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!
