EMS Protocol of the Week - Atrial Fibrillation/Atrial Flutter (Adult)

This week starts off our three tachydysrhythmia protocols! First up – atrial fibrillation and atrial flutter. As in all dysrhythmia protocols, the first step for paramedics is to determine if the patient in front of them is stable or unstable. If unstable, electricity is indicated, and Standing Orders list instructions for synchronized cardioversion at stepwise increases in joule settings as necessary. If stable, crews will progress to OLMC contact to request either diltiazem (0.25mg/kg IV bolus) or amiodarone (fixed dose of 150mg infusion over 10 minutes). If the crew is requesting diltiazem, be sure to check the math for the appropriate weight-based dosing. Also note that the Key Points section recommends halving the dose for certain patient subsets. If the crew requests amiodarone, consider asking them why! The efficacy of amio is questionable, but some crews may prefer it if the patient’s blood pressures are soft, although I’d argue that if the patient is truly hypotensive, you may need to have a conversation with them discussing electrical cardioversion. Whichever medication is requested, don’t forget to think critically about the patient! Why are they sotachycardic? Are they clearly septic? Dehydrated? Maybe fluids – rather than forcing rate control – are in their best interest. Food for thought!

Reach out with any questions! Otherwise, I’ll see you next week for more fast heart stuff! Until then, www.nycremsco.org or the protocol binder for more.

Dave

EMS Protocol of the Week - Bradydysrhythmia (Adult)

Leading off our run of dysrhythmia protocols is our protocol for adult bradydysrhythmias. Not a ton of critical thinking to do here – if the patient is bradycardic and unstable, paramedics will administer a single dose of atropine and start transcutaneous pacing by Standing Order. Beyond that, they will contact OLMC for further medications. Personally, I’ve often encountered calls where EMS providers have only given the dose of atropine prior to calling, so I’ll tend to take the opportunity to discuss with the crew whether they should consider starting to pace prior to freely authorizing other meds. When it comes to Medical Control Options, OLMC can authorize repeat doses of atropine, boluses of calcium chloride or sodium bicarbonate, or a dopamine infusion (might this instance actually be an indication for dopamine? You decide!). 

Short and sweet this week! Like most dysrhythmias, it boils down to meds and/or electricity. Just remember that if you’re electrocuting a conscious person, have some decency and consider some sedation! Another dysrhythmia is coming up next week, but until then, you’ve got www.nycremsco.org and the protocol binder to keep you company!

Dave

EMS Protocol of the Week - Dysrhythmia (Adult)

Similar to the older format of the NYC REMAC protocols, the new and improved version also includes a general dysrhythmia protocol that refers out to specific sub-protocols based on the underlying dysrhythmia. Not a lot of take-home points here, but the ones that are in this broad introductory protocol are important – 

• If the dysrhythmia is, well, pulselessness, refer to the relevant cardiac arrest protocol

• “unstable” dysrhythmias refer to ones in adults with hypotension or AMS; or ones in kids with hypotension for age, depressed mental status, or absent peripheral pulses

• “stable” dysrhythmias refer to those that lack the above features

• If you’re going to electrically cardiovert conscious patients, consider procedural sedation

That’s about it, aside from some considerations for joule settings based on specific equipment capabilities. Keep all of this in mind, though, as it will be important as we discuss specific dysrhythmias in the coming weeks! Until then, www.nycremsco.org or the protocol binder for more.

Dave