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2010 REMAC Protocol Update: Acting on the Evidence

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Title: 2010 REMAC Protocol Update: Acting on the Evidence


1
2010 REMAC Protocol Update Acting on the
Evidence
  • John Freese, M.D., FAAEM
  • Medical Director of Training / OLMC
  • Director of Prehospital Research
  • New York City Fire Department
  • and
  • Department of Emergency Medicine
  • St. Vincents Hospital - Manhattan

2
Introduction
  • As has become our routine, with the coming of the
    New Year so come our new protocols. And again
    this year, there are a number of changes designed
    to continue to ensure that we provide the best,
    most medically appropriate care for our patients.

3
Auld Lang Syne
  • But in the tradition of the New Year, lets begin
    by looking back and gaining some perspective.

4
Auld Lang Syne
  • In Memoriam Dr. Gary Lombardi
  • (January 14, 1951 October 12, 2009)
  • - joined NYC EMS as an ambulance driver in 1968
  • - graduate of the Citys first paramedic class
    in 1974
  • - earned his medical degree in 1982
  • - returned to NYC EMS in 1895
  • - published the first cardiac arrest
  • study in New York City
  • (the PHASE Study) in 1994
  • - continued to work as an OLMC
  • (telemetry) physician
  • until July 2009
  • - one of the most beloved and
  • influential physicians in the
  • New York City EMS system,
  • and he will be missed

5
Auld Lang Syne
  • Weve come a long way in the past six years.
    Just a few years ago in this system
  • - Some patients waited in pain while you called
    for orders.
  • - Other patients continued to seize while you
    called for orders.
  • - STEMI patients went to the nearest hospital
    regardless of the hospitals ability to provide
    the best possible care
  • - and the same was true for stroke patients
  • - and victims of sexual assaults
  • - and post-arrest patients.
  • - All patients with head and spine injuries
    required
  • immobilization.
  • - Cardiac arrest patients received care that
    resulted
  • in significant interruptions in CPR,
  • unnecessary / unproven drugs, etc.
  • - There was no protocol to deal with weapons of
    mass destruction.
  • - BLS providers had to wait for ALS in order to
    treat anaphylaxis unless the patient happened to
    have an Epi-Pen.
  • - Hydroxocobalamin, CPAP, etomidate, ipratropium
    and alternative airways were not part of the
    care that we provided.
  • - And the list goes on and on.

6
Today in New York City
  • STEMI patients, sexual assault victims, patients
    with acute strokes, and post-arrest patients are
    transported to hospitals whose capabilities are
    best suited to treat their condition.
  • Our cardiac arrest protocols have been optimized
    to ensure a focus on the basic principles of
    resuscitation and, as a result, patients are more
  • likely to achieve ROSC today than ever before.
  • BLS care has been expanded to include the
    administration of
  • albuterol to a wider range of patients, the use
    of autoinjectors
  • for anaphylaxis and WMD events, expanded
    defibrillation
  • capabilities through the application of adult
    AEDs for pediatric
  • patients and infants, the application of
    selective spinal
  • immobilization, and a number of other
    improvements related
  • to the care of medical and trauma patients.
  • And ALS care has seen a large number of changes
    including the administration of benzodiazepines
    and narcotics under standing orders, waveform
    capnography monitoring for airway placement and
    maintenance, the option to administer
    benzodiazepines for the sedation of agitated /
    violent patients, the addition of medications
    such as etomidate and hydroxocobalamin and
    vasopressin, the use of biphasic defibrillation
    and alternative advanced airways, mandatory
    12-lead EKG capability and transmission, CPAP,
    management of severe asthma exacerbations under
    standing orders, and the list goes on.

7
But We Cant Stop Now
  • Over 1.2 million patients each year depend upon
    you for their emergency medical care. And they
    have a right to expect that the care that you
    provide will be based on the latest medical
    science.
  • That is why our protocols have and will continue
    to evolve. Medications and skills that have been
    proven to be effective will be added, and others
    that have
  • been shown to lack effectiveness will
  • be removed.
  • But each of these decisions must come
  • from an analysis of the latest science
  • and our own data. They must be
  • evidence-based.

8
Evidence-Based Medicine
  • The concept of evidence-based medicine is fairly
    simple.
  • Our understanding of human physiology,
    pharmacology, and medicine are evolving at an
    incredible rate.
  • And in addition to keeping up with these changes,
    we owe it to our patients to ensure that we
    incorporate this knowledge into the care that we
    provide.
  • In short, we need to ensure that the medicine
    that we practice is based upon the evidence of
    what works, what doesnt work, and - when the
    exact answer is not known - what the most recent
    knowledge tells us is likely to be the best
    decision for our patients.
  • That is evidence-based medicine.

9
Evidence-Based EMS
  • To understand the basis for the yearly changes
    that have been incorporated into our protocols,
    just consider the number of studies and articles
    in the medical literature that have been
    published in recent years
  • As you can see, the number of articles published
    in the medical literature has increased every
    year in each of these categories. And keeping up
    with this rapidly growing and evolving body of
    knowledge has led to the annual protocol changes,
    including those for 2010.

10
And Now The Protocols
  • The 2010 New York City REMAC Protocols will take
    effect on
  • April 1, 2010.
  • This self-tutorial presentation is
  • meant to guide you through the
  • changes that will take effect
  • on that date and to provide
  • you with some information
  • to support / explain these changes.
  • As with all such presentations in
  • the past, this presentation is meant to serve as
    one persons view of these changes, the rationale
    behind them, and associated explanations and
    should not supersede the guidance and thoughts
    of other medical directors, agency directives,
    etc.

