EMS Protocol of the Week!!! - Stridor/croup/epiglottitis (Peds)

It’s that time of year! All the children have been coming in with respiratory distress. These days, most often it’s a child with bronchiolitis. But it’s also important not to forget about the kids coming in with croup, anaphylaxis, airway obstruction, and the rare but scary epiglottitis.

Management?

As always…ABC’s.

1.     Administer high flow O2 via NC or face mask

2.     Consider obstructed airway vs. anaphylaxis as causes of respiratory distress

3.     Stridor at rest? Think croup.

a.     Epi 3mg nebulized OR racemic epi nebulized

4.     Get IV access (in real life, depending on age of the child I feel like this doesn’t always happen, but it’s important for children in respiratory distress who can decompensate quickly)

5.     STEROIDS!! (ONLY if 2 years or older)

a.     Dex 0.6mg/kg to max of 12mg or methylpred 1mg/kg to max of 60mg

If EMS suspects Epiglottitis, EMS will NOT attempt advanced airway – will only ventilate with bag valve mask and transport ASAP

Last but not least, OLMC (which we are all experts on now after Vic’s great emails the other week)

-       EMS must call if kid is <2 y/o in respiratory distress and wants to give steroids

KEY POINTS:

-       Croup = stridor + retractions + barking cough

-       Epiglottitis = stridor + retractions + muffled voice + high fever (TOXIC APPEARING)

-       Unvaccinated = high risk for epiglottitis

-       Airway obstruction (foreign body, mass) = biphasic stridor

-       Don’t agitate a child already in respiratory distress

-       Dex > methylpred in kids

And if you want more... www.nycremsco.org

Jennifer Wolin, MD

Emergency Medicine PGY-2 Resident Physician

Maimonides Medical Center

EMS Protocol of the Week - Adult Respiratory Distress

Hi EM friends,

Time to take your breath away with another EMS protocol of the week. This week's focus will be on adult respiratory distress and how our prehospital counterparts initiate patient care prior to handing them off to us. A few months ago, we discussed the respiratory distress protocol for pediatric patients - a lot of overlap here except EMS providers have a couple more tricks up their sleeves when it comes to adults.

The prehospital approach to respiratory distress exists as a progression of care based on the provider's level of training. CFRs start with ABCs and monitoring vital signs. If needed, these providers can implement airway adjuncts and administer supplemental O2. All patients will be started off on a NRB unless the mask is not tolerated in which case O2 will be given via NC. At this level of training, CFRs can then address potential drug overdose. 

BLS crews can address all of the above and will then transport these patients to the hospital. They can additionally request ALS backup while en route. If available, CPAP therapy can be utilized for patients with persistent distress. 

If the on-scene team is ALS-trained, they can perform advanced airway management as necessary. From here, ALS providers will start cardiac monitoring, EKG interpretation, and establish IV access during transport. They can even assess and treat for a tension pneumothorax or administer Nitroglycerin for suspected flash pulmonary edema.

There is not a lot to be aware of from an OLMC standpoint, but providers have the option of authorizing Lasix to be given to patients that may benefit.

Also important to note, ALL patients who are received by EMS crews in respiratory arrest MUST receive ventilatory assistance unless an official DNR order and/or MOLST form is provided to the crew.

More words to read at www.nycremsco.org.

Best,

Zachary Kim, MD

PGY-2 Emergency Medicine

EMS Protocol of the Week - Non-Traumatic Cardiac Arrest (Pediatric)

Not a ton of difference between the prehospital protocol for pediatric non-traumatic arrest when compared to its adult counterpart, at least in terms of the interventions available. The same medications and electricity can be found in the pediatric toolbox as well, albeit with more of an emphasis on age-and-weight-appropriate dosing, which is explicitly described within the protocol for your reference. Similarly to adult arrests, you may encounter OLMC calls requesting orders for calcium, sodium bicarb, or antiarrhythmics like amiodarone. 

Also worth noting is the caveat describing effective BVM use as a "reasonable alternative" to other advanced airways when needed; the point being that, given the predominance of respiratory etiologies in this population, it is likely more beneficial to focus on adequate bagging and mask seal rather than spend multiple attempts trying to intubate a difficult airway. 

Keep this protocol flagged for future use, as it's a great way to offload memorizing doses for some of these critical meds. Not that any of us would have to do that, since clearly these calls are incredibly low-stress (just...kid-ding?).

Ok bye. www.nycremsco.org for more.

Dave