I love taking requests!
EMS’s approach to anaphylaxis in NYC is explained across 4 different documents:
The four protocols all include degrees of overlap, which can make them a confusing read, but I’ll try to simplify it for you all as best I can. Fortunately, the upcoming version of the protocols for 2021 has a brand new formatting style that makes the transition from BLS to ALS levels of care easier to understand, but we’ll get to that in the coming weeks.
The reason why I’m including the relevant BLS protocols this week is because this is a rare occurrence where BLS can actually give an injectable medication and thus may need to call OLMC for its approval. Protocol 410 (BLS) provides background information on anaphylaxis for EMTs and instructions for evaluating whether epinephrine is indicated. If it is, EMTs are allowed by Standing Order to administer a single dose of IM epinephrine, either via a patient’s own auto-injector, the crew’s auto-injector, or a “Check and Inject” kit wherein EMTs draw the epi into clearly marked syringes, eliminating the need for dose calculations. Whether a crew carries auto-injectors or “Check and Inject” kits comes down to their service’s formulary. BLS crews can then contact OLMC in order to provide a second dose of epinephrine, if needed, so don’t be caught off guard if an EMT calls you with that request.
Protocol 510 (ALS) also includes Standing Orders for IM epinephrine (allowing paramedics to draw it up themselves) while additionally including obtaining IV access for fluids, diphenhydramine, and steroids (methylprednisolone or dexamethasone), as well as albuterol and advanced airway management if necessary. Medical Control Options for OLMC include repeating any of the previous SOs as well as various pressor options for persistent hypotension (epinephrine drips are not yet an option, although push-dose epinephrine is).
The key distinctions of Protocol 455 (BLS) and Protocol 555 (ALS) is that they include more specific language for pediatric dosing of epinephrine. BLS is also supposed to call OLMC for approval prior to the first dose of epinephrine for a child if there was not previously a prescription for an epinephrine auto-injector, although if the BLS crew is unable to reach OLMC for some reason, they are permitted to give the dose emergently and reattempt contact with OLMC as soon as possible afterwards.
Hope that didn’t overcomplicate things for you all! Keep reaching out with requests, emailing or texting with questions, and paying your respects to www.nycremsco.org and the protocols binder!
Dave