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

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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

POTD: Neonatal Resuscitation

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We’ll be going over a few high yield topics pertaining to NALS today. 

It’s 7:30 AM, and you’ve just unwrapped your BEC sandwich and taken your first sip of coffee. You’re settling into the morning getting ready for your 12 hour peds shift… until the phone rings, and you get a note: 

“Mother 38w delivered her baby at home 30 minutes ago. Baby is having labored breathing, and is bradycardic. EMS will be here in 2 minutes.”

Take a deep breath. First, remember the basics. If you’re in a facility that has Peds/NICU, call them immediately. Call respiratory. Call pharmacy. Call Hector. Use the resources available to you. 

The set up.

Get the warmer and set it to 25 C

  • Avoid hypothermia in these patients. The goal is > 36.5-37.5C

Grab the Broselow tape so that it’s available for immediate use.
Get the backboard.
Grab the code cart, zoll
Get a towel to warm and dry the baby.
Get your airway equipment ready:

  • Suction x 2, plugged in, ready to go

  • Oxygen: grab the neonatal BVM and plug it into the oxygen port

  • Airway equipment: have both DL/VL equipment,

    • LMA size 1

    • Pre-loaded tubes

      • 2.5 and 3.0 uncuffed tubes

    • Blades: 0 and 1

    • EtCO2

Access: IO gun + pink needles ready for use; umbilical vein catheters (future POTD)

Grab your PALS card or open up your PediStat app
Ultrasound

Assess the patient.

Pediatric assessment triangle:

  • Appearance – crying? Good tone? Tracking?

  • Breathing – nasal flaring? Stridor? Grunting? Head bobbing?

  • Circulation – Pallor? Cyanosis? Mottling?

Off the bat, there are two numbers you need to remember:
HR < 100→ initiate positive pressure ventilation (PPV)
HR < 60→ initiate CPR / epinephrine if this is sustained more than 30 seconds despite adequate ventilation.

  • NOTE: Bradycardia is almost always related to hypoxia, so atropine isn’t routinely indicated for these patients.

Remember, the most important part of neonatal resuscitation is positive pressure ventilation.


PPV.

If the patient is spontaneously breathing but labored, you can place them on CPAP.
Remember, the targeted SpO2 after birth is much lower for neonates, so see the box below. You’re more interested in ventilating than the oxygenation.
For gasping / apneic / HR < 100 patients, initiate PPV. You can use 5 on the PEEP valve.

  • Rate: 40-60 breaths / minute

MR SOPA mnemonic for ventilation tips:

  • Mask, right size

  • Reposition airway

  • Suctioning nares

  • Open mouth

  • Pressure increase to PEEP to ~5

  • Advanced airway: ETT / LMA

BGM.

They also have lower BGMs. Hypoglycemia for neonates is < 30 for a patient < 24 hours old. It’s recommended to give D10 bolus 2ml/kg if the patient is hypoglycemic.

You can give glucagon IM too: 0.03mg/kg max 1mg

CPR.

It’s recommended to secure an airway (supraglottic or ETT) prior to doing compressions) since most these codes are usually due to respiratory events.
The ideal ratio is3 compressions:1 breath

  • Goal is 90 compressions: 30 breaths in one minute

2 thumb compression technique (*preferred) or 2 finger technique
Pulse checks q1 min
Depth: ⅓ chest diameter

Epinephrine.

IV dosing: 0.01mg/kg q3-5min
ETT dosing: You can give epinephrine through the ETT too if you don’t have access yet! AHA recommends a larger dose 0.1mg/kg of 1:1000 ETT

  • Max dose is 10mg, and follow it with a saline flush

I highly recommend reviewing the following flowchart linked.

I hope this was a good refresher on some of the most important concepts. I would love to learn other tips that others have in managing these stressful situations!

References:

https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/neonatal-resuscitation 

https://emergencymedicinecases.com/neonatal-resuscitation/ 


POTD: Test taking tips

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Today I’m going to be covering some test-taking strategies.

Focus on your weaknesses:

Don’t waste too much of your time reinforcing your strengths. Study your weakest topics that you don’t have daily exposure to in residency. If you have very limited time to study, consider filtering your Rosh Review question bank by your weaker topics, like Environmental, Heme/Onc, etc. 

Spaced repetition:

In order to retain information long term, you will likely need spaced repetition of the material. Don’t finish all of the environmental questions 3 months before the test. Try to revisit the material by doing some of those questions again, or by reviewing some of your notes.
Try to incorporate mental repetition into your daily routine. For example, quiz yourself on some topics that you learned earlier that day while you’re on the train or while you’re walking. 

Quick blocks:

Try to study in small blocks more frequently. 

Actively learn:

Don’t just passively nod your head and highlight each wrong answer you get in Rosh Review. Try to mentally quiz yourself after reading the explanations. Consider keeping a document with high yield notes.

Answering the questions:

All questions are created equal, and unanswered questions are marked as incorrect. Give yourself time to finish the test! Don’t spend too long on one question – it’s more important to finish the entire test.

Know your learning style:

Supplement your learning and tailor your study plan to your learning style. There are excellent free videos (https://www.intrainingprep.com/) and EMRAP Crunch Time audio reviews for the boards. 

Never pick an answer that uses “absolute terms:”

Avoid answer choices that include: always / never. 

If in doubt, pick the “long correct” answer: 

The detailed beautifully explained answer choice is often correct. They might include double options, more information, and caveats. 

1-2 days before the test:

Review a high yield document with a bunch of buzzwords and highly tested concepts. I’ve attached one of my favorite ones to this document. This will help refresh concepts you’ve reviewed a few weeks ago. I highly, highly recommend using this!!! I think like 20+ questions last year came up from this document. 

They’re not trying to trick you:

If the question stem obviously sounds like a PE, it’s probably a PE. Don’t overthink it. Just make sure you read the question carefully, and then move on.

I hope this helps! I know most of this is pretty obvious, but trust yourself and go with your gut. 


References:

https://knowledgeplus.nejm.org/blog/10-mistakes-studying-for-the-boards/ 
https://www.roshreview.com/blog/how-to-increase-your-emergency-medicine-board-exam-score-by-10-points/


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