EMS Protocol of the Week - Bone and Joint Injuries (Adult and Pediatric)

The new protocol for bone and joint injuries is where you’ll find current prehospital analgesia options, at least until a dedicated pain management protocol comes out sometime next year (stay tuned!). This protocol has a couple of other non-medication features worth highlighting, though, so let’s run through it.

Like all of the other trauma-related protocols, ABCs are paramount. Following from those, BLS will focus on extremity immobilization prior to transport. Splinting specifics, including traction splinting, are listed in this section, along with instruction to attempt gentle realignment of the injured extremity if there is a concern for vascular compromise.

The ALS portion of the protocol focuses on analgesia options. Ultimately these amount to morphine and fentanyl, either of which can be given by paramedics as Standing Order only if the injury is limited to a single extremity. For an isolated extremity injury, paramedics can give up to two doses of morphine – to a maximum of 10mg total ­– or up to two doses of fentanyl – to a maximum of 100mcg total. Outside of the isolated extremity injury, crews will call OLMC for Discretionary Orders for one of those same medications. You may also encounter the occasional crew requesting a Discretionary Order for ketamine for pain; if you encounter such a call and decide to authorize ketamine, just be sure to be clear and specific about the dosage and route, given the numerous therapeutic ranges and uses for ketamine.

The last thing to note about this protocol is that it introduces a Medical Control Option for patellar reductions as a procedure for obvious patellar dislocations. If a crew calls OLMC requesting to perform a patellar reduction, I would say to use your discretion for authorization based on how comfortable you feel the crew is with the procedure as well as the overall condition of the patient. Just make sure that they’re describing a patellar dislocation and not a knee dislocation!

That’s all there is for this week, no…bones…about it!

Okay bye.

www.nycremsco.org or the protocol binder for more.

Dave

EMS Protocol of the Week - Seizures (Pediatric)

The pediatric seizure protocol hits all the same buttons as its adult counterpart, just with a slightly different focus on the medications. There’s a higher emphasis on glucagon for hypoglycemia, given that the IN/IM routes allow for rapid administration without having to get IV access. When it comes to benzodiazepine choice, the pediatric protocol limits Standing Order to midazolam, either IM or (preferably) IN. OLMC can permit a broader array of benzos as Medical Control Options, expanding options to lorazepam and diazepam, as well as adding IV as a route for any of the benzos.  

Remember to double check your math to ensure appropriate weight-based dosages for these meds! And always keep in mind the utility of IN as a route, especially for the kids.

Congrats! You’ve mastered prehospital seizures (again!) Again, other protocols will refer to this one as needed - moreso than in the old formatting. So it’s really like you learned a BUNCH of protocols with just a couple of emails! Aren’t you proud? I am!

www.nycremsco.org or the protocols binder for more!

Dave

EMS Protocol of the Week - Seizures (Adult)

I teased the new seizure protocols a few weeks back in discussing the updated head trauma protocols, and guess what? Your patience has been rewarded! We have two separate seizure protocols to talk about, so let’s start with the one for adults. 

As in all things, ABCs are a priority here, with emphasis at the CFR level on avoiding OPAs in favor of NPAs if possible, considering the risk of aspiration. BLS will address any hypoglycemia while requesting ALS backup as needed. And ALS will manage active seizures with one of three benzodiazepines (IV/IM/IN as available) – midazolam, lorazepam, or diazepam, each as Standing Order, with an SO for a single repeat dose of whichever they used, if needed. OLMC will be contacted if additional sedation beyond the two SO doses is needed, so be prepared for those calls for your stat ep patients. 

Remember that status epilepticus is extraordinarily time sensitive, so do what you can to safely help EMS manage these critical patients. Also keep in mind, as the key points section mentions, that relative hypoglycemia in your diabetic patients may be a precipitating factor, so make sure you ask about those fingersticks!

Stay tuned for the peds spin on seizures next week! Until then, www.nycremsco.org or the protocols binder for more.

Dave