Respiratory arrest and Epi for BLS Providers

[EMSGeek]

Before I get to my question let me explain the call and my EMS system. I volunteer in a suburban area on a BLS rig. Our county has a contract with a private ambulance service to provide paramedic response as needed however for my recent call the county had numerous calls going on at once and all the paramedics were unavailable.

My dispatch was for a 35 F with severe difficulty breathing due to athsma. On scene about 12 minutes after the dispatch to find a 30s F kneeling on the floor of her bathroom dry heaving into a toilet with audible wheezes. Power was out and it was fairly dark. I ruled out trauma and got the patient moved out of the bathroom to the living room where there was some light coming in from the outside.

Patient was cool, pale, diaphoretic, and in significant distress. Vitals were: BP of 140/70, HR of 100 strong and rapid, and RR of 20 and labored with wheezes. Patient stated she had been sick for about 16 hours and her Dr had diagnosed her with food poisoning. She had been vomiting for the entire time and in the last 8 hours she started having increasing difficulty breathing due to her athsma.

She had a albuterol inhaler which she had taken twice in the last two hours without any relief. I started her on high flow O2 via NRB at 15lpm, got her in the rig, immediately started transport, and re-requested ALS but no luck. I got a quick medical hx from her with nothing that stood out. No problems other than athsma and the food poisoning, no cardiac problems, no other respiratory problems, etc. Lung sounds were still tight with bilateral wheezes. I gave her a nebulized albuterol treatment per protocol with no improvement.

Our normally 10 minute transport time was increased to 20 going L+S due to severe thunderstorms which made the roads dangerous. 10 minutes into the transport (about 4-5 minutes after the neb treatment) the patient went into respiratory arrest. Patient's pulse was down to around 80 (my educated guess, I didn't count). I dropped an OPA and began bagging the patient while having my driver update the hospital and the medics. Approximately 2 minutes after the patient stopped breathing we got a medic to link up with. We were still almost 10 minutes out from the hospital at that point. I gave him a quick report but he already had some info from our radio transmission. He gave the patient an IM injection of Epi (not sure the dosage) and within seconds she took a gasp of air and I pulled the OPA which she started to gag on. Safe to say she started breathing again. Respirations were still labored with wheezes but at least she was breathing. Paramedic took over treatment and the patient made it to the hospital without any other changes.

Now I can get to my question. I have friends who work in rural areas that have 40+ minute transport times without the possibility of ALS linkup in under 30 minutes. My call got me thinking about what I would have done if I had that call in one of my friend's districts. Should I just stick to my BLS protocol and keep bagging the patient or would it be acceptable to call medical control and request to give an Epi pen? I don't know how the dosages would compare between an auto injector and the dosage drawn up by my medic. Would the .3ml I could give actually hurt the patient?

In terms of the biology I believe ALS uses it for Athsma because it is a broncodialator and BLS uses it for anaphylaxis because it counters the immune response.

Let me make it clear I would not do this without the ok of a Doc so I would like some responses from some of the Docs in the community as well as other EMS providers. Thanks in advance.

[AZCEP]

A tough situation for sure, but it beautifully illustrates why you should go to paramedic school.

Do you understand why the albuterol wasn't working for this patient? From your description you might want to look a little closer at what epinephrine does for asthmatics, and anaphylactic patients. Sounds like you've oversimplified things.

This patient needed an ALS provider from the outset. The fact that only BLS was available is a system issue, not one to slap the band-aid of add on BLS skills onto. Get this patient a paramedic that can provide the treatment(s) she needs more quickly, and the "respiratory arrest" probably doesn't happen.

Medical control may well give you the order to use your epi-pen in this case. The dose is going to be the same as the IM dose the medic used. Unfortunately, if they give you an order outside of your protocol, you are responsible for knowing if it is acceptable or not. The epi-pen usually goes SQ, rather than IM, so the absorption will be less predictable. It may be worth trying, but if it's not approved you will have other problems later.

It's good you are asking the questions now. Get enrolled in a paramedic class and find out how you are woefully unprepared for these types of situations.

[p3medic]

Talking to med control as a BLS provider would be a good idea in that senario, epi sounds appropriate, and if you painted the picture of a hypoxic asthmatic that has accepted and airway, and your actively bagging the patient most docs I'm guessing would ok the order. Another thing you might consider adding to your truck is some corregated tubing that you can run a neb on while ventilating the pt with an ambu.....one end of the tubing attaches to the t-piece of the chamber, the other side attached to the ambu, the tubing then attaches to the mask via and adapter......just my opinion.

