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

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