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

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