Protocol 504 – Suspected Myocardial Infarction is supplemented by two sub-protocols: 504-A – Drug Therapy of Myocardial Ischemia and 504-B – Cardiogenic Shock, and they’re each fairly straightforward, so let’s breeze through.
504 – Suspected Myocardial Infarction: ALS suspects an MI, they start cardiac monitoring, manage unstable dysrhythmias, check a 12-lead, start transport, and monitor vital signs. If the EKG is concerning for a STEMI (either because of the machine’s read or their own), they’ll run it past OLMC (generally FDNY’s OLMC, specifically) for assistance in determining whether the patient is having a slam-dunk, textbook STEMI, and should therefore go directly to a STEMI center, versus being able to be appropriately managed at a hospital that isn’t a STEMI center but might be closer.
504-A – Drug Therapy of Myocardial Ischemia: So, you’ve got a patient concerning for ACS. How are you gonna treat them to start? ALS Standing Orders for this protocol allow for 162mg of aspirin, as well as nitroglycerin every 5 minutes to help with pain. Note that the protocol includes caveats for patients who have recently used erectile dysfunction meds or who are hypotensive. And speaking of hypotension…
504-B – Cardiogenic Shock: Uh-oh, somebody’s hypotensive! ALS is instructed to give a small fluid bolus to these patients to help with preload, but if there’s no improvement in blood pressure at that point, guess what? Peripheral pressors to the rescue! Historically, crews generally had access to dopamine, but as times have changed, so have the protocols, expanding to include norepinephrine and even push-dose epinephrine! Dopamine has stayed in the protocols, however, to allow for services that still carry and are trained in its use. Tough administrative-level decisions often arise in EMS and other health systems when you have to reconcile best medical practices with logistical challenges. Norepinephrine might be the better med, but when you have thousands of providers that would need new training in its use, and a stockpile of dopamine that you’ve already paid for, it’s not hard to see why the change might be a slow one.
That’s it! All of these protocols are Standing Order, so there won’t be much to know for OLMC calls, although occasionally crews may call to ask about switching between pressors (eg, starting on push-dose epi and moving to a norepi drip). Otherwise, bask in your knowledge of EMS care, ever-expanding from these emails, www.nycremsco.org and the protocol binder!
Courtesy of Dr. David Eng, Assistant Medical Director of Emergency Medical Services at Maimonides