National Emergency Resource Group

11/25/2025

https://www.jems.com/commentary/ems-educators-and-author-respond-to-no-win-scenarios-commentary/?utm_source=jems_now_newsletter&utm_medium=email&utm_campaign=2025-11-25&oly_enc_id=0573D7154845G5U

JEMS published an opinion piece on "no-win scenarios" in EMS education, prompting letters from educators expressing concerns about evidence-based practices. JEMS acknowledged the decision to publish was incorrect and is…

11/25/2025

11/25/2025

🔥 𝐏𝐄𝐃𝐈𝐀𝐓𝐑𝐈𝐂 𝐏𝐑𝐄-𝐀𝐑𝐑𝐄𝐒𝐓 𝐑𝐄𝐂𝐎𝐆𝐍𝐈𝐓𝐈𝐎𝐍

👶🚑 𝐂𝐚𝐭𝐜𝐡 𝐭𝐡𝐞 𝐜𝐡𝐢𝐥𝐝 𝐰𝐡𝐨 𝐧𝐞𝐞𝐝𝐬 𝐚𝐠𝐠𝐫𝐞𝐬𝐬𝐢𝐯𝐞 𝐫𝐞𝐬𝐮𝐬𝐜𝐢𝐭𝐚𝐭𝐢𝐨𝐧 𝐛𝐞𝐟𝐨𝐫𝐞 𝐭𝐡𝐞𝐲 𝐜𝐫𝐚𝐬𝐡

You do not regret acting early.
You regret waiting.

Kids hide shock until they cannot.
Your job is to spot the pattern before collapse.

⸻

🚨 𝐖𝐇𝐘 𝐓𝐇𝐈𝐒 𝐌𝐀𝐓𝐓𝐄𝐑𝐒

• More than 60 percent of pediatric arrests show abnormal vitals before collapse.
• Each abnormal vital increases the odds of deterioration and ICU transfer.
• Hypotension is a late marker in kids.
• Early care improves survival only when you catch shock early.

⸻

🔬 𝐖𝐇𝐀𝐓 𝐈𝐒 𝐇𝐀𝐏𝐏𝐄𝐍𝐈𝐍𝐆 𝐈𝐍𝐒𝐈𝐃𝐄 𝐓𝐇𝐄𝐌

❤️ Cardiovascular changes

• Kids depend on heart rate to keep cardiac output up.
• They cannot raise stroke volume much.
• Once tachycardia fails, cardiac output drops fast.

🦠 Septic changes

• Vessels relax.
• Fluid leaks from the vascular space.
• Preload falls.
• Anaerobic metabolism rises.
• Lactate climbs.

💧 Hypovolemic changes

• Low preload triggers vasoconstriction.
• Skin and gut lose blood flow early.
• Pulse pressure narrows.
• Cellular function declines.

🥶🔥 Warm and cold shock

• Warm shock can show bounding pulses and a wide pulse pressure.
• Cold shock shows weak pulses and delayed refill.
• Both patterns progress to organ injury.

⸻

🚩 𝐑𝐄𝐃 𝐅𝐋𝐀𝐆𝐒 𝐘𝐎𝐔 𝐒𝐇𝐎𝐔𝐋𝐃 𝐀𝐂𝐓 𝐎𝐍

👀 Appearance and perfusion

• Cap refill more than 3 seconds
• Cool or mottled skin
• Flash refill with wide pulse pressure
• Weak pulses
• Low urine output
• Irritability or lethargy

❤️‍🔥 Heart rate and blood pressure

• Tachycardia after treating fever and pain
• Infant: above 180
• Toddler: above 160
• School age: above 140
• RR above normal for age
• SBP lower than 70 + 2 × age in years

🧪 Labs and trends

• Lactate 4 or higher
• Rising lactate
• Worsening acidosis
• Increasing oxygen needs

⸻

👨‍👩‍👧 𝐏𝐀𝐑𝐄𝐍𝐓 𝐂𝐋𝐔𝐄𝐒 𝐘𝐎𝐔 𝐒𝐇𝐎𝐔𝐋𝐃 𝐓𝐑𝐔𝐒𝐓

Parents often spot trouble first.

• “He is not himself.”
• “She is too sleepy.”
• “He never breathes like this.”
• “She stopped playing.”

Treat these statements as clinical data.

⸻

📊 𝐒𝐇𝐎𝐂𝐊 𝐈𝐍𝐃𝐄𝐗 (𝐒𝐈𝐏𝐀)

Shock Index = HR ÷ SBP

• High SIPA predicts higher mortality and ICU use.
• A high index with normal BP still signals instability.
• Mortality rises sharply once SIPA exceeds age cutoffs.

