EMS Protocol of the Week - Obstructed Airway (Adult and Pediatric)

The prehospital approach to the obstructed airway shows a nice progression of responsibilities based on level of training. CFRs at the most basic level will encourage coughing and other AHA-recommended choking maneuvers. BLS crews will request ALS backup, but if their expected arrival time is longer than the time it would take to transport to the hospital, they will transport the patient, again attempting to perform basic maneuvers to clear the airway.

If ALS providers are on scene, they will perform DL to attempt to manually remove the obstruction with Magill forceps; if unsuccessful, the subsequent steps walk through how to intentionally right mainstem the foreign body while obtaining an advanced airway.

Not a lot to do on the OLMC side other than to be aware of this stepwise progression, as well as have an understanding of pre-intubation sedation options if needed. What are those options? Stay tuned – the answer may…take your breath away?

www.nycremsco.org and the protocol binder for more!

Dave

EMS Protocol of the Week - Ventricular Tachycardia with a Pulse / Wide-Complex Tachycardia of Uncertain Type (Adult)

Happy Tachy Tuesday!

Another guest post for the week where we will be discussing the EMS protocol for Ventricular Tachycardia with a Pulse / Wide-Complex Tachycardia of Uncertain Type.

First question: is this patient stable or unstable? If this patient is hypotensive, altered, or has signs of hypoperfusion, this is an unstable patient. Standing Order will allow paramedics on scene to perform SYNCHRONIZED CARDIOVERSION up to 4 times (first 100J, then 200J, then 300J, then 360J). If that does not work, they will administer Amiodarone 150mg IV.

If the patient is stable, Standing Order allows administration of Amiodarone 150mg IV or Lidocaine 1mg/kg. If persistence of stable V-Tach after one agent is given, they can give the other one.

For both Stable and Unstable V-Tach, OLMC will be called if nothing above worked for authorization of three options: administration ofMagnesium Sulfate 2g IV, Calcium Chloride 1g IV if suspicious for hyperkalemia or calcium channel blocker OD, or Sodium Bicarb 44-88 mEq IV if suspicious for acidosis.

Check out www.nycremsco.org or the protocol binder on North Side for more.

Sincerely,

Joseph Liu, DO

Chief Resident, Emergency Medicine PGY-3

EMS Protocol of the Week - Smoke Inhalation

Hello all, 

This week's EMS Protocol is brought to you by my obsession with the HBO smash hit House of the Dragon. 

Picture this -- Two Westerosi men walk into a King's Landing bar. They see Princess Rhaenyra and strike up a heated conversation to delight her. After exhausting all the advances in their arson-al, they realize they're no match. Syrax, fuming at this show of smoke and mirrors, suggests they use Tinder and burns them to the ground. EMS arrives at the scene and then has to deal with the rest of the patrons...

Enter the REMAC protocol for smoke inhalation!

-In general, always start with ABC's -- airway is critical.

-Place patients on NRB for O2.

-EMTs can measure carbon monoxide (SpCO) with a pulse co-oximeter.

              -Keep in mind SpCO measured by an external pulse co-ox is less reliable compared to that calculated from blood co-oximetry.

              -Consider transfer to a facility with hyperbaric capabilities (like Jacobi) if you suspect CO poisoning.

-Medics perform advanced airway management.

              -Have a low threshold to use DL/VL.

              -Intubate early for soot/edema in airway, neck burns, progressive hoarseness, AMS.

-Treat cyanide poisoning early (stay tuned for more info).

Don't forget to check out www.nycremsco.org and the protocol binder for more and reach out for questions!

Remember: Winter is coming. And with winter, comes more electric/gas heating fires and potential for burn/smoke injures.

Best,

Chris Kuhner, MD

PGY-2 Emergency Medicine