11
2010 Protocol Changes
  • General Operating Procedures BLS
  • - Oxygen Administration
  • - Initiating Transport
  • BLS Protocols
  • - 401 Respiratory Distress / Failure
  • - 407 Wheezing
  • - 410 Anaphylactic Reaction
  • - 421 Head and Spine Injuries
  • - 423 Chest Injuries
  • - 425 Bone and Joint Injuries
  • - 428 Burns
  • - 430 Emotionally Distrubed Patient
  • - 431 Heat-Related Emergencies
  • General Operating Procedures ALS
  • - Interpretation of Protocols
  • - Communications with Medical Control
    Facilities
  • - Prehospital Sedation
  • ALS Protocols
  • - 500-A and 500-B Smoke / Cyanide
  • - 502 Obstructed Airway
  • - 503-A Ventricular Fibrillation / Pulseless
    Ventricular Tachycardia
  • - 503-B Pulseless Electrical Activity (PEA) /
    Asystole
  • - 504 Suspected Myocardial Infarction
  • - 505-A Supraventricular Tachycardia
  • - 505-B Atrial Fibrillation / Atrial Flutter
  • - 505-C Ventricular Tachycardiac with a Pulse
    / Wide Complex Tachycardia of Uncertain Type
  • - 505-D Bradydysrhythmias and Complete Heart
    Block
  • - 506 Acute Pulmonary Edema
  • - 510 Anaphylactic Reaction
  • - 521 Head Injuries
  • - 540 Obstetric Complications
  • - 551 Pediatric Obstructed Airway

12
BLS Changes
13
General Operating Procedures - BLS
14
General Operating Procedures - BLS
  • The following sections of the GOPs that are
    related to BLS care have been changed, effective
    April 1, 2010
  • - Oxygen administration
  • - Initiating Transport

15
General Operating Procedures - BLS
  • Oxygen Administration
  • In assessing a patients respiratory status, the
    decision to provide assisted ventilations must
    take into account the ability of the patients
    respiratory function to effectively accomplish
    its two primary functions oxygen delivery and
    carbon dioxide exchange, or oxygenation and
    ventilation.
  • Failure of either of these two essential
    functions, or failure to correct them via
    supplemental oxygen administration, should be the
    factor that causes us to assist a patient via
    bag-valve-mask.

16
General Operating Procedures - BLS
  • Most of us learned in our initial EMT-B training,
    as it said in the GOPs, that a respiratory rate
    less than eight or greater than twenty-four,
    assisted ventilations may be required.
  • And the key word in that sentence is may.
  • Think about most of the patients for whom you
    have cared whose respiratory rate was less than
    eight or greater than twenty-four. Most of them
    needed no respiratory assistance.
  • In fact, in 2009, FDNY EMTs and paramedics cared
    for over 25,000 adult patients with those
    respiratory rates, and the vast majority of them
    did not receive BVM ventilation / airway
    management.

17
General Operating Procedures - BLS
  • That is the reason for the first change in the
    oxygen administration section of the
  • GOPs.
  • The reference to respiratory rate has
  • been removed and
  • replaced with language that
  • actually addresses the problem
  • for which we want to assist
  • ventilations hypoxia,
  • inadequate ventilation, and/or
  • (for the ALS providers) an inability
  • to maintain airway protection.

18
General Operating Procedures - BLS
  • Oxygen Administration Assisted Ventilation
  • Hypoxia is the lack of sufficient oxygen,
    particularly within the tissues of the body.
  • Hypoxemia is the lack of sufficient oxygen within
    the blood and typically results in tissue hypoxia
    as well.
  • In assessing the patient for signs of hypoxia, we
    need to look for signs of both hypoxia and
    hypoxemia.

19
General Operating Procedures - BLS
  • Cyanosis is the most easily recognizable sign of
    hypoxemia.
  • When the blood is unable to obtain sufficient
    oxygen to completely fill the available spots
    on the hemoglobin that it contains, it takes on a
    bluish color that is visible in the skin
    (particularly in more pale or fair-skinned
    individuals), mucous membranes, and nail beds.
  • But even cyanosis is not a reliable sign of the
    need
  • for artificial ventilation some patients
    may
  • normally be mildly cyanotic (COPD blue
    bloaters),
  • some may have cyanosis due to other causes
    (drug
  • toxicity), and others may improve simply by
  • providing supplemental oxygen.
  • What we need to look for are other signs and
    symptoms of hypoxia.

20
General Operating Procedures - BLS
  • The list below gives additional signs and
    symptoms of hypoxia. When several of these are
    present, with or without cyanosis, and are not
    rapidly corrected with supplemental oxygen, the
    patient is likely (but not universally) likely to
    need assisted ventilation.

21
General Operating Procedures - BLS
  • Inadequate ventilation results in an inability of
    the body to rid itself of carbon dioxide.
  • Assuming that the patient has an adequate cardiac
    output so that carbon dioxide can be brought to
    the lungs, only two other things determine the
    ability of a patient to successfully ventilate
    themselves respiratory rate and tidal volume
    (the amount of air that passes in and out of the
    respiratory system with each breath).

22
General Operating Procedures - BLS
  • The amount of air that is exchanged over one
    minute is determined by the respiratory rate and
    tidal volume, and this is a good marker for
    adequate respiration.
  • Minute Volume RR x Tidal Volume (VT)
  • Since most of us breathe twelve times per minute
    and 500cc (or ½ liter) per breath, the average
    patient needs six liters of minute ventilation to
    successfully eliminate carbon dioxide from the
    body.
  • With that in mind, lets consider a couple of
    scenarios

23
General Operating Procedures - BLS
  • Scenario 1 A patient with deep sighing breaths
    (800-1,000mL / breath) at a rate of ten breaths
    per minute would have a minute volume of 8-10
    liters. Unless signs of hypoxia were present,
    assisted ventilations would not be needed.
  • Scenario 2 A patient with shallow respirations
    (300ml per breath) at that same rate (ten per
    minute) would have a minute volume of three
    liters. Because their minute volume would
    provide less than half of the ventilation that
    their body is likely to require, assisted
    ventilation would likely be needed.
  • Scenario 3 A patient with those same shallow
    respirations (300ml per breath) and rate (ten
    per minute) who just lost consciousness after
    severe hyperventilation may require no assisted
    ventilation their body is just making up for
    the fact that they blew off too much CO2, so
    the low ventilation rate that you are witnessing
    is all that they require for the moment.

