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

Happy Tachy Tuesday!

Another guest post for the week where we will be discussing the EMS protocol for Ventricular Tachycardia with a Pulse / Wide-Complex Tachycardia of Uncertain Type.

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 administer Amiodarone 150mg IV.

If the patient is stable, Standing Order allows administration of Amiodarone 150mg IV or Lidocaine 1mg/kg. If persistence of stable V-Tach after one agent is given, they can give the other one.

For both Stable and Unstable V-Tach, OLMC will be called if nothing above worked for authorization of three options: administration ofMagnesium Sulfate 2g IV, Calcium Chloride 1g IV if suspicious for hyperkalemia or calcium channel blocker OD, or Sodium Bicarb 44-88 mEq IV if suspicious for acidosis.

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

Sincerely,

Joseph Liu, DO

Chief Resident, Emergency Medicine PGY-3

EMS Protocol of the Week - Smoke Inhalation

Hello all, 

This week's EMS Protocol is brought to you by my obsession with the HBO smash hit House of the Dragon. 

Picture this -- Two Westerosi men walk into a King's Landing bar. They see Princess Rhaenyra and strike up a heated conversation to delight her. After exhausting all the advances in their arson-al, they realize they're no match. Syrax, fuming at this show of smoke and mirrors, suggests they use Tinder and burns them to the ground. EMS arrives at the scene and then has to deal with the rest of the patrons...

Enter the REMAC protocol for smoke inhalation!

-In general, always start with ABC's -- airway is critical.

-Place patients on NRB for O2.

-EMTs can measure carbon monoxide (SpCO) with a pulse co-oximeter.

              -Keep in mind SpCO measured by an external pulse co-ox is less reliable compared to that calculated from blood co-oximetry.

              -Consider transfer to a facility with hyperbaric capabilities (like Jacobi) if you suspect CO poisoning.

-Medics perform advanced airway management.

              -Have a low threshold to use DL/VL.

              -Intubate early for soot/edema in airway, neck burns, progressive hoarseness, AMS.

-Treat cyanide poisoning early (stay tuned for more info).

Don't forget to check out www.nycremsco.org and the protocol binder for more and reach out for questions!

Remember: Winter is coming. And with winter, comes more electric/gas heating fires and potential for burn/smoke injures.

Best,

Chris Kuhner, MD

PGY-2 Emergency Medicine

EMS Protocol of the Week - Brady-Dysrhythmia (Adult)

Joe Liu gave us a great overview of some tachyarrhythmia protocols recently, so I figured I should earn my keep and balance things out with a review of prehospital management of bradydysrhythmias. As always, the first question on scene is going to be whether the rhythm is stable or unstable – does the patient seem to be perfusing well with that low heart rate, or is there evidence of shock?

If it’s the former, OLMC may receive a call to discuss administering one of the Medical Control Options for this protocol, which include atropine, inotropic agents such as dopamine and epinephrine, and reversal/stabilizing agents such as calcium chloride and sodium bicarbonate. Use your discretion with authorizing these meds, understanding that just because the patient appears stable now doesn’t mean they can’t decompensate en route.

If it’s the latter, paramedics will have a bit more autonomy with their Standing Orders, which call for an initial dose of atropine, as well as transcutaneous pacing if needed.

Take your time to really read through the medication options in this protocol, as well as their indications. Remember, slow and steady wins the race (but slow and irregular may get zapped).

www.nycremsco.org and the protocol binder for more!

Dave