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Paramedic Protocol Update 2009

Paramedic Protocol Update 2009 Westchester Regional Emergency Medical Services Council Introduction Each agency will be provided with CD containing the protocol roll-out training materials.

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Paramedic Protocol Update 2009

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  1. Paramedic Protocol Update2009 Westchester Regional Emergency Medical Services Council Westchester Paramedic Protocol Update 5/09 - Overview

  2. Introduction • Each agency will be provided with CD containing the protocol roll-out training materials. • Protocol roll-out presentations cover all changes by section (Adult Medical, Pediatric Medical, Trauma, etc.). • Agencies are expected to deliver content to affiliated paramedics. Agency Medical Director should approve delivery mechanism (i.e., classroom session, computer delivery, follow-up quiz ??) Westchester Paramedic Protocol Update 5/09 - Overview

  3. Introduction • Protocols also included on CD in PDF format. Will also be posted on WREMSCO website. *No field guides initially as additional changes are expected. • Protocol implementation date – July 1, 2009 • Agency Medical Director must affirm that affiliated paramedics have received training (affirmation form included on CD). Westchester Paramedic Protocol Update 5/09 - Overview

  4. Overview • New Format indicating STANDING ORDERS, MEDICAL CONTROL OPTIONS, and NOTATIONS. • Each protocol initiates with M1.0-Routine Medical Care or T1.0-Routine Trauma Care. • To be carried out in conjunction with appropriate policies, procedures, and advisories. • Separate Interfacility Transport Protocols under development Westchester Paramedic Protocol Update 5/09 - Overview

  5. New Format Westchester Paramedic Protocol Update 5/09 - Overview

  6. Trauma Protocols Westchester Regional Paramedic Protocol Update 2009 Westchester Paramedic Protocol Update 5/09 - Overview

  7. Routine Trauma Care T1.0 Replaces old trauma protocols Consolidated: Routine Medical Care, airway, transport consideration, fluid resuscitation for shock, analgesics for pain management, and CPR/rapid transport for Traumatic arrest. Added: Directs provider to Airway Management Protocols, Trauma Transport Algorithm, and Pain Management Protocol. Westchester Paramedic Protocol Update 5/09 - Overview

  8. Trauma Report Appendix 2.3 Westchester Paramedic Protocol Update 5/09 - Overview

  9. Adult Medical Protocols Westchester Regional Paramedic Protocol Update 2009 Westchester Paramedic Protocol Update 5/09 - Overview

  10. Adult Medical Protocols • New Standard Operating Procedures for Advanced Airway Management, Tension Pneumothorax, and Intravenous Access (separate document) • Endotracheal drug administration has been removed from all protocols • Pediatric protocols now in separate pediatric section Westchester Paramedic Protocol Update 5/09 - Overview

  11. Adult Medical Protocols • Routine Medical Care M1.0 - Pulse Oximetry now a Standing Order • Airway Management M2.0 - Etomidate now a standing order. • If patient needs facilitated advanced airway management: • Consider ETOMIDATE 0.3 mg/kg IV or IO, perform ENDOTRACHEAL INTUBATION, and • CONTACT MEDICAL CONTROL • Bronchospasm/Asthma/COPD M3.0 - Methylprednisolone and Magnesium Sulfate now Standing Orders. Terbutaline now administered IM route. Westchester Paramedic Protocol Update 5/09 - Overview

  12. Adult Medical Protocols • Cardiac M4.0 - Refers to appropriate sub-protocol. 12 lead ECG added. • Acute Coronary Syndrome M4.1 -NITROGLYCERIN should be given with caution to patients taking erectile dysfunction (ED) medications (i.e., Viagra, Cialis, Levitra), or suspected inferior wall or right ventricle (RV) myocardial infarctions (MI) • Acute Pulmonary Edema Congestive Heart Failure M4.2 -Administer CPAP if available. Medical Control Option for Lasix changed from 40-80 mg to 80-120 mg Westchester Paramedic Protocol Update 5/09 - Overview

