EMS Protocol of the Week - Obstructed Airway, Pediatric Obstructed Airway, Pediatric Croup/Epiglottitis

Another 3-fer! He’s a madman! 

Yeah, mad like a fox!

There’s plenty of overlap between Protocol 502 – Obstructed Airway, its kid-friendly counterpart Protocol 551 – Pediatric Obstructed Airway, and its adjunct Protocol 552 – Pediatric Croup, and they’re all short and sweet, so let’s knock them all out at once, shall we?

502 deals initially with identifying a foreign body under direct laryngoscopy. Paramedics are directed to attempt removal with Magill forceps, but if this is unsuccessful and there is any issue with patient ventilation, the next steps guide paramedics through advanced airway management (namely, endotracheal intubation), and from there, an intentional right mainstem maneuver to push the obstruction out of the trachea. 551 for peds is the same but includes language to specify cuffed versus uncuffed ET tubes. And 552 adds the consideration for patients whose obstruction is related to potential croup or epiglottitis, in which case crews are instructed to avoid intubation and to stick with BVM if needed during transport.

That’s it! Knew you could do it! Stay tuned for another protocol next week! Until then, you always have www.nycremsco.org and the protocol binder to keep you company.

Dave

EMS Protocol of the Week - Seizures

So, you’re having a seizure. What do you do? 

Well nothing, I guess; you’re having a seizure. 

But paramedics can do stuff! And with this brilliant and natural segue, we’re on to Protocol 513 – Seizures.

The ALS protocol for seizures does what it can to diagnose and treat within the confines of the paramedic’s scope of practice. They should be checking a 3-lead for any concerning arrhythmias that may be mimicking as seizure activity, as well as assessing for hypoglycemia that may need to be reversed. Notice that there is a note included that reminds providers to account for a relative hypoglycemia for diabetic patients who may be euglycemic by non-diabetic standards. Similar to other protocols where hypoglycemia is mentioned, ALS will respond by giving dextrose IV/IO or glucagon IM if unable to obtain vascular access.

From here, the protocol discusses benzos, offering separate IV/IO and IM/IN dosing strategies to account for the time and safety concerns that often come with attempting to secure vascular access in a patient that is actively thrashing about. Check the protocol for specifics, but broadly, ALS providers are allowed to administer up to two doses of lorazepam OR up to two doses of diazepam OR a single dose of midazolam by Standing Order. As an OLMC physician, you can authorize repeat doses of any of those as you see fit.

That’s it! Stop the seizure! Don’t forget that benzos will require a Tracking Number (MMC-####), but don’t be alarmed if the crew asks to call back for the number after they’ve controlled the seizure in front of them; they won’t leave you hanging! While you wait for their call back, you can brush up on the protocols at www.nycremsco.org or with the protocol binder!

Dave

EMS Protocol - Approach to Suspected MI

Protocol 504 – Suspected Myocardial Infarction is supplemented by two sub-protocols: 504-A – Drug Therapy of Myocardial Ischemia and 504-B – Cardiogenic Shock, and they’re each fairly straightforward, so let’s breeze through.

504 – Suspected Myocardial Infarction: ALS suspects an MI, they start cardiac monitoring, manage unstable dysrhythmias, check a 12-lead, start transport, and monitor vital signs. If the EKG is concerning for a STEMI (either because of the machine’s read or their own), they’ll run it past OLMC (generally FDNY’s OLMC, specifically) for assistance in determining whether the patient is having a slam-dunk, textbook STEMI, and should therefore go directly to a STEMI center, versus being able to be appropriately managed at a hospital that isn’t a STEMI center but might be closer.

504-A – Drug Therapy of Myocardial Ischemia: So, you’ve got a patient concerning for ACS. How are you gonna treat them to start? ALS Standing Orders for this protocol allow for 162mg of aspirin, as well as nitroglycerin every 5 minutes to help with pain. Note that the protocol includes caveats for patients who have recently used erectile dysfunction meds or who are hypotensive. And speaking of hypotension…

504-B – Cardiogenic Shock: Uh-oh, somebody’s hypotensive! ALS is instructed to give a small fluid bolus to these patients to help with preload, but if there’s no improvement in blood pressure at that point, guess what? Peripheral pressors to the rescue! Historically, crews generally had access to dopamine, but as times have changed, so have the protocols, expanding to include norepinephrine and even push-dose epinephrine! Dopamine has stayed in the protocols, however, to allow for services that still carry and are trained in its use. Tough administrative-level decisions often arise in EMS and other health systems when you have to reconcile best medical practices with logistical challenges. Norepinephrine might be the better med, but when you have thousands of providers that would need new training in its use, and a stockpile of dopamine that you’ve already paid for, it’s not hard to see why the change might be a slow one.

That’s it! All of these protocols are Standing Order, so there won’t be much to know for OLMC calls, although occasionally crews may call to ask about switching between pressors (eg, starting on push-dose epi and moving to a norepi drip). Otherwise, bask in your knowledge of EMS care, ever-expanding from these emails, www.nycremsco.org and the protocol binder!

Courtesy of Dr. David Eng, Assistant Medical Director of Emergency Medical Services at Maimonides