This week’s gentle reminder to check the protocol binder comes from a recent OLMC call I had with one of our very own residents! I won’t name names, but apparently he’s been “too busy” to keep up with my emails, and my feelings have been hurt ever since!
Cough.
Anyway. Protocol 505-C, Ventricular Tachycardia with a Pulse/Wide Complex Tachycardia of Uncertain Type, is one of a series of four separate protocols dealing with different types of cardiac dysrhythmias (3 tachy, 1 brady). The tachyarrhythmia protocols all have some overlap, but I think it’ll be helpful to look at them one at a time, and since we recently utilized 505-C in a call, it seemed like a good place to start! Here’s the call:
Family called 911 for a 91-year-old female with a week of worsening lethargy and intermittent chest pain. On arrival, patient was pale, with a heart rate ranging from 130s-160s and a blood pressure of 60s/40s. Patient had a weak radial pulse and was making some purposeful movements, but per family she was definitely more lethargic and mildly confused compared to baseline. Here’s the prehospital 12-lead for your convenience!
What do you do in the moment? Is this wide complex tachycardia a VT? AFib with aberrancy? Does it matter right now?
There’s no mysterious, inscrutable EMS secret here. The patient was hypoperfusing from an unstable tachyarrhythmia and needed synchronized cardioversion. Guess who can do that? Paramedics! It’s Standing Order under this protocol once they recognize the patient has unstable (check!), wide complex (easy!) tachycardia (piece of cake!). The SO’s for this protocol also include the initial 150mg bolus of Amiodarone before diving into MCO’s for the patient who may need something more (in this case, continued cardioversion, magnesium, calcium, or bicarb).
So why did the crew call OLMC, if cardioversion and Amiodarone are Standing Order? There were a couple reasons. The first was for more of a discussion with an ED doc about the case. Remember that OLMC can often be framed as analogous to a consultation between a paramedic and you, the Emergency Medicine specialist. In this case, how comfortable would most of you be with zapping a 91-year-old without at least bouncing the idea off someone else? Would you try Amiodarone first? Those sort of talking points are an entirely valid reason to call.
The second reason for calling, once we were all on the same page about zapping the 91-year-old patient, was to discuss sedation medications, since it’s generally poor manners to electrocute an awake 91-year-old patient. True EMS PotW fans will remember from the Prehospital Sedation email that OLMC approval is required for prehospital sedation meds, and dedicated superfans will remember that the only options listed are Etomidate and benzos, neither of which is my preferred choice for hypotensive patients like this one. So instead, we opted to give Fentanyl as a Discretionary Order, and guess what? Patient tolerated the cardioversion, heart rate improved to the low 100s, BP improved to 100s/60s, and mental status improved immensely (to quote the medic after they brought the patient to us in the ED, “when we first got there, we couldn’t get her to talk to us; now, we can’t get her to stop”). All that was left for us to do once the patient got to the ED was…well, pretty much nothing. Labs, repeat EKG, cardiology consult, admission.
Once again, the medicine is all the same as what you already know! But hopefully this keeps helping familiarize you all with how much patient care can be accomplished with good communication with our prehospital colleagues.
www.nycremsco.org and the protocol binder by the phone. Use them!
David Eng, MD
Assistant Medical Director, Emergency Medical Services
Attending Physician, Department of Emergency Medicine
Maimonides Medical Center