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. Vincent’s 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, let’s 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 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

5. 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.

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 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.

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 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.

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. YearEmergency MedicineEMSResuscitation 20012,2219512,393 20022,3049982,407 20032,3931,1222,584 20042,5651,1602,810 20052,9171,2842,960 20063,1941,3933,155 20073,2501,3683,180 20083,7351,4873,422

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 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.

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 - 555 – Pediatric Anaphylactic Reaction

12. BLS Changes

13. General Operating Procedures - BLS

14. 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 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.

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. TachycardiaGasping respirations Increased respiratory rateDizziness Depressed respiratory rateHeadache ConfusionNausea AgitationVomiting ComaLethargy SeizuresPoor judgment AnxietyParesthesias (tingling)

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 (V T ) 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…

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 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?

25. 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.

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: 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.

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 patient’s 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 patient’s 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. 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. DiazepamMidazolamEtomidate Heart Rate - 9 to - 13%- 14 to + 12%- 5 to + 10% Mean Blood Pressure 0 to + 19%- 12 to + 26%0 to + 17% Systemic Vascular Resistance -22 to + 13%0 to + 20%- 10 to + 14% Stroke Volume 0 to + 8%- 28 to - 42%0 to +20%

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).

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 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…

64. 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

65. 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

66. 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

67. 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

68. 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. 2010 ALS Protocol Changes - 502

69. 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 “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.

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 don’t 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 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.

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 <35mg/dL. The resuscitation continued, including D50 administration, and the patient survived (albeit with some neurologic damage) despite a resuscitation time >50 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 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.

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 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.

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, 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.

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 didn’t 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 YurtDr. Glenn AsaedaDr. Doug IsaacsDr. Stephen Lynn Dr. Heidi CordiDr. Josef SchenkerDr. Lewis Marshall (chair)Frank Mineo Anthony ConrardyDr. David Ben-EliDr. Peter WyerDr. Lewis Soloff Dr. Charles MartinezDr. Victor PolitiMartin GrilloJoseph Raneri Dr. Jeffrey HorwitzClifford MillerMarie Diglio (executive director)John Peruggia Dr. David PrezantDr. Bradley KaufmanChristopher SwansonDinorah Claudio Alison BurkeDr. Lorraine GiordanoDr. Joseph BoveRalph Cefalo Dr. George FoltinDr. Eliot LazarDr. Arthur CooperDr. Allen Cherson Dr. Geoffrey DoughlinDr. Heidi CordiDr. Dario GonzalezDr. David Lobel Dr. Katherine VlasciaTony DejarDr. Manuel CejaDr. Robert Crupi Dr. James KennyDr. Charles MartinezDr. Christopher McCarthyDr. Anthony Shallash Dr. Bonnie SimmonsDr. Rachel WaldronGeorge BenedettoRudy Medina Jack QuigleyMadeline FongDr. Yedidyan LangstromDr. Jeffrey Rabrich Dr. Jay ReichRobert GoldsteinNancy BenedettoDr. 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@fdny.nyc.gov or jfreesemd@hotmail.com. freesej@fdny.nyc.gov jfreesemd@hotmail.comfreesej@fdny.nyc.gov jfreesemd@hotmail.com