EMS Protocol of the Week - Non-Traumatic Cardiac Arrest (Adult)

The prehospital approach to general cardiac arrest care is a good introduction to the progression of responsibilities from one level of training to the next. We get a large number of OLMC calls from our own paramedics requesting physician input in arrest cases, so it’s always good to refresh ourselves on what they can or cannot do in these instances.

At the CFR level, by Standing Order, providers who encounter a patient in arrest will initiate CPR and apply an Automated External Defibrillator, following the AED’s instructions until backup arrives.

BLS providers (EMTs) will request ALS backup if not already present, but will otherwise begin to transport the patient to the hospital after 3 rounds of CPR/AED analysis.

It’s not until the ALS (paramedic) level that an actual cardiac monitor will be applied, giving a specific rhythm underlying the arrest. It’s for this reason that you might hear something from the paramedics like “our initial rhythm was asystole; patient was shocked 2 times (by AED) prior to our arrival.” The rest of the ALS Standing Orders consist of continuing CPR, performing a needle decompression for suspected tension pneumothorax, obtaining an advanced airway (either endotracheal tube or supraglottic device) and intravascular access, administering D50 for hypoglycemia, and giving ACLS-dose epinephrine every 3-5 minutes. If the patient is found to be in VT/VF (the “shockable rhythms”) rather than PEA/asystole (the” non-shockable rhythms”), they will also give an initial dose of either amiodarone or lidocaine by Standing Order.

By the time medics call OLMC, they will have generally given a few doses of epinephrine, but they need physician approval to give sodium bicarbonate or calcium chloride, which are Medical Control Options (and as such are found under that section of the protocol). Other MCOs include a second dose of amiodarone or lidocaine for a shockable rhythm, as well as magnesium sulfate for suspected Torsades de Pointes. When deciding whether to authorize these Medical Control Options, it’s worth asking yourself – why do you think this particular patient arrested? Hyperkalemia? TCA overdose? Some sort of electrical storm? It might be worthwhile to administer one of these medications. Or do you think attempts at ROSC are futile? Maybe no medications are indicated, and we should instead consider Termination of Resuscitation (ToR). We’ll discuss ToR in a separate email, but these are the kinds of questions to keep in mind when fielding these calls.

And there you have it! First protocol down, and a big one at that! Some might even say that it’s…the heart…of these protocols? Some people have definitely said that.

Check out www.nycremsco.org and the protocols binder for more! Otherwise, see you next week for the next review!

Dave

EMS Protocol of the Week - Traumatic Cardiac Arrest (Adult and Pediatric)

For the large number of “medical” cardiac arrest calls we field on the OLMC phone, we rarely (if ever) get calls from crews asking for orders in traumatic cardiac arrest. Why? Well for one, as you can see in this week’s protocol, the only real Medical Control Option available in traumatic cardiac arrest is for additional crystalloid fluid resuscitation, which I think we can all agree is probably not the lifesaving intervention here. But more to the point, as you read through the protocol from the top down, you’ll see how high a priority it is for crews to simply transport the patient, starting at the EMT level. Remember, this is in line with most trauma jobs, which are usually managed by EMTs who can more rapidly bring these patients to a trauma center for definitive care rather than spend extra time securing vascular access or an airway in the street. So don’t be caught off guard if BLS rolls in a traumatic arrest rolls with chest compressions, a BVM and nothing else; the EMTs are doing what they were trained to do!

Look at us, gang, we’ve made it through another year of these emails! I really appreciate you all taking the time to read through these and provide feedback, and I’m glad to hear that it’s helped some of you have more informed interactions with our EMTs and paramedics. But look at me, prattling on…such a bleeding heart.

www.nycremsco.org and the protocol binder for all you go-getters out there!

Dave

EMS Protocol of the Week - Ventricular Fibrillation/Pulseless Ventricular Tachycardia (Adult)

Last week, we went over the cardiac arrest protocol for non-shockable rhythms. For this week, it’s all about the ventricles, BABY!

The VF/pulseless VT protocol for EMS isn’t vastly different than the PEA/asystole one from last week. ACLS is still at its core, with consistent, high quality CPR and regular doses of epinephrine. This time, however, Standing Orders also include defibrillation of the offending rhythm, along with the initial 300mg bolus of amiodarone. On the Medical Control Options front, you’ll still find bicarb and calcium, but you’ll also find an option for the second amiodarone bolus (150mg), along with magnesium sulfate if you’re considering things like Torsades de Pointes. 

And there you have it! You all now have a grasp of what paramedics can do for adults in cardiac arrest here in NYC. But what if you want them to do…nothing??? I’ll leave you to chew on that cliffhanger until we discuss Termination of Resuscitation next week! Until then, www.nycremsco.org and the protocols binder for more!

Dave