it serves as a reference for stepwise assessment (with target heart and respiratory rates) and interventions (with target compression/ventilation rates and medication dosages) for when our EMTs and paramedics are stuck in a high stress home environment with a neonate in extremis. Not a ton to add from an OLMC perspective, but recognize that this protocol is here for your reference as well, in case a crew calls looking for assistance.

The attached appendix also includes a review of APGAR scores for your review. 

That's RESUSCITATION...BABY.

And with that, hope you all have some wonderful holidays! If you can't wait for more protocol goodness, there's always www.nycremsco.org

Dave

EMS Protocol of the Week - Severe Bradycardia (Pediatric)

Happy EMS Tuesday!

We're going to slow things down from John Su's riveting email about eye emergencies to discuss the EMS protocol for “Severe Bradycardia (Pediatric)”. These are 3 words that no one wants to hear in a sentence together, so let’s get mentally prepared in case this patient comes in!

To use this protocol, patients should have: 1) HR <60 bpm, and 2) signs of shock or AMS. Any provider taking care of this type of patient can begin chest compressions and ventilations as per AHA guidelines. If an EMT is first on scene, they should immediately request ALS assistance and transport if timing makes more sense. 

For paramedics, cardiac monitoring will be started and IV access will be obtained. Standing Order will allow them to perform the following: 

1) Epinephrine 0.01 mg/kg (0.1mL/kg) IV of 1:10,000 concentration (max 1mg) every 3-5 minutes, 

2) Atropine 0.02 mg/kg IV (min 0.1mg, max 0.5mg), 

3) intubation if unable to provide effective BVM ventilations. 

If that does not work, they will call OLMC for one of two options: 

1) administration of a 2nd dose of Atropine 0.02 mg/kg IV 

2) initiation of transcutaneous pacing. Of note, they may also for procedural sedation authorization for pediatric patients if the patient is conscious.

Check out www.nycremsco.org or the protocol binder on North Side for more.

Sincerely,

Joseph Liu, DO

Chief Resident, Emergency Medicine PGY-3

Maimonides Medical Center