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

Last week, we went 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.

At this point, you may feel that we’ve exhausted all there is to say about adult out-of-hospital cardiac arrest. Maybe you even think the whole topic is…dead and buried?

If not, you’ve got www.nycremsco.org and the protocols binder to keep you company until our next protocol next week!

Dave

EMS Protocol of the Week - Non-Traumatic Cardiac Arrest (Adult)

The prehospital approach to general cardiac arrest care is a good introduction to the progression of responsibilities from one level of training to the next. We get a large number of OLMC calls from our own paramedics requesting physician input in arrest cases, so it’s always good to refresh ourselves on what they can or cannot do in these instances.

At the CFR level, by Standing Order, providers who encounter a patient in arrest will initiate CPR and apply an Automated External Defibrillator, following the AED’s instructions until backup arrives.

BLS providers (EMTs) will request ALS backup if not already present, but will otherwise begin to transport the patient to the hospital after 3 rounds of CPR/AED analysis.

It’s not until the ALS (paramedic) level that an actual cardiac monitor will be applied, giving a specific rhythm underlying the arrest. It’s for this reason that you might hear something from the paramedics like “our initial rhythm was asystole; patient was shocked 2 times (by AED) prior to our arrival.” The rest of the ALS Standing Orders consist of continuing CPR, performing a needle decompression for suspected tension pneumothorax, obtaining an advanced airway (either endotracheal tube or supraglottic device) and intravascular access, administering D50 for hypoglycemia, and giving ACLS-dose epinephrine every 3-5 minutes. If the patient is found to be in VT/VF (the “shockable rhythms”) rather than PEA/asystole (the” non-shockable rhythms”), they will also give an initial dose of either amiodarone or lidocaine by Standing Order.

By the time medics call OLMC, they will have generally given a few doses of epinephrine, but they need physician approval to give sodium bicarbonate or calcium chloride, which are Medical Control Options (and as such are found under that section of the protocol). Other MCOs include a second dose of amiodarone or lidocaine for a shockable rhythm, as well as magnesium sulfate for suspected Torsades de Pointes. When deciding whether to authorize these Medical Control Options, it’s worth asking yourself – why do you think this particular patient arrested? Hyperkalemia? TCA overdose? Some sort of electrical storm? It might be worthwhile to administer one of these medications. Or do you think attempts at ROSC are futile? Maybe no medications are indicated, and we should instead consider Termination of Resuscitation (ToR). We’ll discuss ToR in a separate email, but these are the kinds of questions to keep in mind when fielding these calls.

And there you have it! First protocol down, and a big one at that! Some might even say that it’s…the heart…of these protocols? Some people have definitely said that.

Check out www.nycremsco.org and the protocols binder for more! Otherwise, see you next week for the next review!

Dave

EMS Protocol of the Week - Introduction

Happy New Year, Maimo fam! Hope everyone is tan, hydrated, and getting settled into their new MMC roles. After a bit of a summer break, we’re back with your regular EMS Protocol of the Week emails! These are meant to serve as a longitudinal guide/reference as you start experiencing the new, mysterious, dare I say invigorating world of On-Line Medical Control (OLMC).

Each week, we will review another protocol highlighting the roles and responsibilities of EMS field providers and OLMC physicians in NYC; these protocols are designed by physicians and are a good review of core EM concepts, but they are also intended to help guide you on how to best advise EMTs and paramedics that call us looking for assistance.

This first email for the year will reinforce some OLMC basics, starting with how to read the protocols (found here, at www.nycremsco.org, and the protocols binder next to the phone [you know, the one you always pick up by mistake]). Take a look at the attached pdf for a refresher on protocol formatting, but here are the big points:

1.       Each protocol is divided into dedicated sections for CFR (firefighters), BLS (EMTs), and ALS (paramedics).

2.       Each protocol reads top to bottom, in sequential order, but each section builds on the section before it (remember, “Good ALS care starts with good BLS care”). CFRs will stop at the end of their section, EMTs will cover everything between the CFR section and the BLS section, and paramedics will cover everything from the CFR, BLS, and ALS sections.

3.       Standing Orders (SO) describe everything explicity written in each of these sections that EMS providers are expected to do by default.Medical Control Options (MCOs) are found at the end of each protocol and describe what providers (usually paramedics) can do after calling OLMC for physician approval; the most common example of this would be paramedics requesting to give calcium chloride and sodium bicarbonate during a cardiac arrest.

a.       Discretionary Orders (DO) are those that you, as the OLMC physician, are requesting the providers to perform but are not explicitly written in the protocols as either SO or MCO. The order must be for something that the crew already carries and is trained in using; an example of this might be having our paramedics use fentanyl for intubation, because they use it in another protocol (General Pain Management), and it’s not currently listed as a sedation option for airway management. On the flip side, you cannot ask the crew to give propofol as a Discretionary Order, as this is not a medication that they carry or know how to use. Discretionary Orders highlight the importance of having a general understanding of what EMTs and paramedics can do and how their ambulances are stocked.

4.       While we use 18 as the age cutoff for whether or not a patient is a minor, for the purposes of these protocols, the NYC REMAC defines pediatric patients as up to 15 years of age.

Look this over a few times and please reach out with any questions; we’ll be putting it all into practice next week as we review our first protocol!

Dave