EMS Protocol of the Week - Dysrhythmia (Adult)

Similar to the older format of the NYC REMAC protocols, the new and improved version also includes a general dysrhythmia protocol that refers out to specific sub-protocols based on the underlying dysrhythmia. Not a lot of take-home points here, but the ones that are in this broad introductory protocol are important – 

• If the dysrhythmia is, well, pulselessness, refer to the relevant cardiac arrest protocol

• “unstable” dysrhythmias refer to ones in adults with hypotension or AMS; or ones in kids with hypotension for age, depressed mental status, or absent peripheral pulses

• “stable” dysrhythmias refer to those that lack the above features

• If you’re going to electrically cardiovert conscious patients, consider procedural sedation

That’s about it, aside from some considerations for joule settings based on specific equipment capabilities. Keep all of this in mind, though, as it will be important as we discuss specific dysrhythmias in the coming weeks! Until then, www.nycremsco.org or the protocol binder for more.

Dave

EMS Protocol of the Week - Altered Mental Status (Adult and Pediatric)

At some point in the next year or so, the NYC REMAC protocols will introduce a dedicated section for suspected opioid/drug overdoses. For the time being, naloxone administration patterns can be found here, in the prehospital AMS protocol.

Note that instructions for naloxone doses permeate all three levels of training in this protocol – 1-2mg IN at the CFR level, 1-2mg IN at the BLS level, and up to 4mg IV (in 0.5mg increments) at the ALS level, all by Standing Order. Remembering that this new protocol format is meant to be followed from top to bottom, note that a patient with an opioid overdose has the potential to receive a large cumulative dose of naloxone across all three sections – one administration from a CFR unit, one from a BLS unit, and one from an ALS unit. However, as the Key Points/Considerations section highlights, each level of provider is only permitted to administer naloxone per their specific section; this means that if ALS arrives first on scene, they will only give their IV doses, not the IN doses described in the CFR and BLS portions above.

Starting at the BLS level, EMTs will also assess for hypoglycemia as a cause for AMS and manage if able. This means offering some formulation of oral glucose to patient that can tolerate PO. ALS has a larger toolbox, able to provide parenteral solutions in the forms of IV dextrose or IM/IN glucagon. 

Opioid overdose and hypoglycemia are really the only two etiologies addressed in this protocol, with the expectation that if the crew on scene suspects a different etiology, they will refer to the respective protocol for it. That does make this protocol somewhat of a miscellany section, and as the protocols evolve to become more focused, we may very well lose it in favor of separate overdose and hypoglycemia protocols. When that happens, you can bet I’ll be there with an email and a smile!

See you all next week! www.nycremsco.org and the protocol binder til then!

Dave

EMS Protocol of the Week - Bone and Joint Injuries (Adult and Pediatric)

The new protocol for bone and joint injuries is where you’ll find current prehospital analgesia options, at least until a dedicated pain management protocol comes out sometime next year (stay tuned!). This protocol has a couple of other non-medication features worth highlighting, though, so let’s run through it.

Like all of the other trauma-related protocols, ABCs are paramount. Following from those, BLS will focus on extremity immobilization prior to transport. Splinting specifics, including traction splinting, are listed in this section, along with instruction to attempt gentle realignment of the injured extremity if there is a concern for vascular compromise.

The ALS portion of the protocol focuses on analgesia options. Ultimately these amount to morphine and fentanyl, either of which can be given by paramedics as Standing Order only if the injury is limited to a single extremity. For an isolated extremity injury, paramedics can give up to two doses of morphine – to a maximum of 10mg total ­– or up to two doses of fentanyl – to a maximum of 100mcg total. Outside of the isolated extremity injury, crews will call OLMC for Discretionary Orders for one of those same medications. You may also encounter the occasional crew requesting a Discretionary Order for ketamine for pain; if you encounter such a call and decide to authorize ketamine, just be sure to be clear and specific about the dosage and route, given the numerous therapeutic ranges and uses for ketamine.

The last thing to note about this protocol is that it introduces a Medical Control Option for patellar reductions as a procedure for obvious patellar dislocations. If a crew calls OLMC requesting to perform a patellar reduction, I would say to use your discretion for authorization based on how comfortable you feel the crew is with the procedure as well as the overall condition of the patient. Just make sure that they’re describing a patellar dislocation and not a knee dislocation!

That’s all there is for this week, no…bones…about it!

Okay bye.

www.nycremsco.org or the protocol binder for more.

Dave