As of the 2014 protocol update, EMTs may administer both Albuterol and Atrovent (Ipratropium Bromide) via hand-held nebulizer (HHN) on standing orders. Although EMTs were not, prior to the 2014 update, permitted to administer Albuterol or Atrovent, those medications have been in the EMT curriculum for quite some time and the TEMS protocols now permit EMTs to administer the medications. An ALS provider does not have to be present for the EMT to administer Albuterol and Atrovent.
As always, Virginia Beach EMS providers should follow the TEMS protocols in addition to the following guidance:
For patients with respiratory distress due to bronchoconstriction:
- EMTs may administer Albuterol (MDI or HHN) x 2 on standing orders (no more than 2 doses on standing orders)
- EMTs may administer Atrovent (HHN) x 1 on standing orders (one dose only; administered concurrently with the first or second dose of Albuterol)
For patients with respiratory distress due to anaphylaxis:
- EMTs may administer Albuterol (MDI or HHN) x 1 on standing orders (one dose only)
If the EMT determines that additional doses may be needed, he/she may contact the hospital and request physician orders for additional doses.
Accessing the Medications
Albuterol and Atrovent are carried on the ambulances in the TEMS IV box (and drug box, but BLS providers should not access the drug box unless absolutely necessary). While ALS providers have their own keys to access the box, a key should be available on the ambulance for an EMT to access the IV box. If you are unable to locate the key, contact a member of your squad leadership for assistance. The IV box should be exchanged at the Emergency Department just as you would exchange an IV box used by an ALS provider.
ALS or BLS Transport?
Albuterol and Atrovent are part of the EMT’s scope of practice and are BLS medications. Therefore, just because Albuterol and/or Atrovent is/are administered, the patient does not require an ALS provider for the transport to the hospital and a BLS attendant-in-charge may be sufficient. However, since the patient is complaining of respiratory distress, an ALS provider should be requested (if one is available and not already dispatched or on scene) and the patient should still be evaluated by an ALS provider. The ALS provider is expected to use sound clinical decision-making skills with a comprehensive assessment of the patient and an evaluation of the totality of all circumstances prior to determining whether or not the patient may be transported as a BLS patient. If ALS care has not been provided, the ALS provider determines no additional treatment (beyond that which an EMT is authorized to provide) is required, and the patient is stable and otherwise a candidate for a BLS transport, the ALS provider may leave the patient in the care of the BLS crew. As with all other situations, if an ALS provider is unavailable or the BLS crew would be able to make it to the hospital before the ALS provider could arrive on scene, the BLS crew should still administer the appropriate medication(s) and not delay transport to wait for an ALS provider–transport should be initiated and the ALS provider should be cancelled, if appropriate.