Need help understanding a protocol

[jwraider]

Hello, I'm preparing for my internship and I'm not able to ask my preceptor for help on this yet. I'm trying to show up with protocols memorized and understood. Hopefully you can help!

Sorry I cannot link to the specific protocols but here is the main page with each listed:

http://www.acgov.org/ems/ems_field_manual.htm

The two protocols are 'chest pain' and 'shock'

.....

Our county protocol for chest pain is pretty standard... monitor.. 02... ASA.. NTG and Morphine.

It eventually specifies if there is no STEMI then go to "Cardiogenic shock protocol or other dysrhythmia"

It also has a sidebar that states if the "BP drops below 90 or HR below 50 or above 100 to contact the base MD before continuing MS and NTG."

So the confusing part for me is the Cardiogenic shock protocol defined as: "Ischemic chest pain with signs and symptoms of shock"

(further defined as 2 of the following: Pulse >120 , ALOC, BP < 90 , Pale cool and or diaphoretic skin signs)

Treatment being a fluid bolus and then dopamine (@2-20mcg/kg/min) if needed (if no dysrhythmia present).

Won't that usually fall under the chest pain guidelines to contact the MD???? I'm sure I'm missing something... !

.....

It's almost like you are given options to treat a right sided MI (only if it isn't showing as a STEMI!) but the protocols are handcuffing themselves.

Can anyone help me understand the thinking behind this protocol and what they want me to do?

[JPINFV]

Why can't you link directly to them?

http://www.acgov.org/ems/Resource_policy_m...lemic_adult.pdf

http://www.acgov.org/ems/Resource_policy_m...in_MI_adult.pdf

[AZCEP]

Sounds like you are mixing the three together.

The chest pain indicates to contact the medical control prior to administering NTG/MS with signs of a right sided event. The cardiogenic shock seems to indicate that you don't have to contact medical control before starting fluid replacement and pressors (dopamine).

If you want to use NTG/MS for cardiogenic shock, it would be a good idea to get advice from medical control first.

[Asysin2leads]

JW, I'm never sure exactly what your docs (or mine, for that matter) have in mind when they write the protocols, but here's my best stab at it.

Consider a person having an infarction. At first they call you and you treat under the Chest pain protocol. You give them nitroglycerin and there BP falls below 90, and you follow the rest of the protocol.

Now say that person didn't call you right away. Their infarction has been going on for long enough that their heart is damaged or otherwise unable to function properly and their blood pressure is low because of it. Their signs and symptoms are the same, chest pain, cool, pale, diaphoretic, low BP, but the pathologies are different and need to be treated accordingly.

Being able to recognize the disease process and accurately describe what is occuring and what is necessary is the true hallmark of a quality paramedic, and goes far beyond saying this sign + that symptom = this diagnosis + this medication.

Usually the most clear sign of someone being in cardiogenic shock is the presence of rales. This doesn't mean that someone who is cool, pale, and diaphoretic and has a low BP but no rales is NOT in cardiogenic shock, but someone who has all of these things plus an fitting history and description of onset of symptoms almost certainly is.

Hope this helps.

[firedoc5]

Sounds like you are mixing the three together.

The chest pain indicates to contact the medical control prior to administering NTG/MS with signs of a right sided event. The cardiogenic shock seems to indicate that you don't have to contact medical control before starting fluid replacement and pressors (dopamine).

If you want to use NTG/MS for cardiogenic shock, it would be a good idea to get advice from medical control first.

That's about what I was going to say. When in doubt, contact Med. Control. If not possible go by ACLS protocols, which is standard.

Establish allergies before ASA! Get as much hx. as possible. I know it's passe', and maybe not even taught anymore, even frowned upon, but MAST is another option for hypotension and brady. Doesn't hurt.

If you still haven't talked with your Preceptor, go to your Med. Director.