  13. Adult Medical Protocols • Bradycardia M4.3 - TCP now before atropine. Dopamine under Medical Control Options now 2-10 mcg/kg/min • Supraventricular Tachycardia– Divided into two new protocols • Narrow Complex Tachycardia Unstable M4.4 - Fluid challenge now Standing Order. Doses of energy for Cardioversion depend on the underlying rhythm. Diltiazem added as Medical Control Option • Narrow Complex Tachycardia Stable M4.5 -Diltiazem 15-25mg as Standing Order for ATRIAL FLUTTER, ATRIAL FIBRILLATION or MULTIFOCAL ATRIAL TACHYCARDIA unless patient has a known history of Wolff-Parkinson-White Syndrome (WPW) Westchester Paramedic Protocol Update 5/09 - Overview

  14. Adult Medical Protocols • Wide Complex Tachycardia Unstable M4.6 - Doses of energy for Cardioversion depend on the underlying rhythm. Total maximum dose of Amiodarone in Standing Orders is now 2.2gm/24 hrs. • Wide Complex TachycardiaStable M4.7 - Standing Order of Amiodarone to 150 mg/100 ml of D5W. Repeat if VT persists. Max 2.2 gm/24 hrs.Procainamide now Medical Control Option only. Westchester Paramedic Protocol Update 5/09 - Overview

  15. Adult Medical Protocols • Cardiac (Arrest) Non-Traumatic Cardiopulmonary Arrest M5.0 - This protocol directs the EMS provider to two new protocols: M5.1 – Shockable Rhythm M5.2 – Non-Shockable Rhythm • Notes for consideration of the following medications for all Cardiac Arrests have been added: • SODIUM BICARBONATE 1 mEq/kg IVP or IO with suspected hyperkalemia, profound acidosis, tricyclic antidepressant, cocaine, or diphenhydramine overdoses. Dose may be repeated at 0.5 mEq/kg every 10 minutes. • DEXTROSE 50% IVP or IO if clinically indicated; may be repeated once. • NALOXONE 2 mg IV or IO if clinically indicated. • DOPAMINE 400 mg in 250 ml 0.9% Normal Saline; initiate drip at 5 - 10 mcg/kg/min. • CALCIUM CHLORIDE 250 – 500 mg IVP or IO; may be repeated to a maximum of 1 gm. Only indicated with hyperkalemia, hypocalcemia, or calcium channel blocker toxicity. Westchester Paramedic Protocol Update 5/09 - Overview

  16. Adult Medical Protocols • Cardiac Arrest Shockable Rhythm (VF or Pulseless VT) M5.1 – Follows latest CPR guidelines; single shocks, CPR @ 2 min. intervals. Precordial thump removed. Standing Order added for Magnesium Sulfate for known Hypomagnesemia or Torsades. • Cardiac Arrest Non-Shockable Rhythm M5.2 – Prompt to Search for and treat for contributing factors; address as appropriate. Vasopressin now a Standing Order but under review. Westchester Paramedic Protocol Update 5/09 - Overview

  17. Adult Medical Protocols • Field Termination of Resuscitation Efforts M5.3– Grief counseling removed. • Altered Mental Status M6.0– Naloxone dose now 0.4 mg IV, IN, or IM, may be repeated up to 8 mg. • Anaphylactic Reaction M7.0 - Standing Orders now for Methylprednisolone, rapid fluid infusion, and Albuterol. Epinephrine is indicated as follows: • Cardiovascular collapse present, 1:10,000 1 mg IVP • Mild reaction, 1:1,000 0.3 ml IM • If patient is taking beta-blockers, also administer GLUCAGON 1 mg IM or IV. Westchester Paramedic Protocol Update 5/09 - Overview

  18. Adult Medical Protocols • Toxic Exposure / Poisoning M8.0– For Carbon Monoxide (CO) exposure with history and signs/symptoms - Monitor CO levels (if available) - 100% oxygen therapy • Non-Traumatic Shock M9.0 – Dobutamine added as a Medical Control Option • 400mg/250 ml NS ,initiate drip at 5 – 10 mcg/kg/min. • May be titrated in increments of 5 mcg/kg/min until desired therapeutic effect is reached (max dose of 25 mcg/kg/min) • Post Partum Hemorrhage M10.0 - Oxytocin now a Standing Order “after delivery of placenta” Westchester Paramedic Protocol Update 5/09 - Overview

