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

Another trauma protocol, which means short and sweet! Regarding chest injuries, CFRs onward will manage ABCs, as well as dress any sucking chest wounds with an occlusive dressing. EMTs will initiate transport. And paramedics will perform needle decompressions on suspected tension pneumothoraces, as described in the attached appendix outlining the procedure. Note that current teachings offer two different locations for decompression: the traditional 2nd intercostal space at the mid-clavicular line, as well as the 5th intercostal space at the anterior axillary line (which is more in line with where you’d place a subsequent large-bore chest tube). Other than that, it’s once again all about safe, rapid transport to an appropriate hospital.

See you all next week for more! www.nycremsco.org and the protocol binder to keep you sated until then.

 Dave

EMS Protocol of the Week - Excited Delirium (Adult and Pediatric)

Beyond simple agitation, beyond anxiety, the concept of excited delirium refers to patients posing a potential threat to both themselves and the providers trying to care for them. This may be due to underlying psychiatric disease or a toxicologic etiology, but regardless of the cause, these patients are often found in a hypermetabolic overdrive. Keep that point in mind when considering these patients – they may be violent externally, but internally, they may also be hyperthermic, acidotic, or rhabdomyoly…tic. As such, physical restraints may actually be more harmful than helpful, and the best thing – for both the patient and for providers – may be to pharmacologically cool the patient down, so to speak.

This is the reasoning behind the EMS approach to excited delirium, which starts with attempts at verbal de-escalation but will move to medication interventions if there is impending concern for safety. Standing Order permits paramedics to give adult patients a one-time dose of midazolam, 10mg, IM. If the patient needs additional medication (or is a pediatric patient), crews will call for further Medical Control Options, which include additional doses of benzos, or weight-based ketamine. Take a look at the table in the attached pdf that illustrates the available options to better understand what crews have available.

Lastly, two broad points to remember across all protocols. First, remember to practice good closed-loop communication with the paramedics when giving specific medication and dosage orders (eg, “Paramedic, you are approved for an additional ten milligrams of midazolam intramuscularly; please repeat back”) in order to avoid medication errors. Second, any administration of a controlled substance (opiate, benzo, ketamine, etc), whether by Standing Order or Medical Control Option, will eventually require a Tracking Number (found at the top of each page in the book - MMC-####) for administrative purposes. Please assist crews for this when requested.

That’s it for this week, but don’t fret, I’ll see you all again in just 7 days! www.nycremsco.org or the protocol binder in case you can’t wait that long.

Dave

EMS Protocol of the Week - Bleeding / Hemorrhage Control / Impaled Object (Adult and Pediatric)

For those of you who are still new to the splendor of these weekly emails, one recurring theme is that the EMS approach to trauma in NYC is all about ABCs and rapid transport to the appropriate hospital, often a trauma center. As such, most trauma jobs in the city can be performed at the BLS (EMT) level, with CFRs (FDNY firefighters) able to perform many (if not most) of the interventions.

This is well illustrated in the EMS protocol for bleeding, hemorrhage control, and impaled objects, where the bulk of care is in direct pressure (with hemostatic dressings, if available) and tourniquets (one initially for an uncontrolled bleed, with a second one that can be placed proximal to the first for continued bleeding). Note that, as per the Key Points section, tourniquets can also be used for bleeding dialysis access sites, if the bleed is life threatening and refractory to direct pressure. Impaled objects, briefly referenced, are to be left in place unless they are contributing to airway compromise.

That’s it! Stop the bleed! But don’t stop the learning! www.nycremsco.org or the protocol binder for more.

 Dave