EMS Protocol of the Week - Severe Sepsis and Septic Shock (Adult and Peds)

 ·   · 

Hello EM friends,

For this week's protocol review, we're going to discuss the pre-hospital world of sepsis care. This one's a BOGO deal and will include the approach for both adults and little adults (pediatrics). 

Our EMS colleagues are trained to identify septic patients using very similar criteria to us: 2 SIRS-like + presumed infection. Reference this table to see the differences with our criteria (mainly to increase specificity for correctly identifying septic patients in the field / working with more limited resources):

CFR and BLS crews unfortunately will not be able to offer much in the way of interventions - we're dabbling in the world of critical care. CFRs can assess ABCs/vital signs and administer O2 as necessary. BLS crews can additionally obtain BGMs and treat as indicated; otherwise, they will request ALS assistance if required and transport patients to the hospital. 


ALS crews can administer much more in terms of therapeutics - they can perform advanced airway management, cardiac monitoring, EKG evaluation, IV/IO access, crystalloid administration, and adult vs pediatric specific blood pressure management protocols. Before the adult and pediatric protocols branch, paramedics will  start by administering both groups a 20 mL/kg IV bolus. If the patient is still hypotensive, the protocols are as follows:

  • Adults: 

    • Goal: SBP > 90 mmHg or MAP > 65 mmHg

    • Administer one of the following:

      • Additional 20 mL/kg bolus

      • Norepinephrine IV (20 mcg/min max) infusion

      • Epinephrine 10mcg pushes Q3-5 minutes

  • Pediatrics:

    • Goal: age-appropriate BP goals

    • Activate OLMC to administer one of the following:

      • Additional 20 mL/kg bolus

      • Epinephrine 5mcg pushes Q3-5 minutes

      • Norepinephrine 0.05mcg/kg/min (20mcg/min max) infusion


Over the OLMC phone, we will have the power to authorize Vasopressin infusions to maintain SBP/MAP goals for adults. And again, ALS crews will have to communicate with us to administer any BP support beyond the initial 20 mL/kg bolus for pediatric patients. 

More knowledge to be farmed at www.nycremsco.org.

Best,

Zachary Kim, MD

PGY-2 Emergency Medicine

EMS Protocol of the Week: Obstetric Emergencies!

 ·   · 

Hi all, 

This week we will be focusing on Obstetric Emergencies!

The prehospital approach exists as a progression of care based on the provider’s level of training. CFRs start with ABCS and monitoring vital signs for shock. They will check for crowning and if present prepare for imminent delivery. If delivery has not begun, they will place the patient in a left lateral recumbent position. 

BLS crews can address vaginal bleeding in pregnancy by placing dressing over the vagina to help estimate quantity of blood loss. If immediately postpartum, they can massage the mother’s abdomen over the uterus. 

If the on-scene team is ALS-trained, they can obtain IV access for patients with severe pre-eclampsia, eclampsia or postpartum hemorrhage. For patients with eclampsia, they can administer Magnesium Sulfate 4 g IV over 10 minutes. 

From an OLMC standpoint, providers can authorize 2g Magnesium Sulfate over 10 minutes for patients with concern for pre-eclampsia. 

KEY POINTS: 

  • Consider supine hypotension syndrome as a cause of shock 

  • Severe pre-eclampsia is when pregnant patients have BOTH of the following conditions: 

    • Systolic blood pressure ≥ 160 mm Hg OR a diastolic blood pressure ≥ 110 mm Hg 

    • Symptoms of a headache, visual disturbances, pulmonary edema or lower extremity edema 

  • Eclampsia and pre-eclampsia do not occur prior to 20 weeks of gestation 

  • Eclampsia and pre-eclampsia may occur up to one (1) month post-partum 


More words to read at www.nycremsco.org

EMS Protocol of the Week!!! - Stridor/croup/epiglottitis (Peds)

 ·   · 

It’s that time of year! All the children have been coming in with respiratory distress. These days, most often it’s a child with bronchiolitis. But it’s also important not to forget about the kids coming in with croup, anaphylaxis, airway obstruction, and the rare but scary epiglottitis.

 

 

Management?

 

As always…ABC’s.

 

1.     Administer high flow O2 via NC or face mask

2.     Consider obstructed airway vs. anaphylaxis as causes of respiratory distress

3.     Stridor at rest? Think croup.

a.     Epi 3mg nebulized OR racemic epi nebulized

4.     Get IV access (in real life, depending on age of the child I feel like this doesn’t always happen, but it’s important for children in respiratory distress who can decompensate quickly)

5.     STEROIDS!! (ONLY if 2 years or older)

a.     Dex 0.6mg/kg to max of 12mg or methylpred 1mg/kg to max of 60mg

 

If EMS suspects Epiglottitis, EMS will NOT attempt advanced airway – will only ventilate with bag valve mask and transport ASAP

 

Last but not least, OLMC (which we are all experts on now after Vic’s great emails the other week)

-       EMS must call if kid is <2 y/o in respiratory distress and wants to give steroids

 

KEY POINTS:

-       Croup = stridor + retractions + barking cough

-       Epiglottitis = stridor + retractions + muffled voice + high fever (TOXIC APPEARING)

-       Unvaccinated = high risk for epiglottitis

-       Airway obstruction (foreign body, mass) = biphasic stridor

-       Don’t agitate a child already in respiratory distress

-       Dex > methylpred in kids

And if you want more... www.nycremsco.org

 

Jennifer Wolin, MD

Emergency Medicine PGY-2 Resident Physician

Maimonides Medical Center