MCMAID Resuscitation Protocol

This post is a stub, and is a supplement to “Advances in Resuscitation – CCR, if you’re not doing it now you will be”

——————

EMERGENCY MEDICAL RESPONDER/EMT

A CODE COMMANDER should assign duties according to MCMAID prior to arrival

  • Establish that the patient is unresponsive, and not breathing normally
  • Rule out DNR status, dependent lividity, rigor mortis

First Priority: M-(metronome) Quality Chest Compressions

  • Turn on Metronome, ensuring a rate of 100/minute
  • Initiate 2 minutes of chest compressions, pediatric-follow AHA 2005 Guidelines

Second Priority: C-(compressions) Quality Chest Compressions

  • Assign two compressors switching every minute, checking each others quality
  • Depth should be at least 2 inches
  • The heal of the compressor’s hand should come off the chest, ensuring full recoil

Third Priority: M-(monitor) Defibrillate

  • AED, push analyze (pediatric patient >1 yr , use peds pads up to 8 yrs if available if not use adult pads)
  • Manual, charge max joules during CPR, analyzing for no more than 5 sec (EMT-I/P) – (pediatric 4 joules/kg)
  • Immediately resume 2 more minutes of compressions

Fourth Priority: A-(airway)

  • Oropharyngeal airway and 10 liters O2 via NRB mask
  • Check patency if chocking is suspected
  • No ventilations until after 3 cycles - (unless pediatric-follow AHA 2005 Guidelines)
  • CombiTube/ET after 3 cycles of compressions, unless 1st  rhythm is nonshockable, then as soon as possible, ventilate at 6/minute only enough volume to just make chest rise

 If ROSC, acquire 12-Lead EKG, ***ACUTE MI SUSPECTED*** see STEMI Guidelines.

Give a status report to the ambulance crew by radio ASAP and ensure ALS has been dispatched.

 AEMT

Fourth Priority: I-(IV) Establish venous access

  • Initiate IO 0.9% Normal Saline unless IV is assured and quick, run wide open (20ml/kg boluses for pediatric patients)
  • Consider second IV and chilling both for unresponsive ROSC. Refer to Therapeutic Hypothermia Procedure

 INTERMEDIATE

 Monitor basic rescuer interventions closely, ensure quality, uninterrupted chest compressions

Fifth Priority: D-(drugs) Proceed to ACLS resuscitation medications

  • Obtain venous access, if not already done
  • Epinephrine 1:10,000 1 mg IV/IO every other cycle of compressions (4 minutes)
  • Vasopressin 40 units IV/IO, repeat dose in 10 minutes if no ROSC
  • If multiple shocks have been given, Amiodarone (Cordarone) 300 mg IV/IO, followed by another 150 mg if still refractory (shocks being delivered)
  • After 3 cycles of compressions, (unless first rhythm in non shockable) place advanced airway without interrupting compressions and begin ventilations at 6/minute, using only the volume to just make the chest rise.
  • If initially non-shockable, Identify and correct reversible causes: The Five H’s and the Five T’s This applies mostly to PEA, but to a lesser extent, Asystole, as well.
  • If rate is <60, Atropine Sulfate 1 mg IV. Repeat every 3 – 5 min to a maximum of 3 mg

 “The Five H’s” (treatment orders are in parentheses)

  1. Hypovolemia (Infuse Normal Saline wide open)
  2. Hypoxia (Place an advanced airway and administer high-flow oxygen at a ventilation rate of 6/minute with only enough volume to make chest rise. [1])
  3. Hydrogen Ion, i.e. acidosis (Perform ventilation [1])
  4. Hyperkalemia [2]
    1. Give Calcium Chloride (10%) 1000mg IV over 2 – 5 minutes. May repeat X 1
    2. Give Sodium Bicarbonate (8.4%) 50 mEq IV
    3. Give Albuterol Sulfate 2.5 mg HHN may repeat X 1
  5. Hypokalemia (not treated in the field.)
  6. Hypothermia (See Hypothermia & Frostbite Guidelines)

“The Five T’s” (treatment orders are in parentheses)

