EMS Protocol of the Week - Ventricular Fibrillation/Pulseless Ventricular Tachycardia (Adult)

Last week, we went over the cardiac arrest protocol for non-shockable rhythms. For this week, it’s all about the ventricles, BABY!

The VF/pulseless VT protocol for EMS isn’t vastly different than the PEA/asystole one from last week. ACLS is still at its core, with consistent, high quality CPR and regular doses of epinephrine. This time, however, Standing Orders also include defibrillation of the offending rhythm, along with the initial 300mg bolus of amiodarone. On the Medical Control Options front, you’ll still find bicarb and calcium, but you’ll also find an option for the second amiodarone bolus (150mg), along with magnesium sulfate if you’re considering things like Torsades de Pointes. 

And there you have it! You all now have a grasp of what paramedics can do for adults in cardiac arrest here in NYC. But what if you want them to do…nothing??? I’ll leave you to chew on that cliffhanger until we discuss Termination of Resuscitation next week! Until then, www.nycremsco.org and the protocols binder for more!

Dave

EMS Protocol of the Week - Pulseless Electrical Activity (PEA) / Asystole (Adult)

Our specific cardiac arrest protocols are divided into two categories: VT/VF (the “shockable rhythms”) and PEA/Asystole (the “non-shockable” ones). The attached protocol for PEA/Asystole is probably the more common one our crews encounter prehospitally, and it’s worthwhile to know in order to better assist them over the OLMC phone when they call.

When paramedics arrive on the scene of a cardiac arrest and confirm the rhythm to be either PEA or asystole, their 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. 

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). Why do you think this particular patient arrested? Hyperkalemia? TCA overdose? It might be worthwhile to administer one of those medications. Or do we 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 consider when deciding whether to authorize a Medical Control Option.

That’s about it for PEA/asystole. What about the VF/VT arrests? Stay tuned til next week for the…shocking…conclusion!

Thank you, thank you. 

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

Dave

EMS Protocol of the Week - General Cardiac Arrest Care (Non-Traumatic) (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.

Note that everything in the attached protocol is Standing Order, which, as a reminder, consist of the steps that EMS providers should be performing by default without any additional physician input.

At the CFR level, 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.” From there, paramedics will branch off into separate protocols based on the specific type of arrest, each consisting of their own Standing Orders and Medical Control Options.

Can’t wait to find out more specifics? Tune in next week for more cardiac arrest talk! Or, for spoilers, there’s always www.nycremsco.org and the protocol binder!

Dave