We previously touched briefly on prehospital pressor options for shock states, but the old formatting found them disjointed and scattered between protocols. While the new protocol formatting doesn’t quite fully fix this problem (and, in fact, much cleaner shock-specific protocols are in the works for next year), the newly organized Shock/Sepsis protocol is a step in the right direction.
Very little in the way of CFR and BLS components for this protocol, as you might imagine; we’re clearly pushing into critical care territory here, and the most useful interventions are going to be invasive to an ALS level of training. Note how, even in a circulation-focused protocol, everything falls back on ABCs. The paramedic section leads off with advanced airway management if indicated and follows with assessment for tension pneumothoraces as an etiology of shock. Following those crucial steps comes fluid resuscitation – up to 250mL in suspected cardiogenic shock, or up to 3L if non-cardiogenic. Consistent shock state, either by appearance or blood pressure, now calls for one of three vasopressors – push-dose epinephrine (here defined as a 10mcg IV bolus, for consistency of terminology), norepinephrine infusion, or dopamine infusion (no, we haven’t been able to get rid of dopa yet). Any one of these three options is available to paramedics as Standing Order. However, if the crew feels like they need to switch from one to another (ie, transitioning from persistent pushes of epi to a norepi drip), they require OLMC approval, so be prepared for those calls. Key Points include instructions on mixing push-dose epi, as well as prehospital criteria for severe sepsis/septic shock. Note that the criteria are slightly different from what we consider SIRS criteria in the ED – this was a conscious decision made in an attempt to increase specificity in the out-of-hospital setting. For patients that do fall into the sepsis category, crews are advised to pay particular attention to fluid administration, as well as other data such as temperature and lactate (neither of which is yet commonly available to crews; consider it future-proofing for one day, hopefully, having access to thermometers and some POC bloodwork).
That’s it! You’re all now pros at keeping the patient’s pressure up and your own pressure down! www.nycremsco.org for more!
Dave