Pennsylvania’s new protocols, both BLS and ALS, go into effect by July 1, 2011 at the latest. There are some important changes that may shock some people, but they do follow the research on best EMS patient care practices.
First, some of the problems with the Post-Resuscitation Care protocol.
This is presuming what?
Immediately after ROSC (Return Of Spontaneous Circulation), the blood pressure is unlikely to have stabilized. If the patient’s first pressure is 60 systolic, am I in a hurry to push catecholamines?
Absolutely not.
If the patient is hypotensive after a resuscitation that included the use of epinephrine, the hypotension is often accompanied by tachycardia and is just an indication of epinephrine toxicity. This is to be expected.
The treatment is benign neglect.
If the patient is demonstrating epinephrine toxicity, how will giving more epinephrine make things better? At least the rate of administration is much lower than it was while the patient was dead, so the epinephrine may be metabolized more quickly than it is added.
If the pressure is now 60/xx, I am happy. The pressure just rose by 60 mmHg. I am going to wait before taking any action. To do otherwise is to ignore the likelihood that we will over-correct for problems that might not even continue to exist – if we watch and wait.
As with steering a vehicle while it is sliding, some will grip the wheel tightly and try to force the vehicle to go where they want it to go. They frequently crash. Others will maintain a light grip on the wheel and only make small corrections, realizing that sudden large corrections often produce catastrophic results.
How much of our low resuscitation rates can be attributed to this desire for an immediate production of vital signs that look good on paper?
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The footnote contains an example of a mistake that is repeated frequently in the protocols and appears to be an attempt to appease the most timid/dangerous medical directors.
5. Epinephrine infusion, 0.1-0.5 mcg/kg/min (7-35 mcg/min) titrated until SBP > 100 mmHg, may be used for hypotension following ROSC. Consider mixing epinephrine effusion using 1 mg (1:1,000) in 250 mL NSS, and consider administration with electronic pump.[1]
This problem is the combination of per kilogram dosing with total dosing.
Is the dose 0.1-0.5 mcg/kg/min, but only for patients who are exactly 70 kg?
Or is the dose anywhere in that range, but never to go below the minimum dose for a 70 kg patient and never to go above the maximum dose for a 70 kg patient?
Was anyone thinking when this was written, or was this an attempt to compromise to satisfy the medical directors who do not provide anything that could remotely be considered competent oversight?
What if the adult patient weighs 50 kg? Why isn’t it permitted to start lower than the 70 kg dose range?
What if the patient weighs 200 kg? Why isn’t it permitted to titrate above the maximum dose for a 70 kg patient?
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To be continued in Part II and later in Part III.
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Footnotes:
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[1] Post-Resuscitation Care
Pennsylvania Statewide Advanced Life Support Protocols
3080 – ALS – Adult/Peds
Pages 34-36/128
Free Full Text PDF of All ALS Protocols
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