Emergency RMT Scenarios and Responses
FOR ALL EMERGENCY RMT
- Stay as calm and reassuring as you can.
- Get the health aide’s contact number.
- Find out where the health aide and patient are located.
- Get the patient’s name/DOB and last weight for peds patients.
- Find out who else is helping the health aide-make sure they call for more help.
- Get at least one more provider to help you with true emergency RMT.
- Move patient to clinic if they are at home or another site.
- Have health aides follow CAB/ABCs.
- Make sure:
- O2 plus bag and good fitting mask are available.
- Health aides are ready to do CPR if needed.
- Get all patient’s regular and emergency medications to the clinic.
- Activate medevac ASAP if indicated.
- Set up video with Vidyo for better patient assessment and to assist with health aide resuscitation.
- Intermittently Reassess/Review/Confirm/Validate what has been done and let health aides know they are doing a good job.
- Stay calm and reassuring.
- Take detailed notes as you are able.
- Do not order emergency medications ‘per CHAM’. Give health aides the doses of medications needed such as ceftriaxone and steroids plus fluid rates etc.
- NOTE: CHAs may not give any medications besides IV fluids per IV.
- 1 Adrenal Crisis-Congenital Adrenal Hyperplasia (CAH)
- 2 Anaphylaxis
- 3 Angina/MI
- 4 CPR in process (Code-Resuscitation)
- 5 Death In the Village
- 6 Delivery in the Village
- 7 Drowning
- 8 Fever in Infants less than 90 days – Unstable
- 9 Hypoglycemia
- 10 Hypothermia
- 11 Respiratory distress
- 12 Seizures
- 13 Sepsis
- 14 Stroke (CVA)
- 15 SVT/Arrhythmia
- 16 Syncope (or near-Syncope)
- 17 Trauma
Adrenal Crisis-Congenital Adrenal Hyperplasia (CAH)
Acute adrenal crisis presents as vomiting, diarrhea, dehydration, hypotension and shock. Crisis can be precipitated by illness, trauma and hyperthermia.
- If you get a call on a pediatric patient with CAH who is in crisis, find out if the caretakers have a dose of IM Solucortef for emergencies and give this ASAP.
- Make arrangements for medevac.
- If the patient has no emergency solucortef available, you can give dexamethasone from the village formulary
For patients who present with wheezing/stridor, hives, lip or facial swelling, abnormal vitals, abdominal pain, vomiting, diarrhea
Give epinephrine without delay!
- Adults and peds greater than 25kg give 0.3 mg IM
- Peds less than 25 kg give 0.15 mg IM
- See emergency meds section (link to this section)
Repeat Epinephrine q 5-15 minutes as needed ABCs and Nasal Cannula O2
Lay patient down with feet up
- Adult =50mg po
- Peds=1.25 mg/kg po (12.5mg/5mls)
- Adult= 60 mg prednisone
- Peds=2mg/kg prednisone crushed tabs OR Dexamethasone IV solution 0.6 mg/kg IM or po
Establish an IV
Give IV fluid boluses (20mg/kg for peds and 1L for adults) as fast as possible.
Albuterol nebs as needed.
Most clinics have telemedicine 12-lead ECG capability available to help in the evaluation of ischemic chest pain symptoms that can be loaded into the RAVEN Multimedia Manager. ECG confirmation of concerning symptoms in a middle-aged to elderly patient with cardiac risk factors might warrant medevacking such a patient to the Bethel ER for further evaluation including risk assessment for possible thrombolytics within the 12 hour treatment window. Morphine, Oxygen, Nitroglycerin and Aspirin (MONA) are all available in the village clinic if needed. If chest pain does not appear ischemic, a patient is often commercially transported to the ER in Bethel for further more likely atypical chest pain.
CPR in process (Code-Resuscitation)
There are times when you will get a call from a CHA who is doing CPR on a patient in the home or in the clinic.
- Have the CHA call for more help
- Get as much information as you can about what happened.
- Find out exactly what they are doing and who is there to help them.
- Do not activate a medevac for CPR in progress unless there is a spontaneous return to circulation OR it is a pediatric patient and, in consultation with the pediatrician on call, a decision is made to medevac the patient. CPR in the field without advanced life support is almost never successful. Most CHAs know this. Do the things listed below, keeping in mind that this is generally a futile process, but very necessary for the patient’s family and the CHA.
- Airway open
- Appropriate sized BVM with a good fit and seal
- Patient on O2 with tank O2
- AED placed (even peds)
- Determine if CPR is adequate (fast, effective and can palpate a pulse) and make sure CHA/s are reassessing for this regularly.
- Get glucose and HGB
- Place IV if possible
- Get the patient’s name and DOB, so you can look up the patient’s history.
