What are the current consensus paramedic recommendations for emergency medical situations?

From the Guidelines

Current paramedic recommendations for emergency medical situations emphasize rapid assessment and intervention following the CAB approach (Circulation, Airway, Breathing) as outlined in the 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1.

Key Recommendations

• For cardiac arrest, high-quality CPR should begin immediately with minimal interruptions, using a compression depth of 2-2.4 inches at a rate of 100-120 compressions per minute with complete chest recoil.
• Early defibrillation is crucial for shockable rhythms, and all lay rescuers should, at minimum, provide chest compressions for victims of cardiac arrest 1.
• Advanced airway management may include endotracheal intubation or supraglottic devices, with a focus on maintaining oxygen saturation above 94%.
• For medication administration, epinephrine 1mg IV/IO every 3-5 minutes is standard in cardiac arrest.
• Severe allergic reactions require prompt epinephrine administration (0.3-0.5mg IM for adults) and airway monitoring.
• Opioid overdoses should be treated with naloxone (0.4-2mg IV/IM/IN), titrated to restore adequate respiration without precipitating withdrawal.
• Hypoglycemia requires glucose administration (25g IV dextrose for adults) after confirming low blood sugar.
• For trauma patients, the focus is on controlling hemorrhage, maintaining spinal precautions when indicated, and rapid transport to appropriate facilities.

Importance of Early Intervention

These interventions are time-sensitive as they address the immediate physiological threats to life, with the goal of stabilizing patients for definitive care at medical facilities. The 2020 guidelines also emphasize the importance of a lone healthcare provider commencing with chest compressions rather than with ventilation 1. Additionally, early access to EMS is promoted by a 9-1-1 system, and dispatchers should have medical training and use nationally developed and maintained protocols 1.

From the FDA Drug Label

Do not administer repeated injections of epinephrine at the same site, as the resulting vasoconstriction may cause tissue necrosis. Do not inject into buttock. Injection into the buttock may not provide effective treatment of anaphylaxis and has been associated with the development of Clostridial infections (gas gangrene) Epinephrine is a strong vasoconstrictor. Accidental injection into the digits, hands or feet may result in loss of blood flow to the affected area and has been associated with tissue necrosis. Epinephrine should be administered with caution in patients who have heart disease, including patients with cardiac arrhythmias, coronary artery or organic heart disease, cerebrovascular disease, or hypertension Epinephrine should be administered with caution to patients with hyperthyroidism, Parkinson's disease, diabetes mellitus, pheochromocytoma, elderly individuals, and pregnant women.

The current consensus paramedic recommendations for emergency medical situations involving epinephrine administration are to:

• Avoid injecting epinephrine into the buttock due to the risk of Clostridial infections and ineffective treatment of anaphylaxis.
• Avoid injecting epinephrine into digits, hands, or feet due to the risk of tissue necrosis.
• Administer epinephrine with caution in patients with:
  • Heart disease, including cardiac arrhythmias, coronary artery or organic heart disease, cerebrovascular disease, or hypertension.
  • Hyperthyroidism, Parkinson's disease, diabetes mellitus, pheochromocytoma.
  • Elderly individuals and pregnant women. 2

From the Research

Current Consensus Paramedic Recommendations

The current consensus paramedic recommendations for emergency medical situations can be summarized as follows:

• The use of automated external defibrillators (AEDs) is recommended for out-of-hospital cardiac arrests, as it can significantly improve survival rates 3, 4.
• Early defibrillation and cardiopulmonary resuscitation (CPR) are crucial in improving survival outcomes following out-of-hospital cardiac arrest 3, 4.
• Paramedics should be trained to use AEDs and provide CPR, and should be integrated into primary care services to be effective in contributing to primary care workforces 5, 6.
• The assessment of paramedic competence is a complex process that requires an understanding of conceptual and psychometric principles, and should be based on performance-based assessment (PBA) protocols 7.

Key Recommendations for Paramedic Practice

Some key recommendations for paramedic practice include:

• Paramedics should be supported to expand their existing role through formal education and clinical supervision 6.
• Paramedics should be fully integrated into primary care services to build trusting relationships with patients and physicians 6.
• Patients should be informed about the role of paramedics in primary care and their implications for patient care 6.
• Paramedics should be trained to use diagnostic point-of-care ultrasound during cardiac arrest, and to provide temperature management after cardiac arrest 5.

Future Research Directions

Some potential future research directions include:

• Investigating the effectiveness of AED programs in different settings, such as hospitals and public access areas 4.
• Examining the cost-effectiveness of providing AEDs in different settings, such as homes and apartments 4.
• Developing and evaluating PBA protocols for assessing paramedic competence 7.
• Investigating the impact of paramedics on primary care workforces and patient outcomes 6.