NYC EMS Protocol - Severe Nausea/Vomiting

Author: David Eng, MD

Assistant Medical Director, Emergency Medical Services

Attending Physician, Department of Emergency Medicine

Maimonides Medical Center

For reference here is a link to all of the NYC REMAC protocols as updated in 2019: https://www.nycremsco.org/wp-content/uploads/2017/10/04-ALS_Protocols-January-2019-vALS01012019B.pdf

Hey there, OLMC pros! Short one for review this week – Protocol 531, Severe Nausea/Vomiting.

Note that, compared to the previous protocols we’ve gone over, this one is entirely Standing Orders, meaning that paramedics can do all of these things, starting with fluid administration and vitals and including the administration of Ondansetron, without physician input. In other words, there are no Medical Control Options for paramedics to call in and request. So why do we care?

Well, first off, did you know that paramedics can give Ondansetron without physician approval? A whole whopping 8mg of it! Any chance you’ve given even more to a patient in the ED without realizing they’ve already got some in their system? Probably!

Now knowing that, take a look at the wording for Step 5, discussing the Standing Order for Ondansetron. If we’re really nitpicking and taking the phrasing as literally as possible (which we should be), what it says is that paramedics can give up to two weight-based doses, each up to 4mg, for a total of up to 8mg maximum. Sounds good so far. But what if you have someone that weighs 30kg, such that each weight-based dose is 3mg, so that after the two doses they’ve received 6mg but are still vomiting? Well, this might be an instance where EMS may call to request a Discretionary Order to give those last 2mg (totaling the 8mg maximum). Should you authorize it? Maybe, maybe not; use your discretion! Is this a young, healthy person with a particularly bad gastroenteritis, or could there be something more at play? Is an extra squirt of Zofran more likely to help or hurt? What information could help you decide?

Those questions speak to the broader point addressed in Step 4 – what other nefarious processes could be making someone vomit this much? Is the patient at risk for an atypical ACS presentation? Hopefully the crew checked an EKG, but if they didn’t prior to calling you, it may be worth politely asking for a 12-lead. Does the patient have diabetes, and this is all coming from DKA? Did the crew tell you the fingerstick? Maybe the right choice is to aggressively hydrate while transporting to the ED.

Once again, this is medicine that you all know, and if you’re dealing with this patient in the ED, you’d all know how to proceed with management. The trick is learning how your thought processes and actions interface with those of our prehospital providers. Once you realize that many patients’ presentation and treatment actually begin in the back of an ambulance and not just when they cross our sliding doors, you can begin to see how comprehensive emergency care here in the city really is.

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NYC EMS Protocol - Ventricular Fibrillation/Pulseless Ventricular Tachycardia Arrest

Author: David Eng, MD

Assistant Medical Director, Emergency Medical Services

Attending Physician, Department of Emergency Medicine

Maimonides Medical Center

For reference here is a link to all of the NYC REMAC protocols as updated in 2019: https://www.nycremsco.org/wp-content/uploads/2017/10/04-ALS_Protocols-January-2019-vALS01012019B.pdf

Last time we addressed PEA/Asystole, so for this week’s protocol review, let’s get WILD and UNPREDICTABLE by going over EMS Protocol 503-A, Ventricular Fibrillation/Pulseless Ventricular Tachycardia!

You’ll notice that for VF/Pulseless VT, both the Standing Orders and Medical Control Options are similar to those seen in the PEA/Asystole protocol, with a couple of key differences:

- SOs have, predictably, a large focus on rhythm control, both with the initial bolus of Amiodarone (Step 9) and, more importantly, with frequent attempts at defibrillation if indicated. This follows from the understanding that the only consistently recognized beneficial interventions for out-of-hospital cardiac arrests (OOHCA) are early recognition of the arrest, early high quality CPR, and early defibrillation (when appropriate).

- MCOs now include options for the repeat Amiodarone bolus (Option A) if indicated, as well as the option for Magnesium Sulfate (Option C), such as you’d consider for things like Torsades de Pointes. 

As an aside, one thing not explicitly described in this protocol is the patient experiencing refractory VF. In these instances, no one would be faulted for instructing the crew to just transport the patient to the ED (MCO Option E), but another option you might consider would be Dual Sequence Defibrillation. Many paramedics are familiar with the concept at this point, and while the procedure is not explicitly described in current protocols, you have the option to advise the crew on attempting DSD as a Discretionary Order (DO) (neither an SO nor an MCO, but something the paramedic is equipped with and trained to use, just as an “off label use” in this instance, under physician direction). In this case, they obviously know how to use a defibrillator, except now you’d be asking them to use a second one, at the same time, in a slightly different location. Note that you cannot request interventions like Esmolol as a DO since, unlike a defibrillator, EMS crews neither carry nor receive training in how to use Esmolol. Just some food for thought.

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NYC EMS Protocol - PEA/Asystole Arrest

Author: David Eng, MD

Assistant Medical Director, Emergency Medical Services

Attending Physician, Department of Emergency Medicine

Maimonides Medical Center

For reference here is a link to all of the NYC REMAC protocols as updated in 2019: https://www.nycremsco.org/wp-content/uploads/2017/10/04-ALS_Protocols-January-2019-vALS01012019B.pdf

Let’s take a look at a protocol that’s pretty heavily utilized in OLMC calls, 503-B, PEA/Asystole:

Steps 1-8 constitute STANDING ORDERS (what the paramedics will be performing on their own by default), while the lower part describes MEDICAL CONTROL OPTIONS (what the medics will be calling OLMC to request of you). This means that prior to contacting you for a PEA/Asystole arrest patient, they should have obtained an advanced airway (either an endotracheal tube [ETT] or supraglotic airway [SGA]), checked and accounted for tension pneumothoraces and hypoglycemia, and given epinephrine every 3-5 minutes while continuing CPR, same as you would normally do for an arrest in the ED. Normally, they’ll go through a few rounds of this before contacting OLMC for one or more Medical Control Options (MCOs):

Does the patient have a history of renal failure or another reason to be suspicious for hyperkalemia? Consider authorizing the use of Sodium Bicarbonate (Option A) or Calcium Chloride (Option B)!

Is the arrest due to severe hypovolemia from profound dehydration or septic shock? Is that pulseless, narrow complex rhythm just because the patient has insufficient intravascular volume to generate a pulse? Then maybe they need aggressive fluid bolusing (Option C)!

Is there something else you think is going on that is just better served by having the patient brought to the hospital? You also have the option to tell the crew to focus on just getting the patient into the ambulance and transported to the ED (Option D).

Taken as a whole, the Standing Orders and Medical Control Options do a decent job of addressing most of the H’s and T’s you would consider for the same arrest in the ED, and certainly, if any of these interventions lead to ROSC (or if you otherwise request transportation), the crew will default to bringing the patient to the ED. Of course, under the right circumstances, you are also within your right to withhold any of those MCOs in favor of Termination of Resuscitation, which we can save for a future post!

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