EMS Protocol of the Week - Procedural Sedation (Adult and Pediatric)

Couple of VERY cool updates to the prehospital sedation protocol this past year:

1. Medications can now be given for procedural (eg, cardioversion, pacing, CPAP) or advanced airway management (eg, endotracheal tube, supraglotic device) sedation as Standing Order (ie, without prior OLMC approval). For advanced airway management, these patients need to meet very strict inclusion criteria; otherwise, crews will have to call OLMC for authorization as before.
2. IV ketamine has finally entered the arena as a possible Standing Order and/or Medical Control Option, rather than the Discretionary Order we had previously made it out to be as some hush-hush, off-label use.

Note that all these doses are weight-based, with a limit on the maximum dose to be given at a time. Be sure to practice good closed-loop communication when confirming doses (and routes, for that matter; notice how these are all written as IV formulations, which I think appropriately implies that anyone about to get electrocuted or have a tube shoved down their throat should have vascular access).

Also bear in mind that for pre-airway sedation, even though the protocol is only written as a pre-intubation dose and a post-intubation dose, many crews will often ask for a third dose as a “standby” in case more meds are needed. You might hear “I’d like to give 40 of etomidate followed by 5 and 5 of diazepam as needed post-intubation” while on the phone. Use your discretion for how much medication you feel comfortable approving at once, and again, clearly state your orders in a closed-loop fashion to avoid medication errors.

ALSO also:

Paramedics
Do
Not
Carry
Paralytics
Do
Not
Ask
Them
To
Give
Rocuronium
You
Will
Sound
Silly


And that’s it! You are now all incredibly well…versed…in the world of prehospital sedation! www.nycremsco.org and the protocol binder to keep the knowledge train rolling!


Dave

EMS Protocol of the Week - Cold Emergencies

Happy COLD Tuesday!

Another guest post for the week where we will be discussing EMS protocol for Cold Emergencies that apply to both adult and pediatric populations.

The prehospital approach to cold emergency shows a nice progression of responsibilities based on level of training. CFRs at the most basic level will move the patient to a warmer environment, remove any wet clothing/jewelry, apply heat packs, and dry the patient with warm blankets. BLS crews will monitor for alter mental status, treat any hypoglycemia and request ALS backup. ALS providers on scene will perform advanced airway management as needed, begin cardiac monitoring and record an EKG for evaluation, and obtain IV access to administer warm crystalloid fluids if available.

Not a lot to do on the OLMC side other than to be aware of this stepwise progression, as well as understand localized cold injury vs generalized hypothermia (with possible loss of central pulses.)

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

John Su

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