EMS Protocol of the Week - Severe Bradycardia (Pediatric)

Happy EMS Tuesday!

We're going to slow things down from John Su's riveting email about eye emergencies to discuss the EMS protocol for “Severe Bradycardia (Pediatric)”. These are 3 words that no one wants to hear in a sentence together, so let’s get mentally prepared in case this patient comes in!

To use this protocol, patients should have: 1) HR <60 bpm, and 2) signs of shock or AMS. Any provider taking care of this type of patient can begin chest compressions and ventilations as per AHA guidelines. If an EMT is first on scene, they should immediately request ALS assistance and transport if timing makes more sense. 

For paramedics, cardiac monitoring will be started and IV access will be obtained. Standing Order will allow them to perform the following: 

1) Epinephrine 0.01 mg/kg (0.1mL/kg) IV of 1:10,000 concentration (max 1mg) every 3-5 minutes, 

2) Atropine 0.02 mg/kg IV (min 0.1mg, max 0.5mg), 

3) intubation if unable to provide effective BVM ventilations. 

If that does not work, they will call OLMC for one of two options: 

1) administration of a 2nd dose of Atropine 0.02 mg/kg IV 

2) initiation of transcutaneous pacing. Of note, they may also for procedural sedation authorization for pediatric patients if the patient is conscious.

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: Eye Emergencies

Hey all,

This week's protocol looks at eye emergencies that apply to both the adult and pediatric populations.

The prehospital approach starts with CFRs at the most basic level to evaluate and initiate treatments based on these ocular findings:

1) Non-penetrating foreign objects/chemical eye injuries: flush affected eye with NS for 20 minutes

2) Impaled object to eye: use bulky dressings to stabilize object and cover eye to prevent consensual eye movements

3) Avulsed eye: cover eye with saline, sterile dressings and do NOT place eye back into socket

BLS providers provide the additional support of removing contact lenses as needed.

ALS providers provide the additional support of administering proparacaine 0.5% or tetracaine 0.5% drops for chemical eye injuries to assist with irrigation.

Not alot to do on the OLMC side other than to help assist our EMS providers in each ocular scenario.

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

John Su

PGY-2

EMS Protocol of the Week: Pediatric Respiratory Distress/Failure

Hey all,

This week's EMS protocol is on pediatric respiratory distress/failure. The thought of a pediatric patient experiencing respiratory distress is enough to cause me to go into respiratory distress... but let's discuss how our pre-hospital colleagues initiate care for these patients.

Remember that respiratory distress and respiratory failure fall on a spectrum:

Respiratory distress is characterized by:

- Increased respiratory effort/WOB

- ABSENCE of central cyanosis symptoms: anxiety, nasal flaring, increased respiratory rate, accessory muscle use (ie retractions), lethargy, etc.)

Respiratory failure is characterized by:

- Presence of central cyanosis symptoms: agitation, lethargy, severe dyspnea, labored breathing, head bobbing, grunting, severe retractions, severe bradypnea, etc.

- Hypoxia and/or hypercapnia

The prehospital approach to these kiddos corresponds to a progression of care based on the level of training present. CFRs start with ABCs and monitoring vital signs. If needed, these providers can implement airway adjuncts and administer supplemental O2 at appropriate levels for either respiratory distress or failure. At this level of training, CFRs can then address potential overdose. BLS crews will pick up from here and can additionally request ALS backup and transport the patient. If the on-scene team is ALS trained, they can perform advanced airway management if unable to continually bag ventilate the patient. From here, ALS providers will start cardiac monitoring and establish IV/IO access as necessary while en route. They can even assess and treat for a tension pneumothorax (which may develop after resuscitation has begun!).

If a known cause is identified/suspected such as aspirated foreign body or anaphylaxis, treatment via those protocols will be used. If persistence of respiratory distress/failure, then providers will default back to this protocol.

There is not a lot to be aware of from an OLMC (shameless plug for our e-mailed survey 😊) standpoint other than awareness of the level of care the on-scene providers are able to provide - this will give the receiving team a better idea of what to expect when the patient is rolled in and instill the appropriate level of fear.

See the attached protocol and check out https://nycremsco.org/ for more!

Best,
Zachary Kim

PGY-2 Emergency Medicine