We previously went over the ALS asthma protocol under the old formatting style but had not gotten to discuss the prehospital approach to COPD. In all honesty, the two protocols were nearly identical to each other, so for the new version, they were combined into a single Asthma/COPD/Wheezing protocol for everyone’s convenience. Let’s dive in!
I generally didn’t discuss the CFR and BLS protocols under the old formatting unless they were directly relevant to the ALS protocol, so I won’t spend a ton of time on them now. Just note that, in what is sure to be a running theme, CFRs will perform minimally invasive interventions (seat the patient comfortably, supply supplemental oxygen), and EMTs will provide active medication administration while initiating transport. In this case, that means starting one albuterol neb while getting the patient to the ambulance, and giving up to two more in transit (so three total). If the patient is in severe respiratory distress, the EMTs can give one dose of IM epinephrine (we previously discussed how this could be via an auto-injector or a pre-marked syringe to eliminate the need for the EMT to calculate dose). At this point, the BLS crew should also be requesting ALS backup for the patient. Once on scene, paramedics can begin to administer ipratropium along with the albuterol, give epinephrine if not already given, and obtain IV access for magnesium sulfate and steroids (methylprednisolone or dexamethasone) if indicated.
When this protocol was previously divided separately between asthma and COPD, the key difference was that the COPD protocol did not include orders for magnesium or epinephrine. Currently, magnesium is still reserved for asthma, but epinephrine is permitted for both cohorts, although it “should be used with caution” in COPD, according to the Key Points section. Why? For epi, the biggest concern tends to be about the risk of arrhythmogenicity when given to COPD patients, although my take tends to weigh the risk of tachyarrhythmia versus the risk of respiratory failure. As far as mag? Frankly, I’m not sure why there’s exclusivity for asthma. I haven’t found a ton of literature showing benefit in COPD, but I haven’t really found anything showing it to be blatantly unsafe either. I tried making that case when combining the protocols a couple years ago, but my cries fell flat. Alas, my soapbox wasn’t tall enough. One day…
In any case, under this protocol, OLMC can be contacted by either an EMT or a paramedic requesting to give a second dose of IM epinephrine. When deciding whether to approve the Medical Control Option for repeat epi, again, I tend to weigh the risk of cardiac effects vs respiratory benefits. Remember that ALS can perform cardiac monitoring and cardioversion/defibrillation, if it really comes down to it. Use your judgment, docs.
One final point. Note that this protocol can be followed a few ways in practice –
1. 911 is called for a patient having an asthma attack. CFRs show up first (since they’re around the corner) and perform Steps 1-6 just as a BLS unit arrives. EMTs begin their portion, but as the patient is in marked distress, they request ALS assistance, so that just as they’ve finished putting the patient on CPAP (Step 12), paramedics arrive to take over. The medics then run through Steps 13-17 en route to the hospital.
2. 911 is called for a patient having an asthma attack. CFRs are getting coffee a few blocks away, so EMTs are first on scene. They start the process at Step 1 (the CFR portion) and progress all the way down to Step 12 as indicated, at which point they hit the EMT STOP point and care is either transferred to paramedics or the ED.
3. 911 is called for a patient having an asthma attack. CFRs and EMTs are tied up in a heated debate over which season of The Mandalorian was better (I know, how is it even a question?). ALS is first on scene. Paramedics start the process at Step 1 (the CFR portion) and progress through Steps 7-12 (the EMT portion) prior to working through the actual Paramedic section.
4. And so on.
There are a bunch of different ways this can play out (and in all of them, Season 2 reigns supreme). Just recognize that the new protocol formatting illustrates how much one level of training builds on the level below it, so moving forward, it’ll be to your benefit to familiarize yourself with the progression from CFR to BLS to ALS.
Ready to get a jump start? www.nycremsco.org has the full pdf, and keep an eye out for a shiny new protocol binder!
Dave