So, a bit of housekeeping:
Starting January 1, the NYC REMAC is switching over to the newest version of the city’s EMS protocols. A lot of the content will stay the same, although there will also be some new medications, some changes to dosages, and fair amount of clarified language. But the biggest difference you’ll see is a massive change to formatting. The new “Unified Protocols” get a major facelift, consolidating Certified First Responder (CFR), BLS, and ALS protocols into one contiguous document that reorganizes and hopefully simplifies the protocols for field providers and OLMC physicians alike. We’ll break down how to approach the new protocols after the holidays as they begin to pop up in these emails, but for now, we’ll use the last couple weeks of the year to get through as much of the remaining protocols as we can.
Ready? And away – we – go!
Way, way back in an earlier EMS-PoW we discussed the EMS protocol for VT with a pulse/wide complex tachycardia, which itself was a part of Protocol 505 – Cardiac Dysrhythmias. For this week, I figured you’re all big enough protocol pros at this point to handle the rest of the dysrhythmia protocols, so here we have Protocol 505-A – Supraventricular Tachycardia, Protocol 505-B – Atrial Fibrillation / Atrial Flutter, and Protocol 505-D – Bradydysrhythmias and Complete Heart Block. Let’s get into it!
The crux of the SVT and AF protocols comes down to the initial assessment of whether the patient is in a stable or unstable tachydysrhythmia. Is the patient hypotensive, altered, or otherwise hypoperfusing? Then synchronized cardioversion is indicated by Standing Order. Normotensive, mentating well? They’ll proceed down the protocol.
For SVT, the crew will give up to the full 3 doses of adenosine (6-12-12) as SO. If the patient is still in (a stable) SVT at this point, they may call OLMC for orders to try diltiazem or amiodarone, or you may ask them to attempt synchronized cardioversion at this time. For a stable rapid atrial fibrillation/flutter, there are no SO meds that are given, so you’ll often get a call at the outset requesting diltiazem, although amiodarone is another MCO. Older thinking was that amiodarone might help control the rhythm while being gentler on the blood pressure than diltiazem, but seeing as amiodarone has its own issues as a medication, when a crew asks about giving it to a tachycardic patient with a borderline BP, I often ask them if they want to rethink cardioversion at that time. As far as diltiazem goes, everyone has their own opinion on whether to authorize its use for crews. For me, if the crew provides a clear enough picture of a narrow-complex tachycardia in an otherwise stable-sounding patient, I generally don’t have a problem with giving diltiazem; the half-life of a single IV push is short, and a touch of rate control may be just what the patient needs to prevent decompensation en route. Of course, this approval comes after first assessing whether there’s a compensatory reason for the patient to be tachycardic (hypovolemia, sepsis, etc.), in which case that should obviously be addressed first.
For bradydysrhythmias or complete heart block, ALS will attempt a single 0.5mg dose of atropine and will often call for OLMC approval to give repeat doses up to a total of 3mg. Other MCOs include starting a dopamine infusion or administering pushes of calcium chloride or sodium bicarbonate if indicated. I would also note that transcutaneous pacing is listed as Standing Order for bradycardic patients who are showing signs of shock, although often times crews hesitate to start it on their own prior to calling OLMC. If that’s the case, and you feel like pacing the patient is indicated, be sure to remind them of that as an option.
That’s it for the dysrhythmias! Patient stable? Consider some meds. Unstable? Then electrical interventions are indicated. It’s the same “Medicine versus Edison” decision you’d go through in the ED! Just remember that for either synchronized cardioversion or transcutaneous pacing, the patient may need some sort of sedation, which requires OLMC approval. Refer to the previous Prehospital Sedation protocol overview for details there. Otherwise, www.nycremsco.org and the protocols binder are where it’s at!
Dave