24
General Operating Procedures - BLS
  • The point is that, regardless of the patients
    ventilation rate, your assessment of their
    ventilation status and a decision about their
    need for assisted ventilations has to take the
    bigger picture into account.
  • What is their respiratory rate and volume?
  • Is their ventilation sufficient to meet their
    needs at the present time?
  • Do they demonstrate other signs of inadequate
    ventilation (sonorous respirations, altered
    mental status, etc)?
  • Are they also demonstrating signs of hypoxia?

25
General Operating Procedures - BLS
  • The final point in assessing a patients need for
    assisted ventilation is more of an ALS point,
    because it deals with airway protection.
  • A patients ability to protect their airway from
    saliva, vomit, and other foreign substances is
    essential for proper respiratory function and is
    most easily assessed via the gag reflex.
  • For these patients, assisted ventilation may also
    be needed because of inadequate oxygenation or
    ventilation, but BVM ventilation alone runs a
    high risk for inducing vomiting and causing
    further compromise of oxygenation and ventilation
    due to the fluids and other substances that then
    enter the lungs.

26
General Operating Procedures - BLS
  • So, for patients with an inability to protect
    their airway who also have respiratory compromise
    or hypoxia that does not respond to supplemental
    oxygen, assisted ventilation may be needed. But
    this risk of inducing vomiting and aspiration
    require caution, including assuring that
    ventilations are delivered slowly over one second
    to prevent the forceful movement of air into the
    stomach (gastric insufflation).
  • And when ALS is present, the lack of airway
    protection is best treated by performing
    endotracheal intubation to restore airway
    protection, prevent gastric insufflation, and
    allow for more controlled and monitored
    ventilation.

27
General Operating Procedures - BLS
  • The other change to this GOP is the removal of
    references to
  • mouth-to-mouth or mouth-to-nose ventilation.
  • Because all ambulances are required
  • to have ventilation equipment,
  • including pocket masks, there is no
  • reason that a provider should have to
  • perform these tasks.
  • That said, it is also not forbidden by
  • these protocols, so if there were a
  • need for such respiratory assistance,
  • providers retain the option to perform
  • this potentially life-saving skill.

28
General Operating Procedures - BLS
As our protocols continue to evolve and our
treatments become more specific, there are likely
to be instances for which BLS providers should
wait for ALS arrival instead of transporting the
patient to the nearest 911 facility. When this
is the case, that will need to be specified in
the individual protocols. The GOPs were simply
changed to reflect this expectation.
29
General Operating Procedures - BLS
  • One example of where this is currently the case
    would be cardiac arrests. If ALS is not on
    scene, BLS should not attempt to immediately
    transport the patient. Instead, the patient
    should be treated according to BLS Protocol 403.
    And we expect that other protocols may also
    change to reflect this need for ALS evaluation in
    the future.

30
2010
31
2010 BLS Protocol Changes
  • Changes which will take effect on April 1, 2010
    have been made to the following BLS Protocols
  • - 401 Respiratory Distress / Failure
  • - 407 Wheezing
  • - 410 Anaphylactic Reaction
  • - 421 Head and Spine Injuries
  • - 423 Chest Injuries
  • - 425 Bone and Joint Injuries
  • - 428 Burns
  • - 430 Emotionally Disturbed Patient
  • - 431 Heat-Related Emergencies

32
2010 BLS Protocol Changes - 401
  • Three changes were made to this protocol
  • A reference was added to
  • the MOLST forms.
  • As previously discussed,
  • references to respiratory rate
  • have been replaced in favor
  • of the terms hypoxia and
  • inadequate respiration.
  • References to mouth-to-nose
  • and mouth-to-mouth
  • ventilation have been removed.

33
2010 BLS Protocol Changes - 407
  • In 2007, the FDNY enacted a dispatch algorithm
    that was designed to shift a significant number
    of asthma calls from ALS to BLS response.
  • This was done with the knowledge that the
    majority of asthma patients do not require ALS
    care, that BLS provider can safely and
    effectively administer albuterol, and that the
    patients likely to need only BLS care can be
    identified via a series of questions at the time
    of dispatch.
  • This program has been incredibly effective,
    moving thousands of calls to a BLS response with
    only 2-3 of initially dispatched BLS calls
    requiring a subsequent ALS response / care.
  • But despite that success, within that 2-3 of
    patients there may be a few for whom more
    aggressive and immediate treatment is needed.
    Hence the change to this protocol.

34
2010 BLS Protocol Changes - 407
  • Beginning in July of this past year, BLS
    ambulances were required to carry epinephrine
    autoinjectors for the treatment of anaphylaxis.
  • This was done with the knowledge that BLS
    providers are capable of recognizing anaphylaxis
    and, when ALS is not present, administering
    epinephrinee via autoinjector safely and
    effectively in order to avoid respiratory failure
    and arrest.
  • So, if you can provide it in this manner for
    anaphylaxis, why not for the critical asthma
    patient?

35
2010 BLS Protocol Changes - 407
  • In December, along with the rest of our protocol
    changes, the SEMAC approved a protocol change
    that would allow EMTs to utilize epinephrine
    autoinjectors for the treatment of critical
    asthmatics when ALS was not present.
  • This change will allow patients to receive the
    much-needed medication that they would otherwise
    have to await while ALS responded to the scene.

