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

EMS Protocol of the Week - Non-Traumatic Cardiac Arrest (Adult)

The prehospital approach to general cardiac arrest care is a good introduction to the progression of responsibilities from one level of training to the next. We get a large number of OLMC calls from our own paramedics requesting physician input in arrest cases, so it’s always good to refresh ourselves on what they can or cannot do in these instances.

At the CFR level, by Standing Order, providers who encounter a patient in arrest will initiate CPR and apply an Automated External Defibrillator, following the AED’s instructions until backup arrives.

BLS providers (EMTs) will request ALS backup if not already present, but will otherwise begin to transport the patient to the hospital after 3 rounds of CPR/AED analysis.

It’s not until the ALS (paramedic) level that an actual cardiac monitor will be applied, giving a specific rhythm underlying the arrest. It’s for this reason that you might hear something from the paramedics like “our initial rhythm was asystole; patient was shocked 2 times (by AED) prior to our arrival.” The rest of the ALS Standing Orders consist of continuing CPR, performing a needle decompression for suspected tension pneumothorax, obtaining an advanced airway (either endotracheal tube or supraglottic device) and intravascular access, administering D50 for hypoglycemia, and giving ACLS-dose epinephrine every 3-5 minutes. If the patient is found to be in VT/VF (the “shockable rhythms”) rather than PEA/asystole (the” non-shockable rhythms”), they will also give an initial dose of either amiodarone or lidocaine by Standing Order.

By the time medics call OLMC, they will have generally given a few doses of epinephrine, but they need physician approval to give sodium bicarbonate or calcium chloride, which are Medical Control Options (and as such are found under that section of the protocol). Other MCOs include a second dose of amiodarone or lidocaine for a shockable rhythm, as well as magnesium sulfate for suspected Torsades de Pointes. When deciding whether to authorize these Medical Control Options, it’s worth asking yourself – why do you think this particular patient arrested? Hyperkalemia? TCA overdose? Some sort of electrical storm? It might be worthwhile to administer one of these medications. Or do you think attempts at ROSC are futile? Maybe no medications are indicated, and we should instead consider Termination of Resuscitation (ToR). We’ll discuss ToR in a separate email, but these are the kinds of questions to keep in mind when fielding these calls.

And there you have it! First protocol down, and a big one at that! Some might even say that it’s…the heart…of these protocols? Some people have definitely said that.

Check out www.nycremsco.org and the protocols binder for more! Otherwise, see you next week for the next review!

Dave