EMS Protocol of the Week - Severe Bradycardia (Pediatric)

Happy EMS Tuesday!

We're going to slow things down from John Su's riveting email about eye emergencies to discuss the EMS protocol for “Severe Bradycardia (Pediatric)”. These are 3 words that no one wants to hear in a sentence together, so let’s get mentally prepared in case this patient comes in!

To use this protocol, patients should have: 1) HR <60 bpm, and 2) signs of shock or AMS. Any provider taking care of this type of patient can begin chest compressions and ventilations as per AHA guidelines. If an EMT is first on scene, they should immediately request ALS assistance and transport if timing makes more sense. 

For paramedics, cardiac monitoring will be started and IV access will be obtained. Standing Order will allow them to perform the following: 

1) Epinephrine 0.01 mg/kg (0.1mL/kg) IV of 1:10,000 concentration (max 1mg) every 3-5 minutes, 

2) Atropine 0.02 mg/kg IV (min 0.1mg, max 0.5mg), 

3) intubation if unable to provide effective BVM ventilations. 

If that does not work, they will call OLMC for one of two options: 

1) administration of a 2nd dose of Atropine 0.02 mg/kg IV 

2) initiation of transcutaneous pacing. Of note, they may also for procedural sedation authorization for pediatric patients if the patient is conscious.

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

Sincerely,

Joseph Liu, DO

Chief Resident, Emergency Medicine PGY-3

Maimonides Medical Center

Intubating Asthmatic Patients

Asthma is Greek for panting, which is a fitting translation for a patient that presents with a severe asthma exacerbation. We try to avoid intubating these patients because they are prone to compilations such as pneumothorax, mucus plugging, and increased morbidity and mortality. 

However, there are specific situations when you may consider intubating an asthmatic patient. One reason is that your patient may not be improving despite maximal medical therapy, such as BIPAP, albuterol, ipratropium, magnesium, epinephrine/terbutaline, ketamine, etc. Another reason is that your patient may now be altered, and have worsening work of breathing, and vital sign abnormalities. Remember that a “silent chest” is a poor prognostic indicator; you may not hear wheezing because they are not moving any air. 

If you choose to intubate, there are tricks to maximize your success and optimize your management of your patient on the vent. 

• Use a large ETT (8-9) because it reduces airflow resistance and can facilitate procedures later (such as bronchoscopy). 

• Ketamine is a useful induction agent because of its bronchodilatory effects. It may also be useful if you choose delayed sequence intubation. 

• High airway pressures can cause hypotension after intubation, so consider giving volume if there is a current or prior history of hypotension. 

• If hemodynamics are compromised consider giving an epinephrine drip. It is considered a systemic bronchodilator that can provide hemodynamic support as well as bronchodilation. 

• Keep a low respiratory rate when bagging or on the vent (6-8 breaths/min). Giving them time to exhale will decrease the chances of air trapping and pneumothorax. Another way to do this is to increase the I:E time (1:4 or 1:5). 

• If the vent is alarming, troubleshoot (DOPES mnemonic) but be suspicious for mucus plugs, pneumothorax, or breath stacking. If they are breath stacking, disconnect them from the vent and push on their chest to help them fully exhale.  

A quick note about auto-PEEP and breath stacking: Auto-PEEP refers to trapping gas in the lungs during respiration. This occurs when one breath can’t be fully exhaled before the next inhalation. This trapped gas causes additional positive pressure, known as “auto-PEEP” in the chest which is typically higher than the PEEP set on the ventilator. This process predisposes patients to develop a pneumothorox. 

Thanks for reading!

Ariella

POTD: Needle Sticks

You're in a hectic trauma, the patient is stabbed all over the chest and loses pulses. You crack open the chest. In the chaos, a surgery resident (she-who-will-not-be-named) nicks your palm with a suture needle. You inspect your hand and...shoot, it's definitely a needle stick. Sigh.

So what is my actual risk?

High risk:

- inoculation from deep or wound

- stick with a hollow bore needle/needle used for blood draw

Low risk:

- suture needle

- discarded needle

No risk:

- unused needle

- no break in skin

What bloodwork should I get?

From both the source patient and the exposed patient you will need:

Hep B surface antigen

Hep C antibody

HIV 1/2 Antibody

CBC, BMP, LFT, and UHCG

What exactly is the risk of transmission?

Thankfully, the risk of transmission from a positive source is fairly low!

HIV: 1 in 300, or approximately 0.3%

Hepatitis C: 1.8%, although studies have shown up to 7%

Hepatitis B: Rates vary depending on infectiousness of source patient and whether the exposed patient is vaccinated. prior to vaccinations, infectious rates could be as high as 30-60%. Full vaccination against hep B can reduce transmission to as little was 1-6%. Vaccination is the best protection against Hepatitis B transmission!

So who really needs PEP? and how effective is PEP against transmission?

the answer to that is it depends, and pretty darn effective!

Hepatitis B PEP:

- Hepatitis B immunoglobulin with vaccination series

- Decreases risk of infection by 75%

- If source patient has unclear or positive, the following should be done:

• If exposed patient is fully vaccinated, no PEP is required

• if exposed patient is not fully vaccinated or nonresponder, must be started on PEP

- initiate ASAP. Unknown effectiveness after 7 days post-exposure

- if exposed patient is unvaccinated, they should be initiated on hepatitis vaccination series regardless of status of source patient

HIV PEP:

- triple cocktail (preferred): Truvada (Tenofovir 300 mg + Emtricitabine 200 mg) + Raltegavir 400 mg BID

- 2nd line: nucleoside Reverse Transcriptase Inhibitor + (Integrase vs Protease vs non-nucleoside reverse transcriptase inhibitor)

- decreases risk of infection by 80%

- initiate ASAP, unknown effectiveness after 72 hours

- 28 day regimen. our pharmacy can give 1 week supply and f/u ID for rest of regimen

Hepatitis C PEP:

- sadly none exists, and no vaccines exist. bummer. Best management is close followup and continuous blood work

Regardless of exposure risks, patients should be followed up with ID in 48 hours for further testing!