36
2010 BLS Protocol Changes - 407
  • For patients asthmatic patients who require BVM
    ventilation and for whom ALS is not immediately
    available, this new protocol will allow EMTs to
    administer a single epinephrine autoinjector
    prior to ALS arrival, prior to transport, or
    while en route to the emergency department.

37
2010 BLS Protocol Changes - 407
  • Why epinephrine?
  • You have all listened to the lungs of a critical
    asthmatic and heard thee eerie lack of any lung
    sounds or air movement.
  • When this degree of bronchospasm occurs, the
    patient is unable to move enough air (tidal
    volume) to allow for the delivery of albuterol
    into the lower airways were it is needed.
  • Epinephrine, as in anaphylaxis, is able to be
    absorbed into the blood stream and delivered to
    the lungs. There, through the same mechanism as
    albuterol, it produces relaxation of the smooth
    muscle within the airways, aka bronchodilation.

38
2010 BLS Protocol Changes - 407
  • When faced with a critical asthmatic who requires
    BVM ventilation, one EMT should assemble the
    necessary airway equipment while the other EMT
    obtains and administers an epinephrine
    autoinjector.
  • Administration of the epinephrine should not wait
    for BVM ventilation to be initiated. In fact, it
    should be done simultaneously or even before
    ventilation is begun.
  • If ALS has been requested and is able to arrive
    before patient transport, notify the paramedics
    of the epinephrine administration.
  • Ensure that the use of the autoinjector is also
    properly documented in your ePCR / ACR.

39
2010 BLS Protocol Changes - 410
  • Because there is little risk of causing
    significant adverse cardiac effects (chest pain,
    angina, myocardial infarction) in young patients,
    this protocol has been modified to allow for the
    use of an epinephrine autoinjector to anaphylaxis
    patients under standing orders despite the
    patient not having been prescribed an epinephrine
    autoinjector.
  • Use of epinphrine autoinjectors, under standing
    orders or as a medical control option, must be
    reported to REMAC by the agency.

40
2010 BLS Protocol Changes - 421
  • The wording of this protocol required a little
    clarification. Specifically, the criteria that
    allow for
  • selective spinal
  • immobilization were not
  • meant to be limited to the
  • time of your evaluation
  • of the patient.
  • Rather, if any of these signs
  • or symptoms were present
  • since the time of the injury,
  • even if they have resolved
  • upon your evaluation, the patient requires
    immobilization.

41
2010 BLS Protocol Changes - 423
  • The use of bulky dressings is no longer
    recommended for the treatment of flail segments.
  • While the thought (like with sandbags, for those
    who remember them) used to be that by applying
    pressure to the affected area, you could stop the
    paradoxical movement that resulted in
    hypoventilation of that part of the lung beneath
    the injury.
  • While this may be true, the benefit is limited
    and probably outweighed by the pain that is
    causes the patient and the fact that they then
    breathe more shallowly as a result.

42
2010 BLS Protocol Changes - 423
  • Instead, if the patient is hypoventilating as a
    result of the suspected flail segment, consider
    the need for positive pressure ventilation.
  • If transport is delayed or prolonged, you should
    also consider calling for ALS assistance.

43
2010 BLS Protocol Changes - 425
  • Over five years ago, the REMAC approved the use
    of morphine by ALS providers under standing
    orders for the treatment of pain resulting from
    isolated extremity injuries in adults and
    children.
  • But as you know, most known extremity injuries
    and mechanisms resulting in these injuries
    (falls, pedestrian struck, MVAs) are dispatched
    as BLS call-types in our system.

44
2010 BLS Protocol Changes - 425
  • While our dispatch algorithms for these calls not
    likely to change to an ALS call in the immediate
    future, there are certainly situations in which
    delayed or prolonged transport may allow for ALS
    response in order to provide pain management.
  • So, a note was added to this protocol as a
    reminder of this option.

45
2010 BLS Protocol Changes - 425
  • Some examples of when this may be appropriate
    include
  • - MVAs with prolonged extrication
  • and an isolated extremity injury
  • - an entrapped extremity (i.e.
  • construction site or involving
  • machinery) where extrication is
  • required
  • - falls with severe pain from a hip
  • injury that prevents patient
  • movement
  • But remember that transport should not
  • be delayed simply to provide pain
  • management, particularly when the
  • patients pulses in the affected extremity are
    lost, and such requests are only appropriate for
    injury isolated to one
  • extremity.

46
2010 BLS Protocol Changes - 428
  • A more recent change to the ALS protocols also
    allows for the use of morphine under standing
    orders by our paramedics for the treatment of
    severe pain resulting from burns.
  • So, a note similar to the one added to BLS
    Protocol 425 was also added to this protocol.
  • When transport is delayed or the patients pain
    is so severe that it prevents appropriate
    treatment, consider ALS assistance for the
    provision of pain management.

47
2010 BLS Protocol Changes - 428
  • Also added to this section was the removal of the
    universal use of saline-moistened dressings for
    the treatment of burn injuries in order to remain
    compliant with the latest recommendations from
    the burn experts.
  • Due to the risk of hypothermia and wound
    contamination, saline-moistened dressings should
    only be applied to burns that are less than 10
    total body surface area (BSA). Larger burns
    require treatment with dry, sterile dressings
    only.

48
2010 BLS Protocol Changes - 430
  • Similar to Protocols 425 and 428, a note has been
    added to this protocol as a reminder.
  • If an EDP requires significant physical
    restraint, a request for ALS should be
    considered. Under Protocol 530, paramedics may
    administer sedation to severely agitated /
    violent EDPs.

49
2010 BLS Protocol Changes - 431
  • The recommendation that patients be given normal
    saline to drink has been removed.
  • If you wonder why, drink some. ?
  • As anyone who has ever accidentally swallowed
    water while swimming in the ocean can tell you,
    saline solutions are a quick way to induce nausea
    and vomting.

