EMS Protocol of the Week - Brady-Dysrhythmia (Adult)

Joe Liu gave us a great overview of some tachyarrhythmia protocols recently, so I figured I should earn my keep and balance things out with a review of prehospital management of bradydysrhythmias. As always, the first question on scene is going to be whether the rhythm is stable or unstable – does the patient seem to be perfusing well with that low heart rate, or is there evidence of shock?

If it’s the former, OLMC may receive a call to discuss administering one of the Medical Control Options for this protocol, which include atropine, inotropic agents such as dopamine and epinephrine, and reversal/stabilizing agents such as calcium chloride and sodium bicarbonate. Use your discretion with authorizing these meds, understanding that just because the patient appears stable now doesn’t mean they can’t decompensate en route.

If it’s the latter, paramedics will have a bit more autonomy with their Standing Orders, which call for an initial dose of atropine, as well as transcutaneous pacing if needed.

Take your time to really read through the medication options in this protocol, as well as their indications. Remember, slow and steady wins the race (but slow and irregular may get zapped).

www.nycremsco.org and the protocol binder for more!

Dave

EMS Protocol Of The Week - Seizures

I will start this EMS protocol of the week with a brief story…

You know that uncomfortable time when you’re out enjoying your day, then all of a sudden you hear someone yelling “we need a doctor!” and your like oh god is that me? Am I supposed to go help? The first time this happened to me, I actually was NOT a doctor…yet  I was in my 4th year of med school and was on the subway, and a man in my car started having a seizure. In my head I was like should I get up and do something because technically I’m not a doctor…but I was also telling myself well if this man is having a seizure there’s really not much that can be done without any medications or equipment except for protecting him from injuring himself. Then I hear “someone start CPR!!” At that point I got up and was like “No please don’t do that!” The man stopped seizing, the subway arrived at a station, and EMS was able to take over. 

In the ED, when someone seizing is brought in, our main concerns are terminating the seizure if necessary and airway.

What can EMS do for someone in the field that is seizing?

1.     Protect pt from injury

2.     Airway – patient positioning, NPA (do not use OPAs), advanced airway if needed (paramedics only)

3.     Provide O2

4.     Measure BGM

What meds can be given from paramedics?

-       Midazolam 0.2mg/kg IV/IN/IM (max dose 5mg)

-       Lorazepam 0.1mg/kg IV/IM/IN (max dose 2mg)

-       Diazepam 0.2mg/kg IV (max dose 5mg)

When does online medical control (OLMC) get called?

-       If seizure activity persists despite 2 doses of SAME med at SAME dose

Anticonvulsant meds should be administered as soon as possible, and IV access is the preferred route. Always remember to check the glucose, and also consider eclampsia as a possible cause! And lastly, don't perform CPR on someone who has a pulse :) 

And as always, if you want more information, you can go tot www.nycremsco.org

carpe diem. 

Jennifer Wolin, MD

Emergency Medicine PGY-2 Resident Physician

Maimonides Medical Center

EMS Protocol of the Week - A. Fib / A. Flutter / SVT

Don’t tell A FIB about SVT. You’ll make my heart FLUTTER.

We're interrupting your weekly emails from EMS extraordinaire Dr. Dave Eng to bring you some guest posts. This week we will be discussing EMS protocols for three tachyarrhythmias: 1) A.fib + A.flutter, and 2) SVT

1) Atrial Fibrillation / Atrial Flutter

First question: is this patient stable or unstable? If this patient is hypotensive, altered, or has signs of hypoperfusion, this is an unstable patient. Standing Order will allow paramedics on scene to perform SYNCHRONIZED CARDIOVERSION up to 4 times (first 100J, then 200J, then 300J, then 360J). If that does not work, they will call OLMC for one of two options: administration of Amiodarone 150mg IV or repeating SYNCHRONIZED CARDIOVERSION at max joules setting.

If the patient is stable, there are no Standing Order available so paramedics will call OLMC for one of three options: IVF 10 ml/kg IV, Diltiazem 0.25 mg/kg IV, or Amiodarone 150mg IV. Before authorizing, first assess whether their tachyarrhythmia is compensatory for another cause (i.e. hypovolemia, sepsis, etc.) that may be better addressed first before addressing the rhythm. Choosing what to authorize is dealer’s choice, but typically IVF or Diltiazem is the safest. Diltiazem is great if there is a narrow-complex tachycardia in an otherwise stable patient. I’ve successfully converted a patient with Diltiazem who subsequently arrived at our ED in normal sinus rhythm 15 minutes later. Amiodarone is another option, however has some major side affect profiles as we know. Thoughts are it might help control rhythm while being gentler on the blood pressure in comparison to Diltiazem.

2) SVT

First question again: stable or unstable? If unstable, Standing Order allow paramedics to perform SYNCHRONIZED CARDIOVERSION up to 4 times (first 100J, then 200J, then 300J, then 360J). If the patient is stable, Standing Order allows administration of Adenosine 3 times (first 6mg, then 12mg, then 12mg). If these orders don’t work for both stable or unstable SVT, paramedics will contact OLMC for Diltiazem 0.25mg/kg IV or Amiodarone 150mg IV.

Check out www.nycremsco.org or the protocol binder on North Side for more.

Sincerely,

Joseph Liu, DO

Chief Resident, Emergency Medicine PGY-3

Maimonides Medical Center