EMS Protocol of the Week - Shock/Sepsis (Adult)

We previously touched briefly on prehospital pressor options for shock states, but the old formatting found them disjointed and scattered between protocols. While the new protocol formatting doesn’t quite fully fix this problem (and, in fact, much cleaner shock-specific protocols are in the works for next year), the newly organized Shock/Sepsis protocol is a step in the right direction.

Very little in the way of CFR and BLS components for this protocol, as you might imagine; we’re clearly pushing into critical care territory here, and the most useful interventions are going to be invasive to an ALS level of training. Note how, even in a circulation-focused protocol, everything falls back on ABCs. The paramedic section leads off with advanced airway management if indicated and follows with assessment for tension pneumothoraces as an etiology of shock. Following those crucial steps comes fluid resuscitation – up to 250mL in suspected cardiogenic shock, or up to 3L if non-cardiogenic. Consistent shock state, either by appearance or blood pressure, now calls for one of three vasopressors – push-dose epinephrine (here defined as a 10mcg IV bolus, for consistency of terminology), norepinephrine infusion, or dopamine infusion (no, we haven’t been able to get rid of dopa yet). Any one of these three options is available to paramedics as Standing Order. However, if the crew feels like they need to switch from one to another (ie, transitioning from persistent pushes of epi to a norepi drip), they require OLMC approval, so be prepared for those calls. Key Points include instructions on mixing push-dose epi, as well as prehospital criteria for severe sepsis/septic shock. Note that the criteria are slightly different from what we consider SIRS criteria in the ED – this was a conscious decision made in an attempt to increase specificity in the out-of-hospital setting. For patients that do fall into the sepsis category, crews are advised to pay particular attention to fluid administration, as well as other data such as temperature and lactate (neither of which is yet commonly available to crews; consider it future-proofing for one day, hopefully, having access to thermometers and some POC bloodwork).

That’s it! You’re all now pros at keeping the patient’s pressure up and your own pressure down! www.nycremsco.org for more!

Dave

EMS Protocol of the Week - Asthma/Wheezing (Pediatric)

Despite being a whopping three pages, the protocol for Pediatric Asthma/Wheezing is largely the same as its adult counterpart, just without considerations for COPD since it’s kind hard to rack up a 50-pack-year history of smoking before the age of 15 (although who knows how this kid is doing nowadays? https://www.youtube.com/watch?v=x4c_wI6kQyE ). 

Otherwise, as in the protocol for adults, CFRs will assist with home albuterol, BLS will give up to one albuterol nebulizer and an injection of IM epinephrine, and ALS will continue albuterol and add ipratropium and steroids as needed. Medical Control Options include additional doses of epinephrine or albuterol as indicated (note that Standing Orders allow for a maximum of 3 albuterol nebs for kids, versus continuous for adults). Pediatric dosing considerations are highlighted throughout this protocol, both for epinephrine and for dexamethasone; methylprednisolone, as well as magnesium sulfate for that matter, are reserved for adults).

Hope the new protocol format makes sense! Keep brushing up at www.nycremsco.org and with the protocol binder!

Dave

EMS Protocol of the Week - Asthma/COPD/Wheezing (Adult)

We previously went over the ALS asthma protocol under the old formatting style but had not gotten to discuss the prehospital approach to COPD. In all honesty, the two protocols were nearly identical to each other, so for the new version, they were combined into a single Asthma/COPD/Wheezing protocol for everyone’s convenience. Let’s dive in!

 I generally didn’t discuss the CFR and BLS protocols under the old formatting unless they were directly relevant to the ALS protocol, so I won’t spend a ton of time on them now. Just note that, in what is sure to be a running theme, CFRs will perform minimally invasive interventions (seat the patient comfortably, supply supplemental oxygen), and EMTs will provide active medication administration while initiating transport. In this case, that means starting one albuterol neb while getting the patient to the ambulance, and giving up to two more in transit (so three total). If the patient is in severe respiratory distress, the EMTs can give one dose of IM epinephrine (we previously discussed how this could be via an auto-injector or a pre-marked syringe to eliminate the need for the EMT to calculate dose). At this point, the BLS crew should also be requesting ALS backup for the patient. Once on scene, paramedics can begin to administer ipratropium along with the albuterol, give epinephrine if not already given, and obtain IV access for magnesium sulfate and steroids (methylprednisolone or dexamethasone) if indicated. 

When this protocol was previously divided separately between asthma and COPD, the key difference was that the COPD protocol did not include orders for magnesium or epinephrine. Currently, magnesium is still reserved for asthma, but epinephrine is permitted for both cohorts, although it “should be used with caution” in COPD, according to the Key Points section. Why? For epi, the biggest concern tends to be about the risk of arrhythmogenicity when given to COPD patients, although my take tends to weigh the risk of tachyarrhythmia versus the risk of respiratory failure. As far as mag? Frankly, I’m not sure why there’s exclusivity for asthma. I haven’t found a ton of literature showing benefit in COPD, but I haven’t really found anything showing it to be blatantly unsafe either. I tried making that case when combining the protocols a couple years ago, but my cries fell flat. Alas, my soapbox wasn’t tall enough. One day…

In any case, under this protocol, OLMC can be contacted by either an EMT or a paramedic requesting to give a second dose of IM epinephrine. When deciding whether to approve the Medical Control Option for repeat epi, again, I tend to weigh the risk of cardiac effects vs respiratory benefits. Remember that ALS can perform cardiac monitoring and cardioversion/defibrillation, if it really comes down to it. Use your judgment, docs. 

One final point. Note that this protocol can be followed a few ways in practice – 

1. 1. 911 is called for a patient having an asthma attack. CFRs show up first (since they’re around the corner) and perform Steps 1-6 just as a BLS unit arrives. EMTs begin their portion, but as the patient is in marked distress, they request ALS assistance, so that just as they’ve finished putting the patient on CPAP (Step 12), paramedics arrive to take over. The medics then run through Steps 13-17 en route to the hospital.

2. 2. 911 is called for a patient having an asthma attack. CFRs are getting coffee a few blocks away, so EMTs are first on scene. They start the process at Step 1 (the CFR portion) and progress all the way down to Step 12 as indicated, at which point they hit the EMT STOP point and care is either transferred to paramedics or the ED.

3. 3. 911 is called for a patient having an asthma attack. CFRs and EMTs are tied up in a heated debate over which season of The Mandalorian was better (I know, how is it even a question?). ALS is first on scene. Paramedics start the process at Step 1 (the CFR portion) and progress through Steps 7-12 (the EMT portion) prior to working through the actual Paramedic section.

4. 4. And so on.

There are a bunch of different ways this can play out (and in all of them, Season 2 reigns supreme). Just recognize that the new protocol formatting illustrates how much one level of training builds on the level below it, so moving forward, it’ll be to your benefit to familiarize yourself with the progression from CFR to BLS to ALS. 

Ready to get a jump start? www.nycremsco.org has the full pdf, and keep an eye out for a shiny new protocol binder!

Dave