So how does ALS work in California?

[LACoGurneyjockey]

Follow-up:
The sepsis protocol trial went live Sept 1st and is being done by Liberty Ambulance in cooperation with Ridgecrest Regional.

They are using nasal ETCO2 to detect sepsis early. The metric is ETCO2 <25mmHg, which has a 90% rate of correlation to a lactate of 4. Treatment under the protocol is 250ml bolus for SBP <90mmHg up to 2 liters, with special consideration for renal failure and CHF patients, those patients max at 500ml before you start Dopamine.

Expect to see something added to protocols in 1-2 years following the trial. They plan on adding the protocol regardless of what the trial shows, they just are doing to trial to get the protocol started and track any improvements in patient outcomes prior to a county wide approved protocol.

Pretty much nailed it. The criteria is 2 or more of the following: new onset aloc, bgl>300 in non diabetic, HR>90, RR>20, Temp>100.9 or <97.1, or NC ETCO2 <25, and the unwritten key is with an identifiable source of infection, uti, respirstory, wounds etc. But that hasnt been written into the protocols yet, just voiced by Ridgecrest Regional. If they meet sepsis alert criteria they want any hypotension treated aggressively like you said, and bilateral large bore IVs regardless of BP. It's going pretty good so far, there's been a few legitimate sepsis alerts, but the criteria needs some tweaking so that every tachy diff breather doesn't fall into it.

 

[VentMonkey]

Pretty much nailed it. The criteria is 2 or more of the following: new onset aloc, bgl>300 in non diabetic, HR>90, RR>20, Temp>100.9 or <97.1, or NC ETCO2 <25, and the unwritten key is with an identifiable source of infection, uti, respirstory, wounds etc. But that hasnt been written into the protocols yet, just voiced by Ridgecrest Regional. If they meet sepsis alert criteria they want any hypotension treated aggressively like you said, and bilateral large bore IVs regardless of BP. It's going pretty good so far, there's been a few legitimate sepsis alerts, but the criteria needs some tweaking so that every tachy diff breather doesn't fall into it.

Any critical, or potentially critical patient should and/ or will get two B/L IV's by me, or my nurse, if at all possible regardless of the nature or mechanism.

 

[TransportJockey]

Galveston is apparently implementing Ancef for suspected sepsis, possibly pneumonia and/or UTI, and trauma with open wounds. @TransportJockey , can you clarify?

We are? Since when? I had that in my protocol in Pecos, but hadn't heard that its official for us yet.

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[VentMonkey]

Ancef?

Was is a simple push dose gram?

How did you guys go about giving it and foregoing the need for cultures?

 

[Handsome Robb]

We are? Since when? I had that in my protocol in Pecos, but hadn't heard that its official for us yet.

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That's pretty entertaining right there.

We have a Sepsis protocol but the lack of an FDA approved POC lactate monitor is holding it back from actually allowing us to call "Sepsis Alerts". Our criteria is pretty standard, known or presumed infection with 2 of the three criteria.

HR >90, RR >20 (or EtCO2 <32 <-sounds like this will be changing to 25) or temp >100.4/<96.8. 2 of those plus a lactate >4 makes for a Sepsis Alert.

Word on the street is once we have the lactate meters we'll be administering antibiotics as well.


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[Tigger]

Do we need to draw lactates in order to give antibiotics? There are several screening tools that correlate well to elevated lactate levels.

 

[ParamedicStudent]

1.) call an airship since they can RSI, transport to the closest ED so they can RSI, or wait until we can intubate.

2.) For my area we have to call and get an order for a second 12mg adenosine. We can cardiovert without calling (unless it's a pedi patient).

Just a question: do we ever intubate breathing patients? Wasnt given clear instructions on if the pt is breathing vs not breathing. As in breathing, but wont support their airway much longer, or barely breathing, etc.

 

[NomadicMedic]

Just a question: do we ever intubate breathing patients? Wasnt given clear instructions on if the pt is breathing vs not breathing. As in breathing, but wont support their airway much longer, or barely breathing, etc.

Depending on the service, paramedics may intubate breathing patients frequently. RSI, rapid sequence intubation, is the process in which you sedate and paralyze a breathing patient and then intubate them.

 

[VentMonkey]

As a whole I don't know how realistic it is, or how ready we are as prehospital providers to up and administer antibiotics.

