The Double Set-up

Hi all,

This is going to be a short but important POTD!

I wanted to write about an airway set up technique, colloquially termed “The Double Set Up” that the trauma and northside teams used yesterday during a level 1 trauma.

Without giving any secrets away for a case that will likely be an M&M in the future, for some situational background, the patient was getting progressively hypoxic with vomitus covering the entire airway. It was hard to get visualization of the airway using the Glidescope. The airway options were clear: either tube via DL or crich.

The team smartly employed the double set up technique to secure the airway. 

What does this term mean?

The double set up is when you have simultaneously set up for an orotracheal intubation and for a cricothyroidotomy. The EM/ anesthesia physician is at the head of the bed with the orotracheal airway equipment, while the surgeon is completely prepared for the crich with the scalpel in hand at the neck of the patient. The neck should already be prepped, and the landmarks should be identified.

When should we do the double set up?

Strayer has an amazing blog post about this (see below). Here are some indications where you might want to do the double set-up:

• An unstable maxillofacial trauma patient

• As a last ditch effort to secure the orotracheal tube after a failed attempt

• Rapidly desaturating patient with challenging anatomical features / cannot be successfully bagged

• Concern for an obstructed airway

If the intubator is ultimately unsuccessful, they indicate to the surgical airway physician to proceed. If the orotracheal intubator is successful, then the surgical airway physician can stop.

References:

• Check out Strayer’s excellent post on this: https://emupdates.com/the-emergency-department-double-setup/ 

• https://www.emed.theclinics.com/article/S0733-8627(17)30075-5/pdf 

• http://maryland.ccproject.com/wp-content/uploads/sites/8/2015/09/Leeuwenberg-2015-Airway-Management-of-the-Critically-Ill-Patient-Modifications-of-Traditional-Rapid-Sequence-Induction-and-Intubation.pdf
  

EMS Protocol of the Week - Stroke [Cerebrovascular Accident (CVA)] (Adult and Pediatric)

The bulk of prehospital stroke management has not changed drastically between this year and last. The majority of these calls, like with trauma cases, are handled by BLS units since there are more of them in the city; this increases the likelihood of immediate, rapid transport to a definitive care center, which is ultimately what these patients need.

A few important takeaways:

1.       Any patient with a suspected CVA should be receiving a prehospital glucose measurement, regardless if they’re with a BLS or ALS crew, for the same reason why we check BGM in the ED during stroke codes.

2.       The attached appendix elaborates on the NYC S-LAMS score, which is the go-to prehospital stroke scale in New York City, derived largely from components of the two other major scoring criteria used in the US: The Cincinnati Stroke Scale and the Los Angeles Motor Scale. Look at the attached flowsheet for specifics, but essentially –

a.       if S-LAMS is >= 4 and no exclusion criteria present, the patient has a high concern for acute LVO and should pass potentially closer hospitals to go to the nearest thrombectomy-capable center

b.       if not, the patient should be either brought to a Primary Stroke Center (that can provide medical stroke care, thrombolysis, but not thrombectomy) or a non-stroke center ED, depending on the presentation

c.       you are NOT expected to know which hospitals are Primary Stroke Centers vs Comprehensive (Thrombectomy) Stroke Centers vs general EDs, BUT you should be able to assist crews that call OLMC to determine which TYPE of destination WOULD be appropriate, after which they can work with their own dispatch to determine which hospital to go to; again, refer to the flowsheet for specifics

3.       One NEW feature in this year’s protocol is the addition of metoprolol, 5mg slow IV push, as a Medical Control Option for patients hypertensive to >210/120 (assuming ALS providers are present). As with other MCOs, listen to the crew’s entire presentation, use your discretion, and make sure to utilize great closed-loop communication in your orders.

As always, reach out with questions/comments/concerns, make the most of www.nycremsco.org and the protocol binder, and we’ll see you next week!

Dave

EMS Protocol of the Week - Overdose (Adult and Pediatric)

In last year’s version of the protocols, the main place to find guidance regarding naloxone administration was in the protocol for Altered Mental Status. This year, naloxone is given its own spot to shine in a broader protocol for various types of overdose. Bear in mind as read through the protocol top down that, when indicated, patients may receive up to 4mg of naloxone IN as well as up to 4mg naloxone IV prior to arrival – important information to have when taking EMS report. Another interesting addition to this protocol for 2022 are Medical Control Options for diphenhydramine, sodium bicarbonate, and a variety of benzodiazepines – to be used for dystonic reactions, TCA overdoses, and sympathomimetic overdoses, respectively – so don’t be caught off guard if the OLMC phone rings with a request for one of those.

Cool stuff – better organization, extended spectrum of meds, what more could you want? www.nycremsco.org or the protocol to see what else we have in store!

Dave