  19. Adult Medical Protocols • Obstetrical Toxemia of Pregnancy M11.0– PRE-ECLAMPSIA now defined as – combination of BP 140/90 or greater, peripheral edema, and symptoms: headache, visual disturbances, upper abdominal pain. Magnesium Sulfate 4 gm/250 ml NS over 20 minutes now a Standing Order for Pre-Eclampsia and Eclampsia. • Seizures M12.0– “measure serum glucose”, and treat hypoglycemia after initiating Routine Medical Care. Standing Order now for “a Benzodiazepine”(Diazepam, Lorezapam, or Midazolam). Westchester Paramedic Protocol Update 5/09 - Overview

  20. Pediatric Medical Protocols Westchester Regional Paramedic Protocol Update 2009 Westchester Paramedic Protocol Update 5/09 - Overview

  21. Pediatric Medical Protocols • Endotracheal drug administration has been removed from all protocols • 14 years or youngerfor pediatric patient Westchester Paramedic Protocol Update 5/09 - Overview

  22. Pediatric Medical Protocols • Pediatric Airway Management P1.0– Etomidate dose 0.3 mg/kg IV or IO now a Medical Control Option for all Paramedics. Continuous EKG, pulse oximetry and wave-form capnography added. • Bronchospasm / Asthma P2.0 –Separated from Croup/Epiglottitis in old protocol. Albuterol 2.5 mg plus one unit dose of Ipratropium 0.5 mg via nebulizer may be repeatedonce if needed under standing orders. Dexamethasone 0.6 mg/kg IM added as a Medical Control Option. Westchester Paramedic Protocol Update 5/09 - Overview

  23. Pediatric Medical Protocols • Croup/Epiglottitis P3.0– Nebulized Epinephrine or Racemic Epinephrine now a Standing Order. Dexamethasone 0.6 mg/kg IM added as a Medical Control Option • Cardiac P4.0 – Refers to appropriate sub-protocol. 12 lead ECG added. • Bradycardia P4.1 - Now states “ If increased vagal tone, or primary AV Block, administer Atropine 0.02 mg/kg IV or IO – minimum dose 0.1mg; maximum single dose: • 0.5 mg for children • 1 mg for adolescents. • If inadequate response, may repeat once” Westchester Paramedic Protocol Update 5/09 - Overview

  24. Pediatric Medical Protocols • Narrow Complex Tachycardia P4.2– If Sinus Rhythm, consider Fluid Challenge of 0.9% Normal Saline (10-20 ml/kg rapid infusion) if indicated; search for and treat any causes found as appropriate • Wide Complex Tachycardia P4.3 –New protocol. Apply cardiac monitor to determine rhythm. • If patient is Unstable: • If it does not delay CARDIOVERSION, administer ADENOSINE 0.1 mg/kg IV or IO first to determine if the rhythm is SVT with aberrant conduction. • SYNCHRONOUS CARDIOVERSION 0.5 J/kg – 1 J/kg; if no change, repeat at 2 J/kg (c);consider sedation / analgesia, CONTACT MEDICAL CONTROL. • If rhythm FAILS TO COVERT after 2nd CARDIOVERSION to a supraventricular rhythm, CONTACT MEDICAL CONTROL Westchester Paramedic Protocol Update 5/09 - Overview

  25. Pediatric Medical Protocols • Cardiac (Arrest) Non-Traumatic Cardiopulmonary Arrest P5.0–This protocol directs the EMS provider to two new protocols: P5.1 – Shockable Rhythm P5.2 – Non-Shockable Rhythm • Cardiac Arrest Shockable Rhythm (VF or Pulseless VT) P5.1 – Follows latest CPR guidelines; single shocks, CPR @ 2 min. intervals. Precordial thump removed. “In the event of return of spontaneous circulation (ROSC), CONTACT MEDICAL CONTROL for post-resuscitation care.” Westchester Paramedic Protocol Update 5/09 - Overview

  26. Pediatric Medical Protocols • Cardiac Arrest Non-Shockable Rhythm P5.2– Search for and treat for contributing factors; address as appropriate. • Altered Mental Status P6.0 – For documented or suspected hypoglycemia: • Administer DEXTROSE 1g/kg IV or IO: • For patients 40 kg or less, DEXTROSE 25% 4 ml/kg • For patients 40 kg or more, DEXTROSE 50% 2 ml/kg • if no response in 5 minutes, repeat the same dose. Westchester Paramedic Protocol Update 5/09 - Overview

