Author: David Eng, MD
Assistant Medical Director, Emergency Medical Services
Attending Physician, Department of Emergency Medicine
Maimonides Medical Center
For reference here is a link to all of the NYC REMAC protocols as updated in 2019: https://www.nycremsco.org/wp-content/uploads/2017/10/04-ALS_Protocols-January-2019-vALS01012019B.pdf
Last time we addressed PEA/Asystole, so for this week’s protocol review, let’s get WILD and UNPREDICTABLE by going over EMS Protocol 503-A, Ventricular Fibrillation/Pulseless Ventricular Tachycardia!
You’ll notice that for VF/Pulseless VT, both the Standing Orders and Medical Control Options are similar to those seen in the PEA/Asystole protocol, with a couple of key differences:
- SOs have, predictably, a large focus on rhythm control, both with the initial bolus of Amiodarone (Step 9) and, more importantly, with frequent attempts at defibrillation if indicated. This follows from the understanding that the only consistently recognized beneficial interventions for out-of-hospital cardiac arrests (OOHCA) are early recognition of the arrest, early high quality CPR, and early defibrillation (when appropriate).
- MCOs now include options for the repeat Amiodarone bolus (Option A) if indicated, as well as the option for Magnesium Sulfate (Option C), such as you’d consider for things like Torsades de Pointes.
As an aside, one thing not explicitly described in this protocol is the patient experiencing refractory VF. In these instances, no one would be faulted for instructing the crew to just transport the patient to the ED (MCO Option E), but another option you might consider would be Dual Sequence Defibrillation. Many paramedics are familiar with the concept at this point, and while the procedure is not explicitly described in current protocols, you have the option to advise the crew on attempting DSD as a Discretionary Order (DO) (neither an SO nor an MCO, but something the paramedic is equipped with and trained to use, just as an “off label use” in this instance, under physician direction). In this case, they obviously know how to use a defibrillator, except now you’d be asking them to use a second one, at the same time, in a slightly different location. Note that you cannot request interventions like Esmolol as a DO since, unlike a defibrillator, EMS crews neither carry nor receive training in how to use Esmolol. Just some food for thought.