- VTC Video monitoring if able
- Get the CHA contact number/s in case you get disconnected.
- Stay calm and as reassuring as you can.
- Reassess frequently-Confirm what has been done and let them know they are doing a good job
- Take good notes with times, medications given, interventions done and responses
- Prepare the CHA’s, family and helpers (keep in mind that you are often on speaker phone) for next steps depending on how resuscitation is going.
- If a patient responds to resuscitation , a medevac needs to be activated.
- If the patient is not in the clinic, they should be taken to clinic if safe transportation is possible.
- If resuscitation appears futile (ie effective CPR for > 20 minutes) you will need to go over everything that has been done and make sure there is nothing else that you and the CHAs thinks can be done.
- Prepare the CHAs and family for calling the code.
- It may be necessary to continue CPR longer than you would normally to give the family time to gather and adjust.
- Have the lead CHA step away and talk to you privately for a moment to help them prepare for stopping CPR.
- Epinephrine 1:1000 (1 ampule vials).
- NS Fluid resuscitation
If a code is called you will need to follow the protocol for a Village Death * Link here.
- Fax Village death form to Medical Examiner office (if this was an expected death (ie. Palliative care, comfort measures), this form may have already been faxed)
- Call medical examiner’s office
- Notifly Life Alaska (number is on bulletin board on northwing)
- Call state Trooper
- Write free text note documenting events, time of death, etc. And send to Ellen Hodges and Rebecca Tunuchak.
Death In the Village
Delivery in the Village
CPR should be continued as safe and able in the field or village clinic. In the latter environment, re-warming with blankets and heated IV bags for likely additional hypothermia will help the resuscitation effort. Generally, without a confirmed pulse, a medevac should not be activated with the possible exception of drowning involving hypothermia in a nearby village.
Fever in Infants less than 90 days – Unstable
Infants with fevers 100.4° or greater are at risk for sepsis and meningitis. Any infant with fever who appears ill, i.e. is irritable, lethargic, tachycardic, tachypneic, vomiting or has a rash needs to be medevaced to Bethel ASAP. IM ceftriaxone at 100mg/kg should be given in the village while awaiting a medevac. A blood culture should be obtained prior to Ceftriaxone if the patient is in a SRC. Have the blood culture sent in with the patient. Please consult peds on call for any questions or assistance in managing these patients.
Any seizing patient should get a glucose accucheck as soon as possible to evaluate for hypoglycemia as this is a correctable cause of seizures. Additionally, patients with a history of diabetes or patients with symptoms of AMS or acute illness including sepsis might also be tested as appropriate for low blood sugar. Instaglucose, administered via the mucous membranes, is available in the village clinic to treat this. Also be aware that carnitine palmitoyltransferase (CPT) 1 deficiency is relatively common in our population and during periods of fasting or during an illness can present as hypoglycemia.
- Correct hypothermia any way possible.
- If the patient fully recovers in the village clinic, transport to Bethel may not be necessary.
While assuring that the patient has sufficient supplemental O2 available in the clinic, inquire if he/she normally has Home O2, is an Expected Home Death or Palliation patient to better meet both the needs and planned desires of this patient. Once full treatment of the patient is established, at least one trial of a nebulized bronchodilator with clinical progression of treatment as is indicated. Consider PO prednisone 40-60 mg x1 for broncho-constricted adult patients. Also consider medevac if after a trial of treatment, spO2 remains <90% or moderate to severe respiratory distress persists.
- Give Two back-to-back albuterol nebs
- O2 administered –preferably with NC, but blow by ok to start with
- If patient is febrile, give Tylenol and/or Motrin
- Find out who else is helping the CHAs, where the patient is and patient’s name and DOB
- Make sure the CHA calls for at least two more people to help.
- Move patient to clinic if they are at home or another site
- Make sure bag and good fitting mask is available
- Get patient information to look up past history medications etc
- Frequent reassessment and keep good documentation of times and interventions
- If patient improves with these interventions then reassess O2 requirement, RR and WOB.
- Consider close monitoring and possibly regular flight to Bethel
- Activate medevac if not improving
- VTC video monitoring if able
- Increase nasal cannula O2 to 3-5 L as needed
- Frequent nebs or continuous Albuterol if required
- Try Atrovent nebs or racemic or nebulized epinephrine (IV solution)
- Call peds or a pediatric partner for help
- Consider prednisone 2mg/kg of crushed tablet in liquid/pudding or syrup.
Stridor at Rest
Remember Supportive Measures
- Keep child upright
- May take child outside for cool air
- Minimize invasive measures – keep child CALM!