50
ALS Changes
51
General Operating Procedures - ALS
52
General Operating Procedures - ALS
  • Changes to the GOPs that pertain to ALS care
    include
  • - Interpretation of Protocols
  • - Communications with Medical Control
    Facilities
  • - Prehospital Sedation

53
General Operating Procedures - ALS
  • As has been done with some other sections in the
    past, it was decided that rather than rewriting
    this section every year, the wording would be
    changed to make it apply each and every year,
    regardless of what changes are made.

54
General Operating Procedures - ALS
  • In the olden days, when standing orders were
    limited and easily exhausted within a few
    minutes, there was a perceived need for medical
    control contact to prompt transport and/or obtain
    further medical orders.
  • Today, with the greatly expanded use of standing
    orders, this is no longer the case. So this
    section has been modified accordingly.

55
General Operating Procedures - ALS
  • There are a number of different protocols for
    which the sedation section of the GOPs pertain.
  • When there is a need for cardioversion, the
    current GOPs allow for the use of diazepam or
    midazolam.

56
General Operating Procedures - ALS
  • The problem with these agents is the effect that
    they may have on blood pressure.
  • Keeping in mind that you will only be performing
    cardioversion for patients who are already
    unstable, a medication that will decrease blood
    pressure is not our best choice.
  • The ideal would be a drug that lasts for a very
    brief time (just the few minutes that it takes to
    perform the cardioversion) and which has little
    to no effect on blood pressure or myocardial
    performance.

57
General Operating Procedures - ALS
  • Enter etomidate an sedative with rapid onset
    (2-3 minutes), rapid offset (8-9 minutes), and
    that results in no reduction of blood pressure or
    stroke volume.

58
General Operating Procedures - ALS
  • For these reasons, this agent (which is
    frequently used by emergency medicine physicians
    for sedation for brief procedures) has been added
    to our prehospital sedation options in the GOPs.
  • Note that the dose is different than what we use
    for intubation, with a 0.15mg/kg dose (or half of
    the dose used for facilitated intubation).

59
(No Transcript)
60
2010 ALS Protocol Changes
  • This year is no diffferent than the past several
    years in that there have been a number of
    improvements to the ALS protocols
  • - 500-A and 500-B Smoke / Cyanide
  • - 502 Obstructed Airway
  • - 503-A Ventricular Fibrillation / Pulseless
    Ventricular Tachycardia
  • - 503-B Pulseless Electrical Activity (PEA) /
    Asystole
  • - 504 Suspected Myocardial Infarction
  • - 505-A Supraventricular Tachycardia
  • - 505-B Atrial Fibrillation / Atrial Flutter
  • - 505-C Ventricular Tachycardiac with a Pulse
    / Wide Complex Tachycardia of Uncertain Type
  • - 505-D Bradydysrhythmias and Complete Heart
    Block
  • - 506 Acute Pulmonary Edema
  • - 510 Anaphylactic Reaction
  • - 521 Head Injuries
  • - 540 Obstetric Complications
  • - 551 Pediatric Obstructed Airway
  • - 555 Pediatric Anaphylactic Reaction

61
2010 ALS Protocol Changes - 500
  • The changes to Protocols 500-A and 500-B are
    identical and related to the administration of
    sodium thiosulfate.
  • After a lot of research by Dr. Doug Isaacs (FDNY)
    and discussions with other world experts, the
    decision to made to administer the sodium
    thiosulfate via IV infusion.
  • To do this, 12.5g (typically one vial or 50cc) of
    sodium thiosulfate should be mixed in 100cc of
    D5W. The protocol has been changed to reflect
    this and the resulting dosing for pediatric
    patients.

62
2010 ALS Protocol Changes - 500
  • And because of this change, the list of contents
    necessary for the Cyanide Toxicity Kit have been
    modified.

63
2010 ALS Protocol Changes - 502
  • You may recall that although it was not
    specifically written out in the protocol, last
    years protocol update included the use of
    intentional right mainstem displacement of a
    foreign body for the rare instance when a patient
    can be intubated but cannot be ventilated because
    of a foreign body.
  • Lets take a moment to review those slides from
    last year

64
2010 ALS Protocol Changes - 502
  • ALS Protocol 502 Obstructed Airway
  • What the protocol does not address is when you
    are able to intubate but still cannot ventilate.
  • So we will address that scenario here with what
    can be a truly life-saving technique

65
2010 ALS Protocol Changes - 502
  • ALS Protocol 502 Obstructed Airway
  • In such cases endotracheal intubation will not be
    successful either, as the obstruction
    must lie beyond the tip of the endotracheal
    tube shown here in blue (which is the
    reason that you would still be unable
    to ventilate).

66
2010 ALS Protocol Changes - 502
  • ALS Protocol 502 Obstructed Airway
  • And if you are able to intubate a patient, but
    still unable to ventilate, the obstruction must
    also be below the level of the cricoid membrane.
  • In such cases, a Needle Cricothyroidotomy
    (blue arrow) will only ventilate the
    trachea. And since no oxygen / CO2
    exchange occurs here, it will be
    ineffective and the patient will die.

67
2010 ALS Protocol Changes - 502
  • ALS Protocol 502 Obstructed Airway
  • The only maneuver that will save the patients
    life at this point is if you can find a way to
    open up part of the lung to allow for
    ventilation.
  • To accomplish this, after visual
    confirmation of tube placement, deflate
    the cuff on the endotracheal tube, note the
    tube depth, and then advance the tube as
    far as possible. This should displace the
    foreign body into the right lung (mainstem
    bronchus or lower).

68
2010 ALS Protocol Changes - 502
  • ALS Protocol 502 Obstructed Airway
  • Then withdraw the endotracheal tube to its
    original depth. By displacing the obstruction
    further into the airway (likely into the right
    lung), you should be able to effectively
    ventilate at least the left lung (light blue
    arrow).
  • Though this technique is not without
    risk of injury to the airway, the
    alternative is to not ventilate or oxygenate
    the patient until after their arrival in
    the emergency department, which will
    almost universally result in death. So for
    the patient, it seems worth the risk.