  27. Pediatric Medical Protocols • Anaphylactic Reaction P7.0– Standing Orders for Methylprednisolone, Albuterol, and rapid fluid infusion added. Prior to initiating Routine Medical Care, Epinephrine is indicated as follows: • Cardiovascular collapse present, 1:1,000 0.01 mg/kg (max dose 0.3mg) IM • Post RMC, if patient still manifests Cardiovascular collapse, administer Epinephrine 1:10,000 0.01 mg/kg IV or IO • Toxic Exposure / Poisoning P8.0 – For Carbon Monoxide (CO) exposure with history and signs/symptoms - Monitor CO levels (if available) - 100% oxygen therapy Westchester Paramedic Protocol Update 5/09 - Overview

  28. Pediatric Medical Protocols • Non-Traumatic Shock P9.0– Fluid Challenge 0.9% Normal Saline IV or IO 5-10 ml/kg, rapid infusion; may be repeated as needed. Avoid in the presence of pulmonary edema • Note: PALS recommends giving smaller volumes if myocardial dysfunction or distributive shock is present of suspected but more rapid infusion boluses may be needed to correct hypotensive or septic shock. • REMAC contends that infusion volumes of 20 ml/kg may be necessary. Plans to appeal to SEMAC. Westchester Paramedic Protocol Update 5/09 - Overview

  29. Pediatric Medical Protocols • Neonatal Resuscitation P10.0– Now states: If thick meconium is observed in amniotic fluid AND the newborn demonstrates absent or depressed respirations, heart rate under 100 per minute, or poor muscle tone: • Clear the airway using endotracheal intubation and directly suction the endotracheal tube. • Repeat the procedure until the endotracheal tube is clear of thick meconium up to a maximum of three (3) times. • DO NOT re-intubate once the airway has been cleared of thick meconium unless the newborn still meets the criteria in STEP 2. Westchester Paramedic Protocol Update 5/09 - Overview

  30. Pediatric Medical Protocols • Seizures P11.0– After initiating Routine Medical Care, “measure serum glucose”, for hypoglycemia administer: • DEXTROSE 1g/kg IV or IO: • For patients 40 kg or less, DEXTROSE 25% 4 ml/kg • For patients 40 kg or more, DEXTROSE 50% 2 ml/kg • If no response in 5 minutes, repeat the same dose. • GLUCAGON 0.1 mg/kg IM if IV or IO route is not available, up to a maximum dose of 1 mg. • Standing Order now for “a Benzodiazepine”(Diazepam, Lorezapam, or Midazolam). Westchester Paramedic Protocol Update 5/09 - Overview

  31. Special Protocols Westchester Regional Paramedic Protocol Update 2009 Westchester Paramedic Protocol Update 5/09 - Overview

  32. Pain Management S1.0 Replaces old protocols 31 and 31a Changed: For patients presenting with need for pain management (a) with a SBP greater than 110 mmHg: MORPHINE 0.1 mg/kg IV or IO (maximum 5 mg) (b); For continued pain, repeat once (maximum total dose 10 mg) Contact Medical Control Westchester Paramedic Protocol Update 5/09 - Overview

  33. Pain Management S1.0 Replaces old protocols 31 and 31a Added: Notes a & b. a. Pain management is CONTRAINDICATED for patients presenting with (including but not limited to): Altered Mental Status, Moderate or Severe Head Trauma, Overdoses, or Hypotension b. If HYPOVENTILATION develops: in the ADULT PATIENT, administer NALOXONE up to 2 mg IV, IO or IN. in the PEDIATRIC PATIENT, administer NALOXONE 0.1 mg/kg IV, IM, IO or IN Westchester Paramedic Protocol Update 5/09 - Overview

  34. Rapid Sequence Intubation S2.0 Replaces old protocol S-1 Added: Note b. Once medication is used to facilitate intubation, whether or not it is successful, the patient’s respiratory effort MUST be monitored with CONTINUOUS WAVEFORM CAPNOGRAPHY. Westchester Paramedic Protocol Update 5/09 - Overview

