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Frequently Asked Questions - Emergency Medical Services Administrative Guidelines
All lift assist (invalid assist) or found down persons meet the definition of a patient. Responders should follow standard operating procedures for their agency regarding documentation for these patients.
No, individuals involved in a MVC without any injuries or complaints do note meet the definition of a patient. Only those persons involved in an MVA and having a chief complaint meet the definition of a patient Responders should follow standard operating procedures for their agency regarding documentation for these patients.
The one true contraindication to giving nitrates in patients with chest pain is hypotension. The old teaching is that patients with possible inferior MIs should not be given nitrates (or be given with cautious) due to the potential for right-sided heart involvement and need for high preload to maintain blood pressures. However, more recent studies have shown no increased incidence of hypotension post nitro administration in patients with inferior MIs compared to other territorial MIs. Therefore, suspected inferior MI alone should not prohibit you from giving nitrates. However, it is best practice in ALL patient’s receiving nitroglycerine to monitor their blood pressure closely and be prepared to give IV fluids if hypotension develops. Finally, patients on phosphodiesterase inhibitors, such as erectile dysfunction medications like Viagra or Cialis, should not receive nitroglycerine due to the risk of severe and refractory hypotension.
If a patient has ROSC, Amiodarone should NOT be initiated in an IV drip. Evidence has shown that Amiodarone does have the potential to cause Bradycardia and Hypotension, and can cause the patient to rearrest more rapidly.
No! While our post-ROSC patient’s ultimately need definitive care at a cardiac arrest receiving center, what they need MOST in the 5-10 minutes after achieving ROSC is optimization of their hemodynamics and ventilation. These patients have suffered a significant neurologic insult by the very nature of having had a cardiac arrest and any further episodes of hypoxemia or hypotension only compounds this, making favorable neurologic recovery less likely. Additionally, getting an EKG on scene can help us identify a STEMI earlier, and have a cardiac cath lab ready for the patient on arrival. If the patient DOES rearrest, knowing that the patient had a STEMI can also better direct their care once they arrive to the emergency department. As long as it is safe at the scene to do so, we recommend that all crews take 5-10 minutes to do the following prior to loading the patient for transport
- Obtain a set of post-ROSC vital signs
- Get IV access and hang dopamine (if initial BP is WNL you do not have to start the infusion, but it is best practice to have it hanging and ready to go should they become hypotensive)
- Obtain an EKG
- Check the patient’s airway, SpO2, EtCO2 and ensure their advanced airway is still functioning appropriately and is secured prior to transport
Once these things have been done, initiate transport and continue to monitor the patient throughout transport for signs of rearrest.
We think it is best practice to hang dopamine and have it ready for infusion on every cardiac arrest patient after achieving ROSC. Even patients whose initial BP after ROSC is within normal limits, will likely become hypotensive over time and we see many of them become progressively more hypotensive and bradycardic during transport until they eventually rearrest. These patients invariably have underlying physiologic derangements associated with and/or exacerbated by their cardiac arrest and will likely all eventually need augmentation of their blood pressure. Additionally, it’s important to remember that these patients have just suffered massive neurologic insult and so optimizing their oxygenation/ventilation and blood pressure is imperative to survival with good neurologic outcome. Therefore, we want to be able to recognize and treat hypotension immediately and we think the best way to do this is to have your dopamine infusion ready to go.
Ideally, no. Trauma patients are often agitated because of their underlying injury and resulting physiologic derangements (i.e., TBI, hypoxemia, blood loss and hypotension, etc…), which makes versed administration for this patient population potentially dangerous. There are some patients for whom versed may be necessary, but we should try to avoid it if possible. Finally, if a patient is already hypotensive or hypoxemic we simply cannot give versed to and unfortunately have to use restraints and man power to restrain the patient.
Patients with penetrating trauma to the torso should be transported immediately to the nearest trauma center and transport should not be delayed in order to provide on-scene care. This is because life-threatening injuries from penetrating trauma to the torso can truly only be treated in an operating room and nothing we do in the field (or even in the emergency department, for that matter) is likely to improve their outcome. However, for all other trauma patients, especially patients with possible head injury, optimizing their hemodynamics and oxygenation/ventilation in the first 5-10 minutes after injury can really improve their long-term outcomes. For these patients it is preferrable to take the time on scene to get an 18G IV, provide a fluid bolus if indicated, and provide supplemental O2 with goal O2 saturation of 100%.
Technically speaking, no, Narcan is not going to harm someone in cardiac arrest in and of itself. However, we also know that the interventions that are most likely to save someone in cardiac arrest are: early defibrillation and high-quality chest compressions. The more interventions and medications we add to our cardiac arrest care, the less we focus on the things that matter most. Furthermore, Narcan does not take effect immediately. In a patient who has become so hypoxic from their opioid overdose that they have suffered a cardiac arrest, the treatment they need is active oxygenation/ventilation with an iGel or ETT. Narcan alone will not be enough to reverse this person’s hypoxia and cardiac arrest, but active airway management will. If these patients eventually get Narcan, great, but we don’t want administration of Narcan to take priority over active ventilation as this is what ultimately gives us the best shot at achieving ROSC, not the administration of Narcan itself.
If a patient suffers a trauma and loses consciousness but are AAOx4 with a GCS of 15 by the time you are evaluating them, they do not necessarily require ALS transport so long as they have no other concerning exam findings and meet all other BLS thresholds. However, please be aware that some TBI patients will have falsely reassuring exams immediately after their injury and so it is important that we still provide routine TBI care for any patient who may have suffered a head injury (IV access, fluids if indicated, O2 goal of 100%).
Our goal oxygen saturation for TBI patients is 100%, or as close to 100% as possible. We know that even brief periods of hypoxia are detrimental to TBI patients. Our initial O2 saturation goal was ≥ 94% based on data gathered from the EPIC TBI trial. However, further review of the data revealed that outcomes continue to improve linearly with improved oxygen saturations. With this in mind, we now recommend targeting an oxygen saturation goal of 100%.
The second dose, 150mg of Amiodarone, should be given if a patient is not successfully cardioverted after 4 attempts or 8 minutes after the first dose.