69
2010 ALS Protocol Changes - 502
  • This year, after we provided the SEMAC with
    rationale for including this language in the
    protocol, they approved its inclusion.
  • But it has already saved lives..

70
2010 ALS Protocol Changes - 502
  • On April 9, FDNY Paramedics John Louis and David
    Fein responded to the scene of a three year-old
    choking on food.
  • Before they arrived, the mother stated that the
    child was dyingnot breathing
  • They arrived to find the child in cardiac arrest
    and asystole. Unable to ventilate the child,
    they visualized a foreign body in the trachea
    that was unable to be grabbed by Magill
    forceps.
  • So, the food bolus was pushed into the right
    mainstem bronchus and the resuscitation
    continued, achieving ROSC upon arrival in the ED
    14 minutes after they made patient contact.
  • That child is alive today because of those two
    paramedics and their use of this technique.

71
2010 ALS Protocol Changes - 502
  • The other change to this protocol was the removal
    of the needle cricothyroidotomy, a decision that
    was based upon data from our own system.

72
2010 ALS Protocol Changes - 502
  • The initial description of the needle
    cricothyroidotomy as a rescue maneuver was first
    described over 100 years ago, published in early
    1909.
  • The dogs used to prove this technique were not
    ill, were not hypoxic, and were well-ventilated
    at the time of the procedure, and the conclusion
    was that a needle cric with BVM ventilation
    could maintain a patient for 20 minutes by
    slowing the rate at which they exhaust their
    reserves.
  • The obvious problem is that the patients for whom
    you must perform this skill (in addition to not
    being dogs) are in severe state of respiratory
    compromise, have been for several minutes as you
    tried to use other airway maneuvers, and dont
    have 20 minutes of reserve. They are as sick
    as they can possibly be.

73
2010 ALS Protocol Changes - 502
  • Perhaps that is why a review of all of the
    needle crics performed by FDNY paramedics in
    recent years found that their outcomes were
    universally poor. Those in arrest at the time of
    the procedure remained in arrest, and those not
    in arrest quickly progressed to an arrest none
    survived.
  • For this reason, and in light of the prolonged
    scene times associated with the need to perform
    this procedure, it has been removed from the
    protocols.

74
2010 ALS Protocol Changes - 502
  • This means that, if you have a patient whom you
    cannot intubate, cannot place an alternative
    airway, and cannot effectively ventilate, you
    must immediately transport the patient.
  • The BVM ventilation that you provide, even if not
    fully effective, will still provide them with
    better oxygen delivery and ventilation than a
    needle cric and will allow you to focus on rapid
    transport to the ED for placement of a definitive
    or surgical airway.

75
2010 ALS Protocol Changes - 503
  • Only one change was needed to this part of the
    Protocol 503 series, and that was to remove the
    one item that no one uses any longer.

76
2010 ALS Protocol Changes 503A
  • For the longest time ,we have used the term or
    equivalent biphasic. But what does that mean?
  • If you were to ask the manufacturers of our ALS
    monitors, it may mean 150J, 135J, 200J, or some
    other value.
  • In reality, biphasic defibrillation should be
    delivered at high energies, just as with a
    monophasic defibrillator. But because some
    defibrillators will not allow you to set them as
    high as 360J, the wording here was changed as
    shown.

77
2010 ALS Protocol Changes 503B
  • Recently, the use of dextrose was removed from
    our protocols.
  • The thought at the time was that, even if a
    patient was hypoglycemic, the administration of
    epinephrine would mobilize their glycogen stores
    and increase their blood sugar.
  • And there have even been articles written by some
    of the worlds experts describing the science
    behind why hypoglycemia is not a reversible
    cause of PEA or asystole.
  • So, recognizing that cardiac arrest is not the
    ultimate altered mental status (just like it is
    not the ultimate anaphylaxis, the ultimate
    CVA, the ultimate asthma attack or any other
    such idea), D50 was removed from the PEA /
    asystole protocol.

78
2010 ALS Protocol Changes 503B
  • Nevertheless, over the course of the next few
    years, thousands of cardiac arrest patient
    received D50 as part of their resuscitation
    efforts (some of them even as an OLMC order).
  • But because this was being done for refractory
    PEA / asystole, the issue was not pursued (MCRs,
    restrictions) because the thought was that there
    was no risk of harm to the patient.

79
2010 ALS Protocol Changes 503B
  • Then, just a few months ago, a 23 year-old male
    in cardiac arrest who did not respond to any
    resuscitation efforts was transported to Bellevue
    Hospital.
  • There he was found to have a blood glucose
    lt35mg/dL.
  • The resuscitation continued, including D50
    administration, and the patient survived (albeit
    with some neurologic damage) despite a
    resuscitation time gt50 minutes.

80
2010 ALS Protocol Changes 503B
  • This prompted us to take a look at our own
    cardiac arrest data, and what we found was
    unexpected
  • Among known diabetics who received D50 as part of
    their resuscitation, ROSC and sustained ROSC
    rates were higher than in those patients who did
    not receive D50.
  • And the even more unexpected finding the same
    was true for non-diabetics!

81
2010 ALS Protocol Changes 503B
  • So, the protocol has been changed.
  • If a patient does not respond to the initial
    resuscitation efforts, D50 should be administered
    (without checking the blood sugar) for all
    patients, diabetic or not.

82
2010 ALS Protocol Changes - 504
  • There were two changes to this protocol, both of
    which were meant to emphasize the need for very
    timely care for suspected MI patients.
  • The first change was a note meant to point out
    the need for early 12-lead acquisition and OLMC
    contact (before any medical treatment other than
    BLS care) is initiated.