[EMSGeek]

Thanks for the replies guys. I absolutely realized from the onset that the PT needed ALS but I was the best she had for the time being. I figured good BLS goes before ALS anyway so I might as well try to do that and hope for the best.

I agree that I've over simplified the pharmacology of Epi but part of that is due to the depth which the EMT-B program covers Epi. I'm reading up on the pharmacology of epi now.

I already plan on paramedic school. It's in my near future but between wishing a little more experience as a BLS provider and not having the time yet (already a full time student) it won't happen for about a year.

Thanks again guys.

[kristo]

First of all, yes, this patient needed ALS. Yes, there should not be any BLS/ALS seperation in health care workers because all of them should be educated enough to provide ALS (the BLS/ALS distinction, by the way, is obsolete, IMHO, as it is skills-based, not education-based).

All that aside, where there is only BLS available, they should be able give asthmatics in respiratory arrest epi. An appropriate dosage is available in epi-pens (0.3 mg), but the "official", as far as I know, is 0.01 mg per kg body weight up to 50 kg (0.5 mg epi). For really long transports, consider oral corticosteroids like prednisone (40-60 mg).

After getting that protocol through, though, they should start working on educating their staff up to ALS level so that they don't need to let BLS providers provide semi-ALS...

In Iceland, anyone with a first responder course plus a little workshop on anaphylaxis and asthma can do this, there's a protocol issued by the surgeon general...I realize this is "a bit" extreme.

[BEorP]

I am wondering about a few more things about this pt:

- She was short of breath for eight hours prior, took her puffer two hours ago. What finally happened that made her call 911? Did her condition suddenly worsen in some way?

- How bad does her asthma usually get and what usually triggers it? Would the two puffs she took usually fix her right up? Has she ever been hospitalized for an asthma attack before?

- How many word dyspnea did she have?

[sassy_emt]

EMSgeek,

the best advise I could re-state is Call your medical command if the inhaler doseage isn't working......they have the power to authorize the epi-pen administration. never be afraid to call them....that was always stressed to me in my emt training....if ALS is deayed and you are the first there and you are delayed in transport (due to weather or unexpected road delays) or your patient's conditions during transport call medical command and meet up as as soon as you can with ALS.

[chbare]

"A tough situation for sure, but it beautifully illustrates why you should go to paramedic school." Agreed.

That aside, I think you provided excellent care within your level of training. You recognized the life threat and took aggressive measures within the BLS scope to treat the condition. You recognized the need for ALS and it sounds like you tried your best to deliver the patient to a higher level of care.

It sounds like you have the BLS stuff down, all the more reason to get your butt back into school. :wink:

Take care,

chbare.

[EMSGeek]

Thanks for the compliments chbare, but I have yet to leave school...unfortunately the college degree I'm pursuing doesn't do a lick of good in EMS. Paramedic is coming my way sooner than later.

[csuprun]

I absolutely realized from the onset that the PT needed ALS but I was the best she had for the time being. I figured good BLS goes before ALS anyway so I might as well try to do that ...

Whoa, whoa, whoa...I disagree with some of my fellow posters I guess, but never run from the fact that you are "only" BLS. Your system may run out of medics -- it happens in a lot of systems...for profit, not for profit country third service, fire based EMS, whatever...medics aren't always around and being able to provide good BLS and first recognize that your patient was in respiatory arrest, start bagging with an OP in place is awesome. I know several medics who probably aren't that on top of their game as much as you are. It sounded like your patient made it to the hospital still with a pulse and still alive and kicking...you weren't the best she had just for the time being...it sounds like to me, you did make the difference for this patient.

We can argue and talk all day about whether or not you should have epi (I would probably argue not since you are in a tiered system), should the system be tiered (I came from this type of system originally, so I tend to favor them), and whether or not our education differs (ALS vs. BLS)...but that day you did your job and delivered a viable patient to the ER for them to provide definitive care to. Remember please, even us Paragods are still human too and can't deliver every patient to the ER alive and well.

If you had a longer transport time of thirty to forty minutes in a more rural area, why not keep bagging, maintaining an airway as best possible and get to the hospital safe (good job slowing down on the unsafe roads)? Epinephrine isn't the be all, end all and while it worked in this case, any experienced medic will tell you it dont always work and sometimes we have to get a little more aggresive with other medications that hospitals give and arent even on many rigs. I don't know if it is available to you in your system but since she had no gag at one point, why not a Combitube or King Airway device. Again, you have an airway secured and you can monitor the patient's cardiovascular status from there. Just a thought, but please don't think we are any better. You were large and in charge on that call it sounds like and quite frankly got a "save."