NYC EMS Protocol - PEA/Asystole Arrest

Author: David Eng, MD

Assistant Medical Director, Emergency Medical Services

Attending Physician, Department of Emergency Medicine

Maimonides Medical Center

For reference here is a link to all of the NYC REMAC protocols as updated in 2019: https://www.nycremsco.org/wp-content/uploads/2017/10/04-ALS_Protocols-January-2019-vALS01012019B.pdf

Let’s take a look at a protocol that’s pretty heavily utilized in OLMC calls, 503-B, PEA/Asystole:

Steps 1-8 constitute STANDING ORDERS (what the paramedics will be performing on their own by default), while the lower part describes MEDICAL CONTROL OPTIONS (what the medics will be calling OLMC to request of you). This means that prior to contacting you for a PEA/Asystole arrest patient, they should have obtained an advanced airway (either an endotracheal tube [ETT] or supraglotic airway [SGA]), checked and accounted for tension pneumothoraces and hypoglycemia, and given epinephrine every 3-5 minutes while continuing CPR, same as you would normally do for an arrest in the ED. Normally, they’ll go through a few rounds of this before contacting OLMC for one or more Medical Control Options (MCOs):

Does the patient have a history of renal failure or another reason to be suspicious for hyperkalemia? Consider authorizing the use of Sodium Bicarbonate (Option A) or Calcium Chloride (Option B)!

Is the arrest due to severe hypovolemia from profound dehydration or septic shock? Is that pulseless, narrow complex rhythm just because the patient has insufficient intravascular volume to generate a pulse? Then maybe they need aggressive fluid bolusing (Option C)!

Is there something else you think is going on that is just better served by having the patient brought to the hospital? You also have the option to tell the crew to focus on just getting the patient into the ambulance and transported to the ED (Option D).

Taken as a whole, the Standing Orders and Medical Control Options do a decent job of addressing most of the H’s and T’s you would consider for the same arrest in the ED, and certainly, if any of these interventions lead to ROSC (or if you otherwise request transportation), the crew will default to bringing the patient to the ED. Of course, under the right circumstances, you are also within your right to withhold any of those MCOs in favor of Termination of Resuscitation, which we can save for a future post!

How to use the Reichert Tono-pen AVIA

How to use the Reichert Tono-pen AVIA:

1) Put on the protective cover. Make sure not to make it too tight or too loose.
2) Press the blue button once. You will hear one beep. The green light will turn on and the screen will show a series of dashed lines in the bottom right corner. 

3) Hold the Tono-pen perpendicularly to the corneal surface. Tap gently and try to avoid wild variations in the pressure you apply between taps. For each tap that is recorded, a number will appear in the bottom right corner. You need 10 in total. The final reading will look like this: 

The larger number is your pressure reading. The smaller number is your confidence interval. 

Video on how to use the Tono-pen: https://youtu.be/Hqcf9Ll-pl0 

Notes:

• The Tono-pen is gravity independent and patient does not have to be any particular position for this to work.

• If you are using your fingers to spread apart the eyelids, be sure your fingers are on a bony surface and that you are not pressing on the eye itself as this will give you a falsely elevated reading.

Having trouble getting accurate readings with the Tono-pen? Try calibrating it before using:

1) Hold Tono-pen with the tip pointing downwards. Hold down blue button for 5 seconds. You should hear 5 beeps in succession.

2) The display will now show “dn” which is Tono-pen code for “down.” Continue to hold with the tip downwards until the screen changes to “UP.”

3) Quickly and smoothly flip Tono-pen so that the tip is now upwards until the screen says “pass” or “fail.” If it says “pass” then you’re done. If it says “fail” you can repeat the calibration steps above. If it continues to say “fail” after multiple attempts, the device may require servicing.

Tono-pen calibration video: https://www.youtube.com/watch?v=y1Mg5Zkr-qE&feature=youtu.be

Procedural Sedation and Analgesia - Part 3

Welcome to the third and final post about PSA. Now you know what PSA is and which medications you will be using, so what’s next?

What else do I need to perform PSA?

Signed consent form (if non-emergent)

BVM

Oxygen source and delivery system

End tidal capnography

Vital signs monitor

Intubation equipment

Supraglottic airway

Airway adjuncts

PSA agent(s)

Paralytic (should you need to intubate)

Easily accessible reversal agent (if applicable)

At least 2 providers: One person must be dedicated to monitoring the PSA, watching the monitor and watching the patient to look for changes in respiration. This person should have an unobstructed view of the monitor, patient’s face and chest. Second person to perform whatever procedure you are doing the PSA for.

Here is a great checklist to go through before every PSA: https://emupdates.com/perm/PSAChecklistv2emupdates.com_screen.pdf

Additional notes/tips:

• Most important job of the EP performing the PSA is to watch the patient, especially changes in respiratory rate and depth

• Do not delay procedural sedation based on fasting time. There is no evidence to support that fasting for any duration reduces the risk of emesis or aspiration with PSA.

• If providing supplemental O2, be aware that this can delay recognition of respiratory suppression, especially if looking at the SpO2. It can take an additional 4-5 minutes for you to see a drop in the pulse oximetry reading while the patient is apneic.

• Capnography is a great adjunct to help you detect airway or respiratory compromise. Note the end-tidal CO2 prior to administering the sedative. If there is a significant consistent change in this number (>10mmHg) or if you notice that the waveform plateaus, begin addressing possible airway/respiratory compromise. Here is a great resource to practice interpreting capnography: https://www.medtronic.com/content/dam/covidien/library/us/en/product/capnography-monitoring/capnostream-tutorial-quiz/tutorial.html

• Do not discharge the patient until she has returned to her baseline mental status. Make sure to provide the proper discharge instructions. Adverse effects of sedation are rare once patients have returned to baseline mental status but they should be instructed to return to the ED if they begin experiencing difficulty breathing or vomiting.