EMS Protocol of the Week - Pediatric Asthma/Wheezing

Last week, we went over the REMAC protocol for asthma, but in a cliffhanger not seen sinceAvengers: Infinity War, we were all left wondering what NYC EMS does with asthmatic/wheezing kids. Well worry not, faithful readers, because this week we’re taking a look at Protocol 554 – Pediatric Asthma/Wheezing!

There are a bunch of pediatric-specific protocols (remember that for the NYC REMAC, pediatric means up to 15 years of age), each with certain differences from its adult counterpart. Some differences are subtle, some not, so it’s worthwhile to at least have some awareness that these peds protocols exist in case the OLMC phone rings for a kid.

Protocol 554 is a good place to start with pediatric protocols since it’s not hugely different from 507, which we discussed last week. Albuterol and ipratropium are still being utilized as Standing Order, although a half dose of ipratropium is instructed for kids less than 6 years old. Further, while the adult protocol permits for continuous albuterol to be used, the pediatric protocol only allows for 3 doses as Standing Order. For children older than one year in severe distress, medics will also give epinephrine as Standing Order at a weight based dose (up to 0.3mg IM, the adult dose). After this point, OLMC may be utilized to request additional albuterol nebs and repeat doses of epi.

At this point, the only other significant difference in management is that the pediatric protocol does not include steroids or magnesium as adjuncts to treatment, either as SO or MCO, so just be aware that these kids will likely not have received any of those meds by the time they reach the ED (as opposed to adult patients).

That’s pretty much it for pediatric wheezers. Similar to the adult protocol, this one will generally leave most kids (and their parents) feeling much better by the time you see them, but just be aware of what may or may not have been done for them before immediately sending them out the door.

We’ll revisit other pediatric-specific protocols in the future, so be sure to keep an eye out! In the meantime, here’s your weekly plug forwww.nycremsco.org and the protocols binder by the OLMC phone.

David Eng, MD

Assistant Medical Director, Emergency Medical Services

Attending Physician, Department of Emergency Medicine

Maimonides Medical Center

EMS Protocol of the Week - Asthma

EMS Protocol of the Week - Asthma 

From the perspective of an ED physician, Protocol 507 – Asthma (attached below) is one of the most frustrating ones to encounter. Not because it’s particularly complicated, but rather because it often doesn’t leave you with anything to do. The Standing Orders for 507 include almost everything you would do yourself for a patient coming through walk-in triage with an acute asthma exacerbation: albuterol/ipratropium nebs x3 followed by continuous albuterol, IV access, steroids, magnesium, and even IM epinephrine for severe exacerbations. Checking an EKG is also included for appropriate patients. The only MCO for these cases is for the patient that may benefit from a repeat dose of IM epi. Otherwise, everything else is done by the paramedics on their own. It’s not unusual to receive a patient who was in extremis on EMS arrival, got IM epi, multiple nebs, steroids, and magnesium, and who now feels entirely better on ED arrival and wants to go home. And maybe sometimes the patient can go home, but be extraordinarily careful in these instances that you’ve fully reviewed the patient’s prehospital course. Note that in this case, the patient in front of you is wildly different from the one EMS encountered, and consider that fact at length when determining the patient’s disposition. In any event, whether it’s admission, discharge, or observation, the only thing left for you to do at that point is order the chest x-ray and maybe labs.

See? Boring for us, fun for the medics. And good for the patient, which I GUESS is what really matters.

Questions, comments, concerns? Send an email! Otherwise keep checking www.nycremsco.organd the protocol binder for more fun stuff.

 PS, while it doesn’t say so explicitly, this protocol is written for adults. What do we do with the kids? Stay tuned!

David Eng, MD

Assistant Medical Director, Emergency Medical Services

Attending Physician, Department of Emergency Medicine

Maimonides Medical Center

EMS Protocol of the Week - Obstetric Complications

Short cooldown email for today’s EMS PotW (EMS-PoW? Is that catchier?). Protocol 540 – Obstetric Complications, attached below, shockingly addresses potential complications with the obstetric patient. For context, NYC REMAC is using a 160/110 cutoff for severe preeclampsia, associated with some sort of symptomatology. The protocol opens with reference to BLS procedures, which in this case is essentially just checking ABC’s, calling for ALS if needed, and considering IVC syndrome, moving the patient into a left lateral position if indicated. At this point, the only SO ALS intervention is IV access and fluids, and ultimately an OLMC call to you fine folks for discuss magnesium administration.

The MCO for magnesium is written as a 2 gram IV dose over 10-20 minutes, with a repeat dose of 2 grams if needed. Seeing as we normally start at 4 grams for our preeclampsia/eclampsia patients, this allows for an early start for the loading dose at a lower rate while getting the patient to the ED for further eval. Generally, I tend to have a low threshold for authorizing the magnesium, assuming the crew paints a picture of a patient who could benefit from it.

www.nycremsco.org and the protocol binder, both there for you when you need them most.

David Eng, MD

Assistant Medical Director, Emergency Medical Services

Attending Physician, Department of Emergency Medicine

Maimonides Medical Center