  35. Nerve Agent Antidotes S3.0 Replaces old protocol S-2 Added: Commercially available DuoDoteTM auto-injectors, or the previously manufactured Mark I kits, may be possessed / used by a paramedic only under the following conditions… Changed: Directs provider to Adult Administration Protocol (S3.1) and Pediatric Administration Protocol (S3.2) (Continued on Next Slide) Westchester Paramedic Protocol Update 5/09 - Overview

  36. Nerve Agent Antidote-Adult S3.1 Changed: Standing Orders now: MILD - 1 MARK I KIT /1 DUODOTETM KIT or ATROPINE 2 mg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 1 g IV, IM or IO over 10 minutes MODERATE - 2 MARK I KITS / 2 DUODOTETM KITS or ATROPINE 4 mg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 2 g IV, IM or IO over 10 minutes SEVERE - 3 MARK I KITS /3 DUODOTETM KITS or ATROPINE 6 mg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 2 g IV, IM or IO over 10 minutes (Continued on Next Slide) Westchester Paramedic Protocol Update 5/09 - Overview

  37. Nerve Agent Antidote-Pediatric S3.2 Changed: Standing Orders now: MODERATE - 2 MARK I KITS / 2 DUODOTE KITS or ATROPINE 0.02 mg/kg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 40 mg/kg IV, IM or IO over 10 minutes SEVERE- 3 MARK I KITS /3 DUODOTE KITS or ATROPINE 0.04 mg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 40 mg/kg IV, IM or IO over 10 minutes If the patient is presenting with MILD exposure symptoms, CONTACT MEDICAL CONTROL. 1 MARK I KIT /1 DUODOTE KIT or ATROPINE 0.02 mg/kg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 40 mg/kg IV, IM or IO over 10 minutes Westchester Paramedic Protocol Update 5/09 - Overview

  38. Standard Operating Procedures Westchester Regional Paramedic Protocol Update 2009 Westchester Paramedic Protocol Update 5/09 - Overview

  39. Standard Operating Procedures • Three new procedures: • Advanced Airway Management • Tension Pneumothorax • Intravenous Access Westchester Paramedic Protocol Update 5/09 - Overview

  40. Advanced Airway Management Includes: • Endotracheal Intubation (ETT) • Laryngeal Mask Airway (LMA) • Multi-lumen Airway (i.e. Combitube) • Foreign Body Airway Removal via direct Laryngoscopy • Needle Cricothyrotomy • Tracheal Suctioning (including meconium aspiration) • Gastric Decompression • Needle Decompression • Rapid Sequence Intubation (RSI)* *May only be performed by with approval of WREMAC Westchester Paramedic Protocol Update 5/09 - Overview

  41. Advanced Airway Management Must document PRIMARY confirmation of ETT placement using: • Qualitative Methods • Colormetric end-tidal CO2 detectors • Quantitative Methods • Digital end-tidal CO2 detectors • Wave form capnography Westchester Paramedic Protocol Update 5/09 - Overview

  42. Advanced Airway Management • Document secondary confirmation using accepted clinical parameters per ACLS guidelines. • Continuous Waveform Capnography must be monitored if medication is used to facilitate intubation. Westchester Paramedic Protocol Update 5/09 - Overview

  43. Tension Pneumothorax Evidence of respiratory/cardiovascular compromise and two of the following: - Absent/decreased breath sounds on affected side- Tracheal deviation- Subcutaneous emphysema Pleural decompression is indicated using a large bore over the needle catheter or other REMAC approved device. Procedure may be repeated if signs and symptoms recur. Westchester Paramedic Protocol Update 5/09 - Overview

  44. Intravenous Access IV KVO of NS or IV lock unless fluid challenge is required. • IV NS with large bore (18ga or larger) catheter for patients requiring rapid volume replacement. • Peripheral veins (not external jugular) should be used as primary access site. • IO may be used only if other sites are not accessible. • IO med administration is preferred over ETT if no IV. • Blood drawing as indicated. Before med administration. Westchester Paramedic Protocol Update 5/09 - Overview

  45. Future SOPs Additional SOPs will be added as needed Westchester Paramedic Protocol Update 5/09 - Overview

  46. Questions • WREMSCO Office • 914-231-1616 Westchester Paramedic Protocol Update 5/09 - Overview

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