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 - Procedural Sedation (Adult and Pediatric)

Couple of VERY cool updates to the prehospital sedation protocol this past year:

1. Medications can now be given for procedural (eg, cardioversion, pacing, CPAP) or advanced airway management (eg, endotracheal tube, supraglotic device) sedation as Standing Order (ie, without prior OLMC approval). For advanced airway management, these patients need to meet very strict inclusion criteria; otherwise, crews will have to call OLMC for authorization as before.
2. IV ketamine has finally entered the arena as a possible Standing Order and/or Medical Control Option, rather than the Discretionary Order we had previously made it out to be as some hush-hush, off-label use.

Note that all these doses are weight-based, with a limit on the maximum dose to be given at a time. Be sure to practice good closed-loop communication when confirming doses (and routes, for that matter; notice how these are all written as IV formulations, which I think appropriately implies that anyone about to get electrocuted or have a tube shoved down their throat should have vascular access).

Also bear in mind that for pre-airway sedation, even though the protocol is only written as a pre-intubation dose and a post-intubation dose, many crews will often ask for a third dose as a “standby” in case more meds are needed. You might hear “I’d like to give 40 of etomidate followed by 5 and 5 of diazepam as needed post-intubation” while on the phone. Use your discretion for how much medication you feel comfortable approving at once, and again, clearly state your orders in a closed-loop fashion to avoid medication errors.

ALSO also:

Paramedics
Do
Not
Carry
Paralytics
Do
Not
Ask
Them
To
Give
Rocuronium
You
Will
Sound
Silly


And that’s it! You are now all incredibly well…versed…in the world of prehospital sedation! www.nycremsco.org and the protocol binder to keep the knowledge train rolling!


Dave

EMS Protocol of the Week - Excited Delirium (Adult and Pediatric)

Ever wonder why the occasional crew would look to give a whopping 10mg IM midazolam to the curmudgeonly, 50-pound grandma?

Historically, the only protocol that has allowed for sedative medications to be given to facilitate transport has been that for excited delirium, which by definition is supposed to be the hypermetabolic state in which the patient that is presenting an acute risk to self or others; there has not been a protocol for the simply agitated, uncooperative patient. That is still the case now, but in instances of dangerously aggressive geriatrics and pediatrics, there is now a greater shift to weight-base dosing when administering these meds. This has been an overarching change to many of the updated protocols this year, and it means that while the young, large, violent adult may still get the appropriate 10mg IM midazolam by Standing Order, the old, tiny, violent nana might only get 5mg, or less. Time will tell, but hopefully this leads to fewer instances of oversedation, without a large increase in OLMC calls requesting additional meds.

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

Dave