Granted there are tons of intelligent providers capable of exhibiting sound clinical judgement, but my take is that it takes a bit more insight, and willingness to learn and understand why it is we would give "X" patient "Y" antibiotic.

Can we? Sure, but I would think the proper training be in order prior to implementing this in a protocol. This is why I am so interested in knowing if there are any systems out there that have implemented an antibiotic, and if so what are their parameters, and outcomes.

 

[VentMonkey]

Just a question: do we ever intubate breathing patients? Wasnt given clear instructions on if the pt is breathing vs not breathing. As in breathing, but wont support their airway much longer, or barely breathing, etc.

You may also find an occasional service that still allows their paramedics to perform nasal intubations.

 

[Handsome Robb]

Just a question: do we ever intubate breathing patients? Wasnt given clear instructions on if the pt is breathing vs not breathing. As in breathing, but wont support their airway much longer, or barely breathing, etc.

Depending on the service, paramedics may intubate breathing patients frequently. RSI, rapid sequence intubation, is the process in which you sedate and paralyze a breathing patient and then intubate them.

All but one of the patients that have gotten intubated by my partner and I have been breathing. Like DE said, some services allow Paramedic's to sedate and paralyze people to intubate them.


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[NomadicMedic]

You may also find an occasional service that still allows their paramedics to perform nasal intubations.

Nasal tubes have been in my protocols at everyplace I've worked. Finding a trigger tube and a BAAM, now that's another story.

 

[NPO]

Just a question: do we ever intubate breathing patients? Wasnt given clear instructions on if the pt is breathing vs not breathing. As in breathing, but wont support their airway much longer, or barely breathing, etc.

Yes, we do. At least here, because we don't have RSI. You just have to time it right; when they take a breath the cords open and you slide it in. Depending what protocol you're operating under you can give versed after passing the tube.

 

[VentMonkey]

Nasal tubes have been in my protocols at everyplace I've worked. Finding a trigger tube and a BAAM, now that's another story.

Our NTI procedure was removed about a year ot two ago. Our medical director sited that there had only been 2 performed in the previous year.

Ironically, I was one of the two, the successful one I might add, but CPAP's all but done away with it in the eyes of many medical directors.

I think I would rather have RSI, personally, but the handful of times I used it, it came in handy, and worked well. I do miss the sound of the BAAM "whistling" at me.

 

[DesertMedic66]

Just a question: do we ever intubate breathing patients? Wasnt given clear instructions on if the pt is breathing vs not breathing. As in breathing, but wont support their airway much longer, or barely breathing, etc.

Yes. We don't have RSI where I am at however. We had a trauma patient about a year ago with a GCS of 3-4 breathing on her own kinda. Trauma center was about 45 minutes away with no airships available. We ended up tubing her.

 

[VentMonkey]

The "poor man's RSI", or MAI/ DAI is just not the way to go, IMO.

I once sat in on an ACLS class where another paramedic remarked how in Kern County we're "allowed to snow" our patients with MS/ sedatives to intubate (thankfully no longer common practice in our county). This did not sit well with me, and just shows such lack of forward thinking, progression, and overall clinical knowledge, but I digress...

RSI requires a lot of understanding and perhaps also an understanding that the word "rapid" doesn't mean we are to always rush through this procedure post haste.

 

[VentMonkey]

Do we need to draw lactates in order to give antibiotics? There are several screening tools that correlate well to elevated lactate levels.

https://www.scemsportal.org/sites/default/files/GCEMS Sepsis.pdf
http://www.jems.com/articles/print/...s-in-hospital-sepsis-care-into-protocols.html
I found this interesting and good read.

 

[Tigger]

My medic program had us do a few research papers and this is what I focused on. Greenville County seems to have figured it out.

 

[VentMonkey]

My medic program had us do a few research papers and this is what I focused on. Greenville County seems to have figured it out.

I found it interesting that the article used Epinephrine for anaphylaxis as a comparison for a life-saving procedure.

It's my opinion that many paramedics neglect this medication for allergic reactions as it currently stands, so to say that antibiotics and proper identification utilizing SIRS criteria may take a bit more convincing to general paramedics as a whole on just how life-threatening sepsis can be is, well, frankly an understatement to me.

I have met, and spoken to more than one who didn't even know what MODS was. Kinda scary, I think.

 

[NPO]

I have met, and spoken to more than one who didn't even know what MODS was. Kinda scary, I think.

Those are the guys who message you and tell you to settle down on the forum.