EMS Protocol Of The Week - Seizures

I will start this EMS protocol of the week with a brief story…

You know that uncomfortable time when you’re out enjoying your day, then all of a sudden you hear someone yelling “we need a doctor!” and your like oh god is that me? Am I supposed to go help? The first time this happened to me, I actually was NOT a doctor…yet  I was in my 4th year of med school and was on the subway, and a man in my car started having a seizure. In my head I was like should I get up and do something because technically I’m not a doctor…but I was also telling myself well if this man is having a seizure there’s really not much that can be done without any medications or equipment except for protecting him from injuring himself. Then I hear “someone start CPR!!” At that point I got up and was like “No please don’t do that!” The man stopped seizing, the subway arrived at a station, and EMS was able to take over. 

In the ED, when someone seizing is brought in, our main concerns are terminating the seizure if necessary and airway.

What can EMS do for someone in the field that is seizing?

1.     Protect pt from injury

2.     Airway – patient positioning, NPA (do not use OPAs), advanced airway if needed (paramedics only)

3.     Provide O2

4.     Measure BGM

What meds can be given from paramedics?

-       Midazolam 0.2mg/kg IV/IN/IM (max dose 5mg)

-       Lorazepam 0.1mg/kg IV/IM/IN (max dose 2mg)

-       Diazepam 0.2mg/kg IV (max dose 5mg)

When does online medical control (OLMC) get called?

-       If seizure activity persists despite 2 doses of SAME med at SAME dose

Anticonvulsant meds should be administered as soon as possible, and IV access is the preferred route. Always remember to check the glucose, and also consider eclampsia as a possible cause! And lastly, don't perform CPR on someone who has a pulse :) 

And as always, if you want more information, you can go tot www.nycremsco.org

carpe diem. 

Jennifer Wolin, MD

Emergency Medicine PGY-2 Resident Physician

Maimonides Medical Center

EMS Protocol of the Week - A. Fib / A. Flutter / SVT

Don’t tell A FIB about SVT. You’ll make my heart FLUTTER.

We're interrupting your weekly emails from EMS extraordinaire Dr. Dave Eng to bring you some guest posts. This week we will be discussing EMS protocols for three tachyarrhythmias: 1) A.fib + A.flutter, and 2) SVT

1) Atrial Fibrillation / Atrial Flutter

First question: is this patient stable or unstable? If this patient is hypotensive, altered, or has signs of hypoperfusion, this is an unstable patient. Standing Order will allow paramedics on scene to perform SYNCHRONIZED CARDIOVERSION up to 4 times (first 100J, then 200J, then 300J, then 360J). If that does not work, they will call OLMC for one of two options: administration of Amiodarone 150mg IV or repeating SYNCHRONIZED CARDIOVERSION at max joules setting.

If the patient is stable, there are no Standing Order available so paramedics will call OLMC for one of three options: IVF 10 ml/kg IV, Diltiazem 0.25 mg/kg IV, or Amiodarone 150mg IV. Before authorizing, first assess whether their tachyarrhythmia is compensatory for another cause (i.e. hypovolemia, sepsis, etc.) that may be better addressed first before addressing the rhythm. Choosing what to authorize is dealer’s choice, but typically IVF or Diltiazem is the safest. Diltiazem is great if there is a narrow-complex tachycardia in an otherwise stable patient. I’ve successfully converted a patient with Diltiazem who subsequently arrived at our ED in normal sinus rhythm 15 minutes later. Amiodarone is another option, however has some major side affect profiles as we know. Thoughts are it might help control rhythm while being gentler on the blood pressure in comparison to Diltiazem.

2) SVT

First question again: stable or unstable? If unstable, Standing Order allow paramedics to perform SYNCHRONIZED CARDIOVERSION up to 4 times (first 100J, then 200J, then 300J, then 360J). If the patient is stable, Standing Order allows administration of Adenosine 3 times (first 6mg, then 12mg, then 12mg). If these orders don’t work for both stable or unstable SVT, paramedics will contact OLMC for Diltiazem 0.25mg/kg IV or Amiodarone 150mg IV.

Check out www.nycremsco.org or the protocol binder on North Side for more.

Sincerely,

Joseph Liu, DO

Chief Resident, Emergency Medicine PGY-3

Maimonides Medical Center

EMS Protocol of the Week - Termination of Resuscitation (ToR) Guidelines

Last week, we went over everything EMS is capable of doing for an adult in cardiac arrest. This includes what they will do under Standing Orders, as well as what they may request of OLMC as a Medical Control Option. But what if they are unable to obtain ROSC after all of those interventions? Or what if they’ve only performed Standing Orders, and you don’t think any of the Medical Control Options will make a difference? Do all of these patients need to be transported to the hospital?

No!

There are plenty of instances where you’ll be asked – or where you deem it appropriate – to terminate resuscitative efforts of EMS providers in the field, rather than having them transport the patient to continue efforts in the ED. Attached are current guidelines for when you, as the OLMC physician, may consider Termination of Resuscitation (ToR), but keep in mind that these are just guidelines and thus exist secondarily to your own clinical judgment. You are not required, for example, to insist on exactly 30 minutes of resuscitative efforts on the 106-year-old who was last seen alive a week ago. But given that these guidelines are based on a combination of AHA recommendations and other EMS best practices, it’s worth your time to look over these criteria. In general, they tend to identify those patients with the least likelihood of making a meaningful recovery, which ideally is what you’re already assessing for when speaking with the paramedics on the phone.

At this point, you may feel that we’ve exhausted all there is to say about adult out-of-hospital cardiac arrest. Maybe you even think the whole topic is…dead and buried?

If not, you’ve got www.nycremsco.org and the protocols binder to keep you company until our next protocol next week!

Dave