The prehospital approach to general cardiac arrest care is a good introduction to the progression of responsibilities from one level of training to the next. We get a large number of OLMC calls from our own paramedics requesting physician input in arrest cases, so it’s always good to refresh ourselves on what they can or cannot do in these instances.
At the CFR level, by Standing Order, providers who encounter a patient in arrest will initiate CPR and apply an Automated External Defibrillator, following the AED’s instructions until backup arrives.
BLS providers (EMTs) will request ALS backup if not already present, but will otherwise begin to transport the patient to the hospital after 3 rounds of CPR/AED analysis.
It’s not until the ALS (paramedic) level that an actual cardiac monitor will be applied, giving a specific rhythm underlying the arrest. It’s for this reason that you might hear something from the paramedics like “our initial rhythm was asystole; patient was shocked 2 times (by AED) prior to our arrival.” The rest of the ALS Standing Orders consist of continuing CPR, performing a needle decompression for suspected tension pneumothorax, obtaining an advanced airway (either endotracheal tube or supraglottic device) and intravascular access, administering D50 for hypoglycemia, and giving ACLS-dose epinephrine every 3-5 minutes. If the patient is found to be in VT/VF (the “shockable rhythms”) rather than PEA/asystole (the” non-shockable rhythms”), they will also give an initial dose of either amiodarone or lidocaine by Standing Order.
By the time medics call OLMC, they will have generally given a few doses of epinephrine, but they need physician approval to give sodium bicarbonate or calcium chloride, which are Medical Control Options (and as such are found under that section of the protocol). Other MCOs include a second dose of amiodarone or lidocaine for a shockable rhythm, as well as magnesium sulfate for suspected Torsades de Pointes. When deciding whether to authorize these Medical Control Options, it’s worth asking yourself – why do you think this particular patient arrested? Hyperkalemia? TCA overdose? Some sort of electrical storm? It might be worthwhile to administer one of these medications. Or do you think attempts at ROSC are futile? Maybe no medications are indicated, and we should instead consider Termination of Resuscitation (ToR). We’ll discuss ToR in a separate email, but these are the kinds of questions to keep in mind when fielding these calls.
And there you have it! First protocol down, and a big one at that! Some might even say that it’s…the heart…of these protocols? Some people have definitely said that.
Check out www.nycremsco.org and the protocols binder for more! Otherwise, see you next week for the next review!
Dave