CNYEMS 2008 Protocol Additions Phase 1

1. CNYEMS 2008 Protocol Additions Phase 1 Medical Director, Daniel Olsson, DO Executive Director, Susie Surprenant Central New York EMS 50 Presidential Plaza Jefferson Tower, Suite LL1 Syracuse, New York 13202

2. Purpose • The purpose of the lesson is to familiarize Advanced Life Support (ALS) providers with the following new CNYEMS protocols: • Severe Pain Management • Antiemesis • Adult Intraosseous Access

3. Severe Pain Management • Protocol will allow EMT-CC and Paramedics to administer Morphine as a Standing Order for the following indications: • Patients with pain secondary to: • Severe burns without hemodynamic compromise • Suspected extremity fractures or dislocations with severe pain

4. Severe Pain Management • Contraindications (for standing order): • Painful conditions not listed under “indications (for standing order)” • Altered mental status • Hypoventilation • Hypotension • Significant non-extremity traumatic injuries • Known hypersensitivity to medication

5. Severe Pain Management • Steps: • Routine Medical Care • Assess patient eligibility • If patient is eligible for standing order • Morphine 4mg IV • Dose may be repeated once after 5 minutes as needed (standing order) • Additional Morphine 4mg IV every 5 minutes as needed up to 20mg (requires Medical Control order) • If patient is ineligible for standing order a Medical Control order must be obtained for all doses

6. Antiemesis • Protocol applies to EMT-CC and EMT-P • Indications: • For the prevention and treatment of nausea and vomiting • Contraindications: • Know hypersensitivity to medication

7. Antiemesis • Protocol uses Ondansetron (Zofran) as the Antiemetic • Agencies may use either the generic or brand name version of this medication

8. Ondansetron (Zofran) • Indications: • Nausea and vomiting • Contraindications: • Known hypersensitivity to this, or other, antiemetic medications (Anzemet, Kytril, Aloxi)

9. Ondansetron (Zofran) • Side Effects: • blurred vision or temporary blindness; • fever; • slow heart rate, trouble breathing; • anxiety, agitation, shivering; • feeling light-headed, fainting; or • urinating less than usual or not at all

10. Ondansetron (Zofran) • Side Effects (continued): • diarrhea or constipation; • weakness or tired feeling; • headache; • dizziness or drowsiness;

11. Ondansetron (Zofran) • Use Zofran with caution in patients taking the following medications: • phenytoin (Dilantin), phenobarbital (Luminal); • carbamazepine (Carbatrol, Tegretol); • tramadol (Ultram); or • rifampin (Rifadin, Rimactane, Rifater)

12. Steps: Routine Medical/Trauma Care Ondansetron (Zofran) 0.1mg/kg up to 4mg IV Repeat once after 2 minutes as needed Additional dose per Medical Control Order Antiemesis

13. Adult Intraosseous Access • Protocol allows for the use of Adult IO devices to obtain vascular access • Written generically so that agencies may choose which device to use • Device may be used in any FDA approved access site

14. Adult Intraosseous Access • Devices currently available include: • EZ IO® • Bone Injection Gun (BIG®) • FAST1TM

15. EZ-IO® • Approved for use in patients weighing 3kg or more • Allows access in both the Proximal Humerus and Proximal Tibia • Further information available at http://www.vidacare.com/Products/index_4_29.html

16. Bone Injection Gun (BIG®) • Approved for all patients regardless of age or weight • Approved for use in the Tibia • Further