Transcript 2010 REMAC Protocol Update: Acting on the Evidence

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. Vincent’s Hospital - Manhattan
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.
Auld Lang Syne
But in the tradition of the New Year, let’s
begin by looking back and gaining
some perspective….
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 City’s 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
Auld Lang Syne
We’ve 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 hospital’s 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.
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.
But We Can’t 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.
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 doesn’t 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.
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:
Year
Emergency Medicine
EMS
Resuscitation
2001
2,221
951
2,393
2002
2,304
998
2,407
2003
2,393
1,122
2,584
2004
2,565
1,160
2,810
2005
2,917
1,284
2,960
2006
3,194
1,393
3,155
2007
3,250
1,368
3,180
2008
3,735
1,487
3,422
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.
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 person’s
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.
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
- 555 – Pediatric Anaphylactic Reaction
BLS Changes
General Operating Procedures - BLS
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
General Operating Procedures - BLS
Oxygen Administration
In assessing a patient’s respiratory status, the decision to
provide assisted ventilations must take into account the
ability of the patient’s 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.
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.
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.
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.
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 fairskinned 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.
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.
Tachycardia
Gasping respirations
Increased respiratory rate
Dizziness
Depressed respiratory rate
Headache
Confusion
Nausea
Agitation
Vomiting
Coma
Lethargy
Seizures
Poor judgment
Anxiety
Paresthesias (tingling)
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).
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, let’s consider a couple of scenarios…
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.
General Operating Procedures - BLS
The point is that, regardless of the patient’s 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?
General Operating Procedures - BLS
The final point in assessing a patient’s need for assisted
ventilation is more of an ALS point, because it deals with
airway protection.
A patient’s 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.
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.
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.
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.
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.
2010
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
2010 BLS Protocol Changes - 401
Three changes were made to this protocol:
1) A reference was added to
the MOLST forms.
2) As previously discussed,
references to respiratory rate
have been replaced in favor
of the terms hypoxia and
inadequate respiration.
3) References to mouth-to-nose
and mouth-to-mouth
ventilation have been removed.
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.
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?
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 muchneeded medication that they would otherwise have
to await while ALS responded to the scene.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
patient’s pulses in the affected extremity are lost, and such
requests are only appropriate for injury isolated to one
extremity.
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
patient’s pain is so severe that it
prevents appropriate treatment,
consider ALS assistance for the
provision of pain management.
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, salinemoistened 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.
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.
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.
ALS Changes
General Operating Procedures - ALS
General Operating Procedures - ALS
Changes to the GOPs that pertain to ALS
care include:
- Interpretation of Protocols
- Communications with Medical Control
Facilities
- Prehospital Sedation
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.
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.
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.
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.
General Operating Procedures - ALS
Heart Rate
Mean Blood Pressure
Systemic Vascular Resistance
Stroke Volume
Diazepam
- 9 to - 13%
0 to + 19%
-22 to + 13%
0 to + 8%
Midazolam
- 14 to + 12%
- 12 to + 26%
0 to + 20%
- 28 to - 42%
Etomidate
- 5 to + 10%
0 to + 17%
- 10 to + 14%
0 to +20%
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.
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).
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
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.
2010 ALS Protocol Changes - 500
And because of this change, the list of contents
necessary for the Cyanide Toxicity Kit have been
modified.
2010 ALS Protocol Changes - 502
You may recall that although it was
not specifically written out in the
protocol, last year’s 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.
Let’s take a moment to review those
slides from last year…
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…
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).
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.
2010 ALS Protocol Changes - 502
ALS Protocol 502 – Obstructed Airway
The only maneuver that will save the patient’s 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).
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).
not
Though this technique is
not without risk of injury to the
airway, the alternative is to
ventilate or oxygenate the
patient until after their
the emergency
which will
result
arrival in
department,
almost universally
in death. So for the
patient, it seems worth the risk.
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…..
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 “dying…not
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.
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.
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 wellventilated 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 don’t
have 20 minutes of “reserve.” They are as
sick as they can possibly be.
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.
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.
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….
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.
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 world’s 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.
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.”
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 <35mg/dL.
The resuscitation continued,
including D50 administration,
and the patient survived (albeit
with some neurologic damage)
despite a resuscitation time >50
minutes.
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!
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.
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.
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.
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 patient’s 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.
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 patient’s 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.
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 12lead.
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.
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.
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.
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.
2010 ALS Protocol Changes – 505C
And the same change
applies to this protocol
as well….
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.
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.
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.
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, it’s 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.
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.
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.
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.
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.
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.
2010 ALS Protocol Changes - 521
Hyperventilation is a rapid
way to deal with rising
intracranial pressure.
A pCO2 of 30-35mmHg
(remember normal is 3545mmHg) will resulting in
an up to 25% reduction
intracranial pressure – an
effect that begins within 30
seconds and peaks within
8 minutes.
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.
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.
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.
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 rightmainstem displacement
of tracheal foreign
bodies and the removal
of the needle
cricothyroidotomy
procedure.
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
didn’t communicate that.
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.
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.
2010 ALS Protocol Changes - 555
As with the adult
anaphylactic
protocol, the use of
the epinephrine drip
has been removed.
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.
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. Heidi Cordi
Anthony Conrardy
Dr. Charles Martinez
Dr. Jeffrey Horwitz
Dr. David Prezant
Alison Burke
Dr. George Foltin
Dr. Geoffrey Doughlin
Dr. Katherine Vlascia
Dr. James Kenny
Dr. Bonnie Simmons
Jack Quigley
Dr. Jay Reich
Dr. Glenn Asaeda
Dr. Josef Schenker
Dr. David Ben-Eli
Dr. Victor Politi
Clifford Miller
Dr. Bradley Kaufman
Dr. Lorraine Giordano
Dr. Eliot Lazar
Dr. Heidi Cordi
Tony Dejar
Dr. Charles Martinez
Dr. Rachel Waldron
Madeline Fong
Robert Goldstein
Dr. Doug Isaacs
Dr. Lewis Marshall (chair)
Dr. Peter Wyer
Martin Grillo
Marie Diglio (executive director)
Christopher Swanson
Dr. Joseph Bove
Dr. Arthur Cooper
Dr. Dario Gonzalez
Dr. Manuel Ceja
Dr. Christopher McCarthy
George Benedetto
Dr. Yedidyan Langstrom
Nancy Benedetto
Dr. Stephen Lynn
Frank Mineo
Dr. Lewis Soloff
Joseph Raneri
John Peruggia
Dinorah Claudio
Ralph Cefalo
Dr. Allen Cherson
Dr. David Lobel
Dr. Robert Crupi
Dr. Anthony Shallash
Rudy Medina
Dr. Jeffrey Rabrich
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.
THANK YOU!!!!
If you have any questions about this presentation, please do not hesitate to email me at [email protected] or
[email protected].