BioTel Recent Protocol FAQs

(06/05/2003)

Greetings, all:

For those of you who missed the staff meeting, there were a number of excellent questions asked about some of the protocol changes. So, I will try to answer them as best I can:

Re: Atrovent -- yes, the PDR does say that it is contraindicated for pts with soybean or nut allergy. In actual practice, this is probably not a huge concern (Sheri says they don't even ask at CMC where they use a lot of it), but since it's in the PDR, we need to mention it. yes, the onset is rather slow (which is one reason it is not indicated for pts low sick from anaphylaxis), but for pts with mod-severe asthma or COPD, they have ~30% less chance of needing hospitalization if they get both albuterol and atrovent. yes, it only comes in a bullet that will make dosing of "0.25 mg" for infants under 1 year of age tricky. but, few children this young really have "asthma" (it's an overused term in the lay community), so most of the patients who need this drug will be over 1 yr of age and will get the standard 0.5 mg. i don't think the half dose issue should be much of a problem. these are the official doses recommended by the pedi gurus at CMC.

allergic -- yes, pt's who are low sick with anaphylaxis would be best served getting drugs IVP ASAP. but sometimes they are too sick to get the IV. and they will die without epi. and SC epi is better than no epi. SO, the change was made to read that SC epi comes FIRST in the standing orders, right up front. IOW, while your buddy is putting on the tourniquet and looking for an IV (which he may not get b/c the pt has no BP), go ahead and give the 0.3-0.5 SC of 1:1 epi (massage the site well after injection). if the IV goes in, groovy. go ahead and give the fluid bolus and the benadryl, then reassess. if pt is still bad, THEN give 0.1-0.2 mg (down from 0.3-0.5) of 1:10 epi IVP. IOW, you don't know until the IV is actually in that you will get the IV... and if there is any kind of delay, the pt may die while you are hunting for an IV.

allergic -- yes, there was another typo (thanks, Suzanne). glucagon is a treatment consideration for pedi, not a standing order.

VF -- amio for pedi. it is neither a standing order nor contraindicated for pediatrics. it is now a treatment consideration. the wording was not clear, so it has been changed. the bottom line, however, is that the logistical concerns (the need to infuse it over 30 minutes) will make it unlikely that it will ever be given, at least for now. it is possible that a biotel MD may order it, so it was moved to a "TC".

the "hypotension" issue -- it has been repeatedly and correctly pointed out by a number of folks that there has always been an inconsistent definition of "hypotension" from one protocol to the next ("110" for chest pain, "90" for trauma, etc.). the request has been made to simplify by making a single, rather arbitrary cutoff for ALL the protocols. i addressed this with dr. fowler today (he, too, had been asked about this). on the surface, this seems logical. or at least simpler. however, the answer is: "NO". the obvious rationale is that the medics have to learn to "treat the patient, not the number" and that shock means more than just low BP and such, and that hypotension for one patient may be "normal" for another..... the other explanation is that, esp when it comes to NTG and its ability to really bottom-out folks who might be unstable, one needs an even greater margin of safety than a BP of 90 or 100 affords. IOW, you don't even want to *think* about the patient *possibly* getting to <100, since this correlates with poor outcome. i tend to agree with him. i think it lumps apples, oranges and bananas to make one arbitrary number the cutoff. when the medics ask about this, i think we should make it a teaching point about why we *don't* have the same BP for all the protocols....

asystole -- AHA does not routinely recommend pacing for outofhospital asystole. why? b/c it doesn't work. why? b/c asystole out of hospital is typically an endpoint (pt is dead), rather than a starting point. hence, for almost all aystoles out of hospital, TCP is a waste of time and therefore a treatment consideration, and not any more important than CPR, airway, drugs. etc. the one exception to this is a pt in a pulse (perfusing) rhythm who arrests in front of the medics. in that setting, TCP "might" possibly work, but it has to be done fast and at high current (200 mAmp). so, for that condition only, it is now a standing order..... this does not apply to a pulseless rhythm (say VFib) that is shocked into asystole. in this case, the physiology is different, and TCP probably will not work, so there is no point in TCP as a standing order. the priority should be the CPR, ABC's, drugs, etc..... anyway, this "witnessed by the medics going into asystole" thing doesn't happen very often, so it's not likely to come up very often. yes, it's true that the old message about TCP needing consideration "early" still holds, but it really only applies -- in a practical sense -- to the witnessed asystoles.... (TCP remains a standing order for a symptomatic brady, of course!)

