EMS Protocol of the Week - Severe Sepsis and Septic Shock (Adult and Peds)

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Hello EM friends,

For this week's protocol review, we're going to discuss the pre-hospital world of sepsis care. This one's a BOGO deal and will include the approach for both adults and little adults (pediatrics). 

Our EMS colleagues are trained to identify septic patients using very similar criteria to us: 2 SIRS-like + presumed infection. Reference this table to see the differences with our criteria (mainly to increase specificity for correctly identifying septic patients in the field / working with more limited resources):

CFR and BLS crews unfortunately will not be able to offer much in the way of interventions - we're dabbling in the world of critical care. CFRs can assess ABCs/vital signs and administer O2 as necessary. BLS crews can additionally obtain BGMs and treat as indicated; otherwise, they will request ALS assistance if required and transport patients to the hospital. 


ALS crews can administer much more in terms of therapeutics - they can perform advanced airway management, cardiac monitoring, EKG evaluation, IV/IO access, crystalloid administration, and adult vs pediatric specific blood pressure management protocols. Before the adult and pediatric protocols branch, paramedics will  start by administering both groups a 20 mL/kg IV bolus. If the patient is still hypotensive, the protocols are as follows:

  • Adults: 

    • Goal: SBP > 90 mmHg or MAP > 65 mmHg

    • Administer one of the following:

      • Additional 20 mL/kg bolus

      • Norepinephrine IV (20 mcg/min max) infusion

      • Epinephrine 10mcg pushes Q3-5 minutes

  • Pediatrics:

    • Goal: age-appropriate BP goals

    • Activate OLMC to administer one of the following:

      • Additional 20 mL/kg bolus

      • Epinephrine 5mcg pushes Q3-5 minutes

      • Norepinephrine 0.05mcg/kg/min (20mcg/min max) infusion


Over the OLMC phone, we will have the power to authorize Vasopressin infusions to maintain SBP/MAP goals for adults. And again, ALS crews will have to communicate with us to administer any BP support beyond the initial 20 mL/kg bolus for pediatric patients. 

More knowledge to be farmed at www.nycremsco.org.

Best,

Zachary Kim, MD

PGY-2 Emergency Medicine

POTD: ECMO

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Hello everyone! Let's talk about ECMO. I was first introduced to ECMO in the era of pre-vaccine COVID, where it was often hailed as the Hail Marry of solutions for severe COVID cases in younger patients. But ECMO can be used for so much more, including a recently discussed topic - hypothermia.

What is ECMO?

ECMO, or extracorporeal membrane oxygenation, is a prolonged cardiopulmonary support technique that allows oxygenation of the blood bypassing the heart and lungs. It differs from cardiopulmonary bypass in that it requires less anticoagulation and allows for longer duration of treatment. 

Who qualifies for ECMO?

Criteria for ECMO include acute severe cardiac or pulmonary failure that is potentially reversible and has failed conventional treatment and carries a high risk of death. Conditions include:

  • ARDS and severe respiratory failure (severe hypercapnia pH < 7.20, or P/F ratio < 70)

  • poor gas exchange/obstruction (massive PE)

  • acute pulmonary injury: smoke inhalation, contusion, drowning

  • nonischemic cariogenic shock, cardiac/pulmonary trauma, massive PE

  • bridge to lung or cardiac transplant or LVAD

Who does not qualify for ECMO?

Absolute contraindications include:

  • unwitnessed cardiac arrest

  • non-reversible, progressive lung or cardiac disease that is not a transplant candidate

  • pulmonary hypertension

  • advanced cancer

  • >120 kg

Relative contraindications include:

  • older than 75 years

  • CPR > 60 minutes

  • CNS injury

  • multi organ failure or trauma

What types of ECMO exist?

VV or veno-venous: the most common access, typically central vein IVC access (femoral, IJ), passes through oxygenator, and deposits in a large vein near RA (IJ, subclavian)

  • provides respiratory support but not circulatory support

  • pathologies: COPD, ARDS, PNA, smoke inhalation injury, status asthmatics, airway obstruction, drowning

VA or veno-arterial: can be peripheral or central, access is central vein, passes through oxygenator, and deposits in arterial access around pulmonary artery

  • provides both respiratory and cardiac support

  • pathologies: non-ischemic cardiogenic shock, heart/lung transplant, LVAD failure, PE, sepsis

Complications:

  • clot formation

  • bleeding

  • vessel trauma, LV distension

  • North-south syndrome - hypoxia and cyanosis in cephalic and lower extremities outside of range of circuit access

https://wikem.org/wiki/Extracorporeal_membrane_oxygenation

https://www.emra.org/emresident/article/ecmo-in-the-ed/