EMS Protocol of the Week - Dysrhythmia (Pediatric)



Calling this week's protocol the one for pediatric dysrhythmias is a bit of a misnomer, as severe bradycardia in kids is managed elsewhere. When it comes to tachydysrhythmias, however, this protocol has you covered! If BLS is on scene with one of these kids, they’ll request ALS backup, but they are instructed not to allow this to delay transport. So don’t be surprised if EMTs arrive with a tachycardic kid with minimal interventions; just realize that our ED may have been closer than the closest paramedics. If ALS is on scene, it’s all about recognition and identification of the dysrhythmia. Stable SVT are treated with vagal maneuvers, with adenosine available as a Medical Control Option as backup after calling OLMC. Cases of unstable SVT and VT with a pulse will always come through OLMC, at which point you and the paramedics can discuss synchronized cardioversion. Remember to utilize weight-based energy settings, and consider sedation options for your conscious patients.

It may come as a…shock…to you all, but there are some subtle differences here between this protocol and its adult counterpart, so be sure to…slow down…and read through it, carefully? Idk, I’m writing less of these now, I’m rusty.

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

Dave

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 - 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