whew. i think this was most of it.

please feel free to refer any questions from the field to me. i will try to answer them as best i can or to find someone who can....

r

(06/03/2003)

Hey folks, Excellent presentation by Ronna, as always. Couple of other comments:

1. Anaphylactic shock is a profound disturbance of the circulatory system, an odd mix of the immune system of the body initiating circulatory collapse. It is abrupt, intense, and deadly. Remember that when we talk about anaphylactic shock, we're not just taking about "a rash". This is a " vasodilatory shock" resulting in a direct relaxation of the arteriolar smooth muscle, the opposite you might say of what Levophed does: Anaphylactic shock has as sudden and profound an effect on lowering blood pressure as Levophed does when we use that drug to raise blood pressue. Remember the formula: Blood Pressure = (Cardiac Output) x (Volume) x (Peripheral Vascular Resistance). Maintenance of blood pressure is a "real time" dynamic between those three. Any sudden drop in any of the three parameters can cause a sudden loss of blood pressure. Mortality rates in anaphylactic shock, if hypotension is already present, can exceed 50%. Thus, we are talking about a pathophysiological process that must be dealt with immediately to be able to have a chance to spare the patient.

It has been widely recognized that time to IV starts - meaning time until the IV becomes a satisfactory conduit for medication - can vary in the field from two minutes, if one is REAL lucky, to as long as ten minutes or more. A patient in anaphylactic shock is dying, and the single most important factor to salvage is "time to epinephrine dose". We can give a Sub-cutaneous dose of epi in less than a couple of minutes reliably. Epi given subcutaneously in this setting will have a somewhat unpredictable result, an effect ranging from minimal to life-saving. This means that, by the time the IV is successfully started, if it can be started at all in the setting of circulatory collapse, the patient, due to the effect of the sub-Q epi, will have a condition ranging from "nearly well" to "no better".

The medic will need to quickly reassess the patient, once the IV is started, and determine if weak pulses, tachycardia, AMS, or other evidence of shock is still present. At this point, additional epi may be given, IV if the patient is in shock, or additional sub-Q if the patient has improved. Certainly a volume bolus would be appropriate, as well as the Benadryl. I would also add, rigorous attention to "intake and output" would be an important theme for us to begin to share with our folks, from the standpoint of assessment of circulatory stability.

Finally, a word about IV epi. Of all the drugs in our drug boxes that we might administer in any method, it could be argued that IV epi is one of the most dangerous. It may be said that the effect of IV epi ranges from minimal to life saving to dangerous. Arrhythmias, severe hypertension (like, approaching 300/200), intracranial hemorrhage, and sudden death can result from giving IV epi to someone who has a perfusing circulation. Thus, we give this drug in this manner hesitantly, using it in this manner IF we need it but ONLY if we need it.

So, I just wanted to throw in a few words of explanation and caution about why we have modified the protocol in this way. Finally, I would also add that we duplicated EMS protocols for this condition that we have seen elsewhere, since they seemed to make sense to us.

2. I really want to thank Ronna for being the point person on the protocols this year. From this end, I have seen what a difficult process it has been, and she really took ownership of the development of the protocol set. One important word about the process is in order, as we go out to " wear" this new set of protocol clothes, so to speak. Truly, this has been a democratic process. We collected input from everyone for a year before initiation of this revision. This protocol set has been carefully edited, compared with the standard of care in all issues, and tweaked by all who would contribute. The development, writing, and editing period exceeded six months. I think that we can say that we've "home grown" a "standard of care" that we can really be proud of.

So, congratulations to us all! Talk to you soon,

Ray