83
2010 ALS Protocol Changes - 504
  • The second change, which may be a big change in
    practice for some, was to emphasize the need for
    rapid transport immediately following OLMC
    contact.
  • In the vast majority of STEMI patients, there is
    no need for IV access.
  • Even if the patient were to suddenly arrest, you
    have four to eight minutes after you start the
    resuscitation before you need an IV or IO.
  • So, the protocol was changed to reflect this.
    Transport first, IV en route.

84
2010 ALS Protocol Changes - 504
  • Now some of you may be thinking that a profoundly
    hypotensive patient or patient with a dysrhythmia
    will need IV access.
  • And you are right. But you will also be treating
    the patient under those protocols (cardiogenic
    shock or the appropriate dysrhythmia protocol).
  • For all STEMI patients, aspirin and rapid
    transport are the key elements that will improve
    the patients outcome (not nitro, not IV access,
    not morphine).
  • For the non-STEMI patient, care should continue
    under Protocol 504-A, including establishing IV
    access and administering ALS medications.

85
2010 ALS Protocol Changes - 504
  • The only word of caution in treating a patient
    with a documented STEMI while en route to the ED.
  • If the patients 12-lead EKG demonstrates an
    inferior wall MI, remember that 40-50 may have
    right ventricular involvement.
  • And if a right ventricular infarction is also
    present, their dependence on preload may cause
    them to become significantly hypotensive, so IV
    access should be established before administering
    NTG and/or you should discuss with OLMC (when you
    call for the STEMI) the decision to withhold NTG.

86
2010 ALS Protocol Changes - 504
  • To determine if a patient with an inferior wall
    MI, such as this patient, has right ventricular
    involvement, move the V4-6 leadds to the same
    position but on the right side and repeat the
    12-lead.

87
2010 ALS Protocol Changes - 504
  • If ST-segment elevations appear in the
    right-sided leads on the repeat EKG, then a right
    ventricular infarction is also present.
  • Because this will take less than 30 seconds and
    has the potential to significantly alter patient
    management, the right-sided EKG should be done
    prior to or during your OLMC contact.

88
2010 ALS Protocol Changes 505A
  • As we first discussed with respect to the changes
    in the VF / pulseless VT protocol, this use of
    the phrase or equivalent biphasic is very
    unclear.
  • This protocol (and others to follow) has been
    modified to address this need for clarity.

89
2010 ALS Protocol Changes 505A
  • Whether your ALS monitor is biphasic or
    monophasic, the joule settings will now the same.
  • The only difference may come when the recommended
    monophasic setting exceeds the joules that are
    allowable with a particular biphasic machine.
  • When this occurs, the next cardioversion and all
    subsequent attempts should occur at the highest
    setting possible using the biphasic monitor.

90
2010 ALS Protocol Changes 505B
  • That same change was also made to Protocol 505-B,
    setting the biphasic energies as equal to those
    values listed for monophasic cardioversion and,
    when the recommended energy exceeds the maximum
    possible energy for a particular biphasic
    monitor, the highest possible energy setting
    should be used.

91
2010 ALS Protocol Changes 505C
  • And the same change applies to this protocol as
    well.

92
2010 ALS Protocol Changes 505D
  • For some emergencies, there may be acceptable
    medical treatments which are not useful for our
    protocols.
  • This is the case for epinephrine infusions /
    drips.
  • In recent years, there have been no FDNY OLMC
    contacts that have resulted in the use of an
    epinephrine infusion for the treatment of a
    bradydysrhythmia.

93
2010 ALS Protocol Changes 505D
  • In addition, as compared to most other drugs that
    we provide via IV infusion, epinephrine has a
    significant potential for under- or overdosing
    unless an IV pump is being used.
  • For these reasons, the epinephrine drip was
    removed from this protocol.

94
2010 ALS Protocol Changes - 506
  • After several years of discussion, one change was
    made to Protocol 506.
  • Lasix, or furosemide, has been moved from a
    standing order to a medical control option.
  • And based on the initial reaction to this change,
    it appears that a fair degree of explanation is
    in order.

95
2010 ALS Protocol Changes - 506
  • Furosemide has been part of the management of
    acute pulmonary edema for decades, and when you
    consider its mechanism of action, its not
    surprising.
  • In addition to being a loop diuretic, furosemide
    directly induces some degree of vasodilation.
  • And because both of these mechanisms will help to
    reduce preload, the drug should be beneficial to
    patients with acute pulmonary edema.

96
2010 ALS Protocol Changes - 506
  • But keep in mind that the diuretic effects take
    20-90 minutes to occur, so for the acute
    management of these patients, that part of its
    effects are not rapid enough to make a big
    difference.
  • Add to that the fact that 40 of patients with
    acute pulmonary edema are not fluid overloaded
    (their lungs may be, but their total body has a
    normal volume euvolemic or is actually
    hypovolemic). So for those patients, furosemide
    would be harmful.

97
2010 ALS Protocol Changes - 506
  • And with respect to vasodilation, which is a
    great way to reduce preload, nitroglycerin is
    actually much more effective (and it has the
    benefit in higher doses of reducing afterload as
    well).
  • It is for these reasons that furosemide, when
    given as part of the routine management of all
    pulmonary edema patients, results in higher rates
    of ICU admission, worsening renal function, need
    for intubation, and death.
  • Clearly not something that we want to continue to
    do in this or any other EMS system.

98
2010 ALS Protocol Changes - 506
  • This is not to say that furosemide is
    inappropriate for all pulmonary edema patients,
    but it should be considered after the initial use
    of oxygen, nitrates, ensuring that the patient is
    not having an AMI, and (if available) CPAP.
  • And at that point, the decision should be made
    whether further nitrates and/or furosemide is
    appropriate (is the patient truly hypervolemic),
    a decision that will be made in conjunction with
    OLMC.

