EMS Protocol of the Week - Supraventricular Tachycardia (Adult)

Next up in our dysrhythmia marathon is an oldie but a goodie – SVT! Again, Standing Orders lead off with instructions for synchronized cardioversion for unstable patients. For stable SVT, paramedics will give adenosine by Standing Order in the standard 6-12-12 strategy you all know and love in the ED. If hard rebooting the patient’s heart three times doesn’t fix the rate, OLMC will be called for additional orders. For Medical Control Options, you have access to the same diltiazem and amiodarone that were there for you in the atrial fibrillation/atrial flutter protocol from last week. Are either of those worth it? Who knows? You’re in charge, doc!

At this point, you might be thinking, “Dave, how can I know over the phone that the patient is really in AFib/Aflutter/SVT/etc.? Also, these emails are amazing! And you’re so funny!” Well thank you for the complements, firstly. But to answer your excellent question, different people are going to have different levels of confidence or trust in their paramedics. Processing information over the phone can be tricky since you can’t actually see what the field providers are seeing. But if there’s ever any uncertainty, remember that there are systems in place for transmitting EKGs! Or if that feels like too much, you can just ask about the tracing! Is the rhythm narrow complex? Regular? What’s the rate? Gather as much info as you need, and make your decision from there.

And if the complex is wide? Well, you’ll just have to stay tuned and find out! Or check out www.nycremsco.org or the protocol binder for spoilers!

Dave

EMS Protocol of the Week - Atrial Fibrillation/Atrial Flutter (Adult)

This week starts off our three tachydysrhythmia protocols! First up – atrial fibrillation and atrial flutter. As in all dysrhythmia protocols, the first step for paramedics is to determine if the patient in front of them is stable or unstable. If unstable, electricity is indicated, and Standing Orders list instructions for synchronized cardioversion at stepwise increases in joule settings as necessary. If stable, crews will progress to OLMC contact to request either diltiazem (0.25mg/kg IV bolus) or amiodarone (fixed dose of 150mg infusion over 10 minutes). If the crew is requesting diltiazem, be sure to check the math for the appropriate weight-based dosing. Also note that the Key Points section recommends halving the dose for certain patient subsets. If the crew requests amiodarone, consider asking them why! The efficacy of amio is questionable, but some crews may prefer it if the patient’s blood pressures are soft, although I’d argue that if the patient is truly hypotensive, you may need to have a conversation with them discussing electrical cardioversion. Whichever medication is requested, don’t forget to think critically about the patient! Why are they sotachycardic? Are they clearly septic? Dehydrated? Maybe fluids – rather than forcing rate control – are in their best interest. Food for thought!

Reach out with any questions! Otherwise, I’ll see you next week for more fast heart stuff! Until then, www.nycremsco.org or the protocol binder for more.

Dave

EMS Protocol of the Week - Bradydysrhythmia (Adult)

Leading off our run of dysrhythmia protocols is our protocol for adult bradydysrhythmias. Not a ton of critical thinking to do here – if the patient is bradycardic and unstable, paramedics will administer a single dose of atropine and start transcutaneous pacing by Standing Order. Beyond that, they will contact OLMC for further medications. Personally, I’ve often encountered calls where EMS providers have only given the dose of atropine prior to calling, so I’ll tend to take the opportunity to discuss with the crew whether they should consider starting to pace prior to freely authorizing other meds. When it comes to Medical Control Options, OLMC can authorize repeat doses of atropine, boluses of calcium chloride or sodium bicarbonate, or a dopamine infusion (might this instance actually be an indication for dopamine? You decide!). 

Short and sweet this week! Like most dysrhythmias, it boils down to meds and/or electricity. Just remember that if you’re electrocuting a conscious person, have some decency and consider some sedation! Another dysrhythmia is coming up next week, but until then, you’ve got www.nycremsco.org and the protocol binder to keep you company!

Dave