  1. Tablets (See Toxic Exposure/Overdose Guidelines)
  2. Tamponade (EMT-P: Perform Pericardiocentesis)
  3. Tension pneumothorax (Perform needle decompression)
  4. Thrombosis, cardiac i.e. myocardial infarction (See Chest Pain Guidelines)
  5. Thrombosis, pulmonary i.e. pulmonary embolism (No specific pre-hospital treatment available)

Paramedic

 If there is ROSC, as seen as a sudden large increase in EtCO2 and/or patient movement

  • Give Amiodarone (Cordarone) 150 mg IV/IO over 10 minutes, if multiple shocks given
  • Reassess the need for airway devices
  • Maintain advanced airway, if the patient remains unconscious
  • If the patient wakes up, the airway may be removed. Use the procedures for removing advanced airway devices in the Respiratory Distress Guidelines.
  • Monitor patient’s EtCO2 and ventilate accordingly (12-20 per minute to maintain EtCO2 around 35 mmHg)
  • Maintain SBP >80 mmHg, Consider Dopamine Hydrochloride 10-20mcg/kg/minute IV infusion
  • Consider inducing hypothermia, See Therapeutic Hypothermic Guidelines
  • Consider RSI See Respiratory Distress Guidelines
  • If post-resuscitation 12-lead EKG shows STEMI refer to STEMI Guidelines
  • Contact Medical Control for the following:
    • To discuss termination of resuscitation in the absence of a valid Wisconsin DNR Bracelet
    • Additional medication orders

 FOOTNOTES:

 1. Do not hyperventilate during cardiac arrest, even if hypoxia and acidosis are suspected causes. Strictly follow the ventilation guidelines described above.

2. Suspect Hyperkalemia when patients with a history of chronic renal failure (dialysis patients) develop cardiac arrest. Pre-arrest history may include weakness, missed dialysis appointment(s), vomiting, concurrent illness, and T waves that are peaked and as large as the R wave.

—————————-

This post is a stub, and is a supplement to “Advances in Resuscitation – CCR, if you’re not doing it now you will be”

  • roguemedic

    I have not read through the paper, yet. Why just the CombiTube for an alternative airway?

    Any plans to switch to switch to, or add, other alternative airways?

  • roguemedic

    I have not read through the paper, yet. Why just the CombiTube for an alternative airway?

    Any plans to switch to switch to, or add, other alternative airways?

  • roguemedic

    I have not read through the paper, yet. Why just the CombiTube for an alternative airway?

    Any plans to switch to switch to, or add, other alternative airways?

  • http://roguemedic.blogspot.com/ Rogue Medic

    I have not read through the paper, yet. Why just the CombiTube for an alternative airway?

    Any plans to switch to switch to, or add, other alternative airways?

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

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  • Comments
    Ckemtp
    I Got Attacked – A Paramedic Speaks About Public Trust
    I somewhat agree, though I assure you I didn't set out to waste your time. I probably should have broken this down into two separate points as the second point was the one I most wanted to emphasize. My bad on this one, I'll do better next time. Thanks for the feedback. If you'd like,…
    2014-12-16 20:25:00
    hawk4080
    I Got Attacked – A Paramedic Speaks About Public Trust
    Wow. That was a total waste to read.
    2014-12-16 19:20:00
    retired ems medic
    I Got Attacked – A Paramedic Speaks About Public Trust
    The radios should have had a trouble button to eliminate the need to key the Mike and talk. Maybe the dispatchers need to be rotated out to the streets to get out of the mode of just getting the calls out and only half listening to the radio.
    2014-12-16 14:50:00
    HybridMedic
    I Got Attacked – A Paramedic Speaks About Public Trust
    We use "Signal C" as a code to relay a crew in distress. Takes a second for the dispatchers to confirm it, but it sends the nearest engine, battalion chief, fire investigator (who are sworn LEO's) and makes an officer in distress call to Memphis Police. The arrival of all those resources is quite... Dramatic.
    2014-12-15 14:29:00
    exmedic
    Welcome to the Club
    Not me anymore
    2014-12-15 09:17:00

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