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

Pretty simple one this week for a cool-down, folks. Not a ton for EMS to do for patients with hyperglycemia other than to recognize it. Recognize that EMS should be equipped with blood glucometers starting at the BLS level; if, for any reason, an EMT tells you they do not have a BGM for a patient, remind them that obtaining blood glucose is necessary for their practice, and they should report any malfunctioning equipment to the necessary supervisor. 

Once the patient is confirmed to be hyperglycemic, BLS has a low threshold to request ALS backup, ultimately as a means to support the airway and start fluid resuscitation while transporting.  By Standing Order, ALS will bolus up to a liter of crystalloid (weight-based for pediatrics), and they will contact OLMC for permission to give up to an additional liter (again, weight-based for peds). Given that many of these patients often have extraordinary fluid deficits, this is likely a good place to start, but as with all OLMC requests, use your discretion and ask for as much info as you need to make the decision. Just remember that there is a potentially critical patient in front of the crew while you deliberate, so be prompt about it!

See you all next week! www.nycremsco.org and the protocol binder for more.

Dave

EMS Protocol of the Week - Ventricular Tachycardia with a Pulse / Wide Complex Tachycardia of Uncertain Type (Adult)

One more tachydysrhythmia left! The prehospital approach to wide complex tachycardias with a pulse (including VT) is pretty straightforward. Unstable? Zappy zappy, just like before. Otherwise, Standing Orders call for a single dose of amiodarone – 150mg in 100mL of NS, infused over 10 minutes. OLMC will be called if additional orders are needed. Your Medical Control Options include synchronized cardioversion, magnesium sulfate, calcium chloride, or sodium bicarbonate, to be administered as you see fit based on what you think might possibly be causing the dysrhythmia.

That’s all there is to it! EMS will give a smattering of meds, bring you the patient, and leave you with the honor and privilege of figuring out what the heck the patient’s problem is! Good luck! And take pride in your newfound complete and utter mastery of prehospital dysrhythmia protocols. You did it!

Next week: some new stuff! www.nycremsco.org and the ever-present protocol binder for more.

Dave

EMS Protocol of the Week - Supraventricular Tachycardia (Adult)

Next up in our dysrhythmia marathon is an oldie but a goodie – SVT! Again, Standing Orders lead off with instructions for synchronized cardioversion for unstable patients. For stable SVT, paramedics will give adenosine by Standing Order in the standard 6-12-12 strategy you all know and love in the ED. If hard rebooting the patient’s heart three times doesn’t fix the rate, OLMC will be called for additional orders. For Medical Control Options, you have access to the same diltiazem and amiodarone that were there for you in the atrial fibrillation/atrial flutter protocol from last week. Are either of those worth it? Who knows? You’re in charge, doc!

At this point, you might be thinking, “Dave, how can I know over the phone that the patient is really in AFib/Aflutter/SVT/etc.? Also, these emails are amazing! And you’re so funny!” Well thank you for the complements, firstly. But to answer your excellent question, different people are going to have different levels of confidence or trust in their paramedics. Processing information over the phone can be tricky since you can’t actually see what the field providers are seeing. But if there’s ever any uncertainty, remember that there are systems in place for transmitting EKGs! Or if that feels like too much, you can just ask about the tracing! Is the rhythm narrow complex? Regular? What’s the rate? Gather as much info as you need, and make your decision from there.

And if the complex is wide? Well, you’ll just have to stay tuned and find out! Or check out www.nycremsco.org or the protocol binder for spoilers!

Dave