EMS Protocol of the Week - Non-Traumatic Cardiac Arrest and Severe Bradycardia (Pediatric)

Pediatric cardiac arrests are high stress scenarios in the best of times, so you can imagine how much more taxing they may be in the out-of-hospital setting, with even fewer resources. Keeping things heavily protocolled may be beneficial in these cases, giving EMS a fixed task list to complete to help work through all the chaos of the situation.

We’ve got a few key differences between the pediatric cardiac arrest protocol (which includes all arrest rhythms) and the adult counterparts we just covered. One is the increased emphasis on ventilator support and appropriate CPR at the CFR level, particularly given the heavy respiratory component of most pediatric arrests. Two is the increased priority of initiating transport at the BLS level, as opposed to many adult arrests that are often extensively worked up on the scene. And three is the high detail on defibrillation when indicated, utilizing appropriate Joules (or the lowest setting if unable to administer at the weight-based amount) and pad sizing. Medical Control Options look a little different here compared to the adult protocols, leading off with naloxone (again, considering respiratory etiologies), and following off with options for dextrose, bicarb, magnesium, or crystalloid.

Recognize that most of the paramedic interventions – and hence the calls for MCOs – will take place en route to the hospital, given how early in the protocol BLS is instructed to begin transport. But also realize that these transports can occasionally be prolonged, and they may feel excruciatingly drawn out for the paramedics sitting with the patient in the back of the ambulance, desperate for something to do. So listen closely to their presentations on the OLMC phone, give some real considerations to the meds they’re looking to give, and do what you can to work in tandem with them in those crucial minutes before they hit our ambulance bay. 

That’ll do it for this week, see you all next week, and give some love to www.nycremsco.org or the protocol binder.

Dave

EMS Protocol of the Week - Termination of Resuscitation (ToR) Guidelines

At this point, we've gone over everything EMS is capable of doing for an adult in cardiac arrest. This includes what they will do under Standing Orders, as well as what they may request of OLMC as a Medical Control Option. But what if they are unable to obtain ROSC after all of those interventions? Or what if they’ve only performed Standing Orders, and you don’t think any of the Medical Control Options will make a difference? Do all of these patients need to be transported to the hospital?

No!

There are plenty of instances where you’ll be asked – or where you deem it appropriate – to terminate resuscitative efforts of EMS providers in the field, rather than having them transport the patient to continue efforts in the ED. Attached are current guidelines for when you, as the OLMC physician, may consider Termination of Resuscitation (ToR), but keep in mind that these are just guidelines and thus exist secondarily to your own clinical judgment. You are not required, for example, to insist on exactly 30 minutes of resuscitative efforts on the 106-year-old who was last seen alive a week ago. But given that these guidelines are based on a combination of AHA recommendations and other EMS best practices, it’s worth your time to look over these criteria. In general, they tend to identify those patients with the least likelihood of making a meaningful recovery, which ideally is what you’re already assessing for when speaking with the paramedics on the phone. 

Any questions? Always feel free to reach out! Otherwise, you’ve got www.nycremsco.org and the protocols binder to keep you company until next week!

 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