99
2010 ALS Protocol Changes - 506
  • As discussed previously, the epinephrine drip has
    been removed from the bradydysrythmias protocol
    and, for the same reasons, from this protocol as
    well.

100
2010 ALS Protocol Changes - 521
  • In the face of signs of increasing intracranial
    pressure, hyperventilation is needed, but only to
    a degree.
  • So, for the management of head injuries, the use
    of the GCS and controlled hyperventilation have
    been added.

101
2010 ALS Protocol Changes - 521
  • Hyperventilation is a rapid way to deal with
    rising intracranial pressure.
  • A pCO2 of 30-35mmHg (remember normal is
    35-45mmHg) will resulting in an up to 25
    reduction intracranial pressure an effect that
    begins within 30 seconds and peaks within 8
    minutes.

102
2010 ALS Protocol Changes - 521
  • But the hyperventilation must be based upon CO2,
    and not just respiratory rate.
  • This is because, if the patient is
    hyperventilated too much, and if the pCO2 drops
    below 25mmHg, cerebral vasodilation will occur,
    resulting in increased blood flow, swelling, and
    will actually increase ICP.

103
2010 ALS Protocol Changes - 521
  • So this protocol, unlike the BLS protocol, allows
    for more controlled hyperventilation. The
    ventilation rate is not specified, but rather the
    protocol focuses in on the important thing
    accomplishing an EtCO2 between 30 and 35mmHg.

104
2010 ALS Protocol Changes - 540
  • After several years of discussion, the decision
    was made the remove oxytocin from our protocols.
  • This is because of the risks associated with its
    use, the lack of any data from our system to
    suggest a need for it in our protocols, and a
    preference to have patients with severe
    post-partum hemorrhage transported rather than
    being treated on the scene.

105
2010 ALS Protocol Changes - 551
  • No different than the changes to Protocol 501,
    and for the same reasons, this protocol has been
    modified to include the use of the intentional
    right-mainstem displacement of tracheal foreign
    bodies and the removal of the needle
    cricothyroidotomy procedure.

106
2010 ALS Protocol Changes - 554
  • We were told that there was some confusion about
    the wording of this protocol and, looking back,
    its no wonder.
  • The intent was always to have ipratropium
    (Atrovent) administered with each albuterol
    treatment, but the use of the term may
    certainly didnt communicate that.

107
2010 ALS Protocol Changes - 554
  • So the wording was changed to state that
    ipratropium should be administered in
    conjunction with each albuterol.
  • This still leaves to the discretion of each
    system medical director whether the two drugs are
    to be given together in a single nebulizer
    treatment or as two separate treatments.
  • For FDNY paramedics, the two should be given
    together.

108
2010 ALS Protocol Changes - 554
  • One final note on this protocols
  • Keep in mind that children under the age of six
    (6) should receive a half-dose (i.e. half vial)
    of ipratropium with each albuterol treatment.

109
2010 ALS Protocol Changes - 555
  • As with the adult anaphylactic protocol, the use
    of the epinephrine drip has been removed.

110
Conclusion
  • 2010 is another year of change for the New York
    City REMAC Protocols.
  • And the future will undoubtedly bring even more
    changes as we incorporate the latest medical
    knowledge and science into the care that is
    provided to patients by the EMTs and Paramedics
    of the New York City EMS System.
  • But that is what separates us from other systems.
    We believe that the health of our patients
    requires us to constantly re-evaluate what we are
    doing to see if there are things that we can
    somehow do better.

111
Thanks
  • For all of their work as members of the REMAC and
    its committees, without whom the work that led to
    these protocols would not have been possible, we
    should all extend our thanks to
  • Dr. Roger Yurt Dr. Glenn Asaeda Dr. Doug
    Isaacs Dr. Stephen Lynn
  • Dr. Heidi Cordi Dr. Josef Schenker Dr. Lewis
    Marshall (chair) Frank Mineo
  • Anthony Conrardy Dr. David Ben-Eli Dr. Peter
    Wyer Dr. Lewis Soloff
  • Dr. Charles Martinez Dr. Victor Politi Martin
    Grillo Joseph Raneri
  • Dr. Jeffrey Horwitz Clifford Miller Marie Diglio
    (executive director) John Peruggia
  • Dr. David Prezant Dr. Bradley Kaufman Christopher
    Swanson Dinorah Claudio
  • Alison Burke Dr. Lorraine Giordano Dr. Joseph
    Bove Ralph Cefalo
  • Dr. George Foltin Dr. Eliot Lazar Dr. Arthur
    Cooper Dr. Allen Cherson
  • Dr. Geoffrey Doughlin Dr. Heidi Cordi Dr. Dario
    Gonzalez Dr. David Lobel
  • Dr. Katherine Vlascia Tony Dejar Dr. Manuel
    Ceja Dr. Robert Crupi
  • Dr. James Kenny Dr. Charles Martinez Dr.
    Christopher McCarthy Dr. Anthony Shallash
  • Dr. Bonnie Simmons Dr. Rachel Waldron George
    Benedetto Rudy Medina
  • Jack Quigley Madeline Fong Dr. Yedidyan
    Langstrom Dr. Jeffrey Rabrich
  • Dr. Jay Reich Robert Goldstein Nancy
    Benedetto Dr. Kevin Munjal
  • And, most importantly, a heartfelt thanks to
    every one of you the Certified First
    Responders, Emergency Medical Technicians, and
    Paramedics in the New York City EMS System to
    whom patients turn to in their moment of need
    and, in some cases, to whom they owe their lives.
    Without you, none of this would matter.

112
THANK YOU!!!!
  • If you have any questions about this
    presentation, please do not hesitate to email me
    at freesej_at_fdny.nyc.gov or jfreesemd_at_hotmail.com.
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