- Do NOT give albuterol; this can worsen croup
- May give NS neb
Activate a medevac immediately if patient develops signs or symptoms of severe croup or impending airway obstruction: drooling, lethargy, tripod position, marked retractions, tachycardia, cyanosis or pallor
- Start nebulized racemic epinephrine neb
- Give Dexamethasone by least invasive method possible
- Follow stridor guidelines for ongoing management
- Determine if the patient is still seizing and whether the patient is in the clinic or at another site
- Get the patient’s name/DOB and last weight (for peds).
- Find out who else is helping the CHA and where the patient is
- CHA must call for more help
- Move patient to clinic if they are at home or another site AND bring all patient’s meds to the clinic
- Follow your CAB/ABCs and make sure
- They have on O2
- A bag and good fitting mask is available and
- The CHAs are ready to do CPR if needed.
- VTC Video monitoring if able
- If the patient is a known seizure patient find out if the patient has any rectal Diastat available to give. If they don’t it is good to have an Rx sent to the village by pharmacy in case of future episodes.
- Place IV if possible and give NS bolus
- Get an accucheck glucose as soon as possible (low glucose is a reversible cause of seizures)
- For low blood glucose you can smear Instaglucose on mucous membranes or give glucacon SC/IM/IV
- If Instaglucose or glucacon are not available you use a slurry of sugar water to coat oropharynx or give per NG (may use IV tubing as makeshift NG). The rectum does not absorb glucose well, but can be used if no other options available.
- Confirm what has been done and let health aides know they are doing a good job
- If seizure does not resolve or is prolonged, get help for yourself and get a medevac activated ASAP
- Before giving or stopping anti-seizure medications, determine if the patient is still seizing. This can be very subtle at times and VTC is helpful. The CHA may no longer see tonic-clonic movements, but the patient may still be stiff, have fine tremors or eye deviation, poor O2 sats etc.
- Have a health aide get Diazepam and Phenobarbital out of the village clinic lock box and ready for administering.
- If a patient has seized for more than 5-10 minutes, be prepared to start with either the patient’s rectal diastat prescription or village diazepam IM or rectal. The longer a patient seizes the harder it is to break the seizure.
- Before giving diazepam, make sure the CHA has obtained a good fitting bag and mask and is ready to provide assisted ventilation with bag-mask-valve device to support the patient if the patient becomes apneic. Diazepam can be repeated as often as every 10-15 minutes…waiting a little longer is often better as you must weigh the risk of apnea in the village against prolonged seizure activity.
- Your inpatient pharmacist is available in house or on call for assistance if needed.
- Take notes with times, medications given, interventions done and responses
- Reassess frequently.
- Get VTC set up for video monitoring if possible
- The second line medication will be phenobarbital IV or IM. For adults, the dose of IM phenobarb may exhaust the entire village supply.
If likely signs and symptoms of acute sepsis are present, IV fluids and available antibiotics should be initiated while activating an urgent medevac for transport to the ER in Bethel.
See YKHC Clinical Guidelines and Inpatient/Common Adult Admissions/Cerebrovascular Accident (CVA) (do we have guidelines for suspected stroke in the village? These would be really helpful because this comes up a lot) Consider an urgent medevac if a patient with acute stroke symptoms presents to a village clinic where there might be enough time from onset of symptoms to completion of a Head CT in the ER in Bethel to be within the 4.5 (or 3) hour limit to consider thrombolytics following evaluation with risk assessment. Otherwise commercial transport with an escort to the ER might be a more appropriate option in an otherwise stable patient with neurologic deficiency consistent with an acute or subacute process. While awaiting transport in the village clinic, supplemental O2 and IV fluids may be appropriate but not aspirin until a hemorrhagic process in the brain can be ruled out in the ER.
- A pulse rate of >150/minute is usually consistent with this diagnosis but an AFHCAN TeleHEALTH 12-lead ECG is helpful for confirmation.
- In the village clinic, the following can all be attempted while evaluating the patient with CHA
- carotid artery massage
- Valsalva maneuver
- dive reflex (face in basin of ice water)
- If the above converts the arrhythmia, commercial transport to the Bethel ER is appropriate for further evaluation.
- If symptoms persist, activating a medevac is appropriate to bring this patient to the ER in Bethel, likely already chemically cardioverted by the medevac crew with adenosine.
Syncope (or near-Syncope)
- Generally, this history is concerning and the patient is best sent to the ER in Bethel or an evaluation.
- In the clinic, POC blood sugar and Hgb as well as a 12-lead ECG might all be helpful in this evaluation.
Follow ATLS with attention to ABCs as well as c-collar and back-boarding while transporting as indicated by history or severity of trauma. The “golden hour” should be considered and activating a village medevac from Anchorage (or ramp transfer in Bethel to Anchorage) with ANMC Surgery consultation may be the best plan for an acute and compelling major trauma. LifeMED can coordinate this type of medevac. Consultation with another YK physician, especially the ER attending can be helpful in decision-making.