EMS Protocol of the Week - Shock/Sepsis (Pediatric)

Compared to its adult counterpart, the Shock/Sepsis protocol for pediatrics puts a higher emphasis on addressing unstable tachyarrhythmias, partially because the other dysrhythmia protocols are written specifically for adults. In any event, the CFR and BLS portions of the protocol focus on keeping the child warm and transporting, while paramedics will further assess for hemorrhage or dehydration. If volume status appears to be the primary problem, medics will give up to two 20mL/kg crystalloid boluses (40mL/kg total). For shock states wherein the patient is in SVT or VT with a pulse, crews are instructed to contact OLMC for orders to cardiovert. As the OLMC doc, you are advised to approve synchronized cardioversion ONLY if able to deliver the appropriate weight-based dose. For SVT specifically, if unable to electrically cardiovert, you can give orders for weight-based adenosine.

Ultimately, as previously discussed, the running theme for pediatric protocols tends to be rapid transport to an appropriate hospital. But as always, having this sort of familiarity in your back pocket will help you provide the best care when stuff hits the fan. 

Stay tuned for more! Until then, www.nycremsco.org ! 

Dave

EMS Protocol of the Week - Shock/Sepsis (Adult)

We previously touched briefly on prehospital pressor options for shock states, but the old formatting found them disjointed and scattered between protocols. While the new protocol formatting doesn’t quite fully fix this problem (and, in fact, much cleaner shock-specific protocols are in the works for next year), the newly organized Shock/Sepsis protocol is a step in the right direction.

Very little in the way of CFR and BLS components for this protocol, as you might imagine; we’re clearly pushing into critical care territory here, and the most useful interventions are going to be invasive to an ALS level of training. Note how, even in a circulation-focused protocol, everything falls back on ABCs. The paramedic section leads off with advanced airway management if indicated and follows with assessment for tension pneumothoraces as an etiology of shock. Following those crucial steps comes fluid resuscitation – up to 250mL in suspected cardiogenic shock, or up to 3L if non-cardiogenic. Consistent shock state, either by appearance or blood pressure, now calls for one of three vasopressors – push-dose epinephrine (here defined as a 10mcg IV bolus, for consistency of terminology), norepinephrine infusion, or dopamine infusion (no, we haven’t been able to get rid of dopa yet). Any one of these three options is available to paramedics as Standing Order. However, if the crew feels like they need to switch from one to another (ie, transitioning from persistent pushes of epi to a norepi drip), they require OLMC approval, so be prepared for those calls. Key Points include instructions on mixing push-dose epi, as well as prehospital criteria for severe sepsis/septic shock. Note that the criteria are slightly different from what we consider SIRS criteria in the ED – this was a conscious decision made in an attempt to increase specificity in the out-of-hospital setting. For patients that do fall into the sepsis category, crews are advised to pay particular attention to fluid administration, as well as other data such as temperature and lactate (neither of which is yet commonly available to crews; consider it future-proofing for one day, hopefully, having access to thermometers and some POC bloodwork).

That’s it! You’re all now pros at keeping the patient’s pressure up and your own pressure down! www.nycremsco.org for more!

Dave

EMS Protocol of the Week - Asthma/Wheezing (Pediatric)

Despite being a whopping three pages, the protocol for Pediatric Asthma/Wheezing is largely the same as its adult counterpart, just without considerations for COPD since it’s kind hard to rack up a 50-pack-year history of smoking before the age of 15 (although who knows how this kid is doing nowadays? https://www.youtube.com/watch?v=x4c_wI6kQyE ). 

Otherwise, as in the protocol for adults, CFRs will assist with home albuterol, BLS will give up to one albuterol nebulizer and an injection of IM epinephrine, and ALS will continue albuterol and add ipratropium and steroids as needed. Medical Control Options include additional doses of epinephrine or albuterol as indicated (note that Standing Orders allow for a maximum of 3 albuterol nebs for kids, versus continuous for adults). Pediatric dosing considerations are highlighted throughout this protocol, both for epinephrine and for dexamethasone; methylprednisolone, as well as magnesium sulfate for that matter, are reserved for adults).

Hope the new protocol format makes sense! Keep brushing up at www.nycremsco.org and with the protocol binder!

Dave