EMS Protocol of the Week - Emergency Childbirth

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Hi all, 


This week we will be focusing on Emergency Childbirth! 


The prehospital approach exists as a progression of care based on the provider’s level of training. CFRs start with ABCs and monitoring vital signs for shock. They will check for crowning and if present prepare for imminent delivery. 


This is a general outline to help providers: 


1) Apply gentle pressure against the delivering newborn’s head to prevent tearing of the perineum 

2) Gently clear the airway of secretions using a bulb syringe

3) Support the head and chest as the newborn delivers

4) Repeat suctioning as necessary prior to spontaneous or stimulated respirations

5) Gently guide the head downward until the shoulders appear. Deliver the other shoulder with gentle upward traction

6) Thoroughly but rapidly dry the newborn with a clean, dry towel 


After delivery, delay clamping of the umbilical cord for up to 1 minute after uncomplicated delivery. Wrap the newborn in a dry, warm blanket/towel. Assess the mother for postpartum hemorrhage and shock. When safe to do, place newborn on mother’s chest. 


If the on-scene team is BLS-trained, they will be able to assess and help manage breech presentations, prolapsed cord, nuchal cords, intact (not ruptured) amniotic sacs, shoulder dystocia, and multiple births. See the attached protocol for detailed recommendations for these special considerations. 


KEY POINTS: 

  • Consider supine hypotension syndrome as a cause of shock 

  • Newborns are subject to rapid heat loss and must be kept warm and dry 

  • Miscarriage usually occurs at less than 20 weeks of gestation. Begin resuscitative efforts of the newborn if the gestational period is unknown 

  • The turtle sign is when the newborn’s head retracts back into the vagina, and is an indication of shoulder dystocia 

  • It is no longer suggested to perform aggressive suctioning of the newborn when meconium is present  

  • Do not aggressively suction premature newborns 

More words to read at www.nycremsco.org

John Su

EMS Protocol of the Week - Severe Sepsis and Septic Shock (Adult and Peds)

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Hello EM friends,

For this week's protocol review, we're going to discuss the pre-hospital world of sepsis care. This one's a BOGO deal and will include the approach for both adults and little adults (pediatrics). 

Our EMS colleagues are trained to identify septic patients using very similar criteria to us: 2 SIRS-like + presumed infection. Reference this table to see the differences with our criteria (mainly to increase specificity for correctly identifying septic patients in the field / working with more limited resources):

CFR and BLS crews unfortunately will not be able to offer much in the way of interventions - we're dabbling in the world of critical care. CFRs can assess ABCs/vital signs and administer O2 as necessary. BLS crews can additionally obtain BGMs and treat as indicated; otherwise, they will request ALS assistance if required and transport patients to the hospital. 


ALS crews can administer much more in terms of therapeutics - they can perform advanced airway management, cardiac monitoring, EKG evaluation, IV/IO access, crystalloid administration, and adult vs pediatric specific blood pressure management protocols. Before the adult and pediatric protocols branch, paramedics will  start by administering both groups a 20 mL/kg IV bolus. If the patient is still hypotensive, the protocols are as follows:

  • Adults: 

    • Goal: SBP > 90 mmHg or MAP > 65 mmHg

    • Administer one of the following:

      • Additional 20 mL/kg bolus

      • Norepinephrine IV (20 mcg/min max) infusion

      • Epinephrine 10mcg pushes Q3-5 minutes

  • Pediatrics:

    • Goal: age-appropriate BP goals

    • Activate OLMC to administer one of the following:

      • Additional 20 mL/kg bolus

      • Epinephrine 5mcg pushes Q3-5 minutes

      • Norepinephrine 0.05mcg/kg/min (20mcg/min max) infusion


Over the OLMC phone, we will have the power to authorize Vasopressin infusions to maintain SBP/MAP goals for adults. And again, ALS crews will have to communicate with us to administer any BP support beyond the initial 20 mL/kg bolus for pediatric patients. 

More knowledge to be farmed at www.nycremsco.org.

Best,

Zachary Kim, MD

PGY-2 Emergency Medicine

EMS Protocol of the Week: Obstetric Emergencies!

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Hi all, 

This week we will be focusing on Obstetric Emergencies!

The prehospital approach exists as a progression of care based on the provider’s level of training. CFRs start with ABCS and monitoring vital signs for shock. They will check for crowning and if present prepare for imminent delivery. If delivery has not begun, they will place the patient in a left lateral recumbent position. 

BLS crews can address vaginal bleeding in pregnancy by placing dressing over the vagina to help estimate quantity of blood loss. If immediately postpartum, they can massage the mother’s abdomen over the uterus. 

If the on-scene team is ALS-trained, they can obtain IV access for patients with severe pre-eclampsia, eclampsia or postpartum hemorrhage. For patients with eclampsia, they can administer Magnesium Sulfate 4 g IV over 10 minutes. 

From an OLMC standpoint, providers can authorize 2g Magnesium Sulfate over 10 minutes for patients with concern for pre-eclampsia. 

KEY POINTS: 

  • Consider supine hypotension syndrome as a cause of shock 

  • Severe pre-eclampsia is when pregnant patients have BOTH of the following conditions: 

    • Systolic blood pressure ≥ 160 mm Hg OR a diastolic blood pressure ≥ 110 mm Hg 

    • Symptoms of a headache, visual disturbances, pulmonary edema or lower extremity edema 

  • Eclampsia and pre-eclampsia do not occur prior to 20 weeks of gestation 

  • Eclampsia and pre-eclampsia may occur up to one (1) month post-partum 


More words to read at www.nycremsco.org