⸻

🧠 𝐏𝐄𝐃𝐒 𝐏𝐑𝐄-𝐀𝐑𝐑𝐄𝐒𝐓 𝐂𝐇𝐄𝐂𝐊

✔️ Full Algorithm

Step 1. Three fast questions

• Does this child look sick.
• Are two or more vitals abnormal.
• Is perfusion or mental status abnormal.

One yes means reassess fast.
Two or more yes means unstable.

Step 2. Numbers you need

• HR, RR, BP, SpO₂
• Central and peripheral cap refill
• Shock index
• Blood glucose
• Lactate

Step 3. Identify the pattern

💧 Hypovolemic
• Fluid loss
• Narrow pulse pressure
• Cool extremities
• Delayed refill

🦠 Septic
• Fever or infection
• Warm bounding pulses or cold mottled skin

❤️ Cardiogenic
• Cardiac disease
• Hepatomegaly
• Rales
• Worse after fluids

⸻

💦 𝐖𝐇𝐄𝐍 𝐓𝐎 𝐒𝐓𝐀𝐑𝐓 𝐅𝐋𝐔𝐈𝐃𝐒

Start fluids when you see

• Tachycardia with cold extremities
• Narrow pulse pressure
• Delayed refill
• History of fluid loss
• No overload signs

Slow fluids when you see

• New rales
• Rising liver edge
• Increased work of breathing
• Known cardiac disease
• Shock after boluses

⸻

⚠️ 𝐃𝐎 𝐍𝐎𝐓 𝐌𝐈𝐒𝐒 𝐂𝐀𝐑𝐃𝐈𝐎𝐆𝐄𝐍𝐈𝐂 𝐒𝐇𝐎𝐂𝐊

• Tachycardia with hepatomegaly
• Rales with poor perfusion
• New fatigue after viral illness
• Chest pain with tachycardia
• Shock worse after fluids

⸻

🛑 𝐍𝐄𝐕𝐄𝐑 𝐃𝐎 𝐓𝐇𝐈𝐒

• Never wait for hypotension.
• Never give repeated boluses without reassessment.
• Never ignore a high shock index.
• Never assume fever explains tachycardia.
• Never let a sick child out of sight.

⸻

⏱️ 𝐅𝐈𝐑𝐒𝐓 𝟓 𝐓𝐎 𝟏𝟎 𝐌𝐈𝐍𝐔𝐓𝐄𝐒 𝐎𝐅 𝐀𝐂𝐓𝐈𝐎𝐍

Airway and breathing

• Oxygen
• Position and suction
• Prepare for early intubation if mental status drops

Circulation

• IV or IO
• 10 to 20 ml per kg crystalloid in 5 to 10 minutes
• Reassess after each bolus
• Up to 40 to 60 ml per kg in the first hour if no overload

Watch for overload

• Rales
• Rising liver edge
• New respiratory distress

Vasoactives

• Cold septic or hypovolemic
• Epinephrine
• Warm septic
• Norepinephrine
• Cardiogenic
• 5 to 10 ml per kg boluses
• Epinephrine or dobutamine

Sepsis care

• Antibiotics within 60 minutes
• Control source
• Track lactate and urine output

⸻

🚑 𝐓𝐑𝐀𝐍𝐒𝐏𝐎𝐑𝐓 𝐂𝐔𝐄𝐒

If the child needs vasoactives, an advanced airway, or more than two boluses, transport at a higher level than standard ALS.

⸻

🧰 𝐏𝐄𝐃𝐒 𝐂𝐑𝐀𝐒𝐇 𝐂𝐀𝐑𝐃

Quick Tool

Step A. Count abnormal vitals

Two or more means high risk.

Step B. Check perfusion and brain

• Cap refill
• Extremity temperature
• Pulses
• Interaction
• Speech
• Urine output
Any abnormal is a red flag.

Step C. Shock index

Shock Index = HR ÷ SBP
High for age means unstable.

Step D. Shock pattern

• Hypovolemic
• Septic
• Cardiogenic

Step E. First hour

• Oxygen
• Fluids as needed
• Vasoactives early
• Antibiotics within 60 minutes
• Escalate early

⸻

📘 𝐀𝐆𝐄 𝐑𝐀𝐍𝐆𝐄𝐒 𝐂𝐇𝐄𝐀𝐓 𝐂𝐀𝐑𝐃

• Infant: 0 to 12 months
• Toddler: 1 to 3 years
• Preschool: 3 to 5 years
• School age: 6 to 12 years
• Teen: 13 and older

⸻

🔥 𝐅𝐈𝐍𝐀𝐋 𝐓𝐇𝐎𝐔𝐆𝐇𝐓

Kids do not give long warnings.
Their numbers look normal until they do not.
Your speed matters. Your pattern recognition matters even more.
If you see two abnormal vitals, abnormal perfusion, or a high shock index, you should act.
Early care is disciplined action.
You save lives by refusing to wait for collapse.
Your job is not perfect prediction.
Your job is early action before the child pays the price for silence.
Hold the line. Protect the minutes that matter.

⸻

📚 𝐑𝐄𝐅𝐄𝐑𝐄𝐍𝐂𝐄𝐒

Akre, M., Finkelstein, M., Erickson, M., Liu, M., Vanderbilt, L., & Billman, G. (2010). Sensitivity of the Pediatric Early Warning Score to identify hospitalization among children in the emergency department. Journal of Hospital Medicine, 5(6), 312–318.

Balamuth, F., Weiss, S. L., Neuman, M. I., Scott, H., Brady, P. W., Paul, R., … Alpern, E. R. (2019). Pediatric severe sepsis in U.S. children’s hospitals. Pediatrics, 144(6), e20190505.

Davis, A. L., Carcillo, J. A., Aneja, R. K., Deymann, A. J., Lin, J. C., Nguyen, T. C., … Yeh, T. (2017). American College of Critical Care Medicine clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock. Pediatrics, 140(6), e20174081.

de Oliveira, C. F., de Oliveira, D. S. F., Gottschald, A. F., Moura, J. D. G., Costa, G. A., Ventura, A. M., … Rivers, E. P. (2008). ACCM/PALS hemodynamic support guidelines for pediatric septic shock. Critical Care Medicine, 36(6), 172–178.

de Souza, D. C., Shieh, H. H., Saraiva, F. A., & Silva, C. A. (2017). Epidemiology of septic shock in children. Pediatric Critical Care Medicine, 18(10), e483–e488.

Sankar, J., Ismail, J., Sankar, M. J., Censier, T., & Dubey, N. (2018). Pediatric age-adjusted shock index as a predictor of mortality. Journal of Intensive Care Medicine, 33(11), 676–683.

Scott, H. F., Brou, L., Bryant, K., & Moore, K. (2017). Lactate clearance and outcomes in pediatric sepsis. Pediatric Emergency Care, 33(10), 650–654.

Venturini, S., Bergamini, B. M., Jala, L., & Rolando, N. (2016). Hypotension in pediatric sepsis. Journal of Pediatrics, 169, 191–197.

Weiss, S. L., Fitzgerald, J. C., Pappachan, J., Wheeler, D., Jaramillo-Bustamante, J. C., Salloo, A., … Thomas, N. J. (2014). Delayed antimicrobial therapy increases mortality in pediatric septic shock. Critical Care Medicine, 42(11), 2409–2417.

11/25/2025

Ever had a patient swear they’re “allergic to epinephrine”?
Or a partner ask if the patient has any code drug allergies?
Most of us have heard wild stories in the field, but the evidence is pretty clear.

True allergies to epinephrine, atropine, or even amiodarone are extremely rare. Most “epi allergies” are reactions to preservatives, not the hormone your own body makes. And during a cardiac arrest, the immune system isn’t exactly firing on all cylinders, which means ROSC takes priority every time.

Some medical directors and oversight bodies already back this approach in policy: treat the arrest, manage any reaction later if it actually happens.

If you want the full breakdown with sources, chemistry, and clinical context, here’s the full article.

"The Question of Code Drugs Allergies" - https://ow.ly/BmKI50XxwR8

11/24/2025

The National Registry of Emergency Medical Technicians has opened a public comment period on a member EMS Advisory Group

11/24/2025

This cohort study investigates whether postintubation hypotension is associated with 30-day mortality among patients with severe traumatic brain injury undergoing prehospital rapid sequence induction.

11/23/2025

EMS airway success improves with hyperangulated blades for faster intubation and better patient outcomes.

11/21/2025

https://www.instagram.com/reel/DRR7cNvCRXP/?igsh=MWc0bm52NmxrMWk0eg==

11/20/2025

We always welcome your input for our apps. They are for field crews by field crews. So what do you want in an app? What would help you do your job ?

11/20/2025

https://www.jems.com/patient-care/when-the-streets-disagree/?utm_source=jems_now_newsletter&utm_medium=email&utm_campaign=2025-11-20&oly_enc_id=0573D7154845G5U

The American Heart Association discourages routine use of mechanical CPR devices like LUCAS and AutoPulse, stating they show no proven survival benefit compared to manual CPR.

11/20/2025

A new review summarizes the genetics, diagnosis, and treatment of long QT syndrome, a major cause of sudden death in young people. Risk stratification and genotype-guided therapy are essential.

11/20/2025

Among patients receiving mechanical ventilation following a cardiac arrest, use of a lower or intermediate Spo2 target was associated with a higher incidence of a favorable neurologic outcome compared with a higher target. A randomized trial comparing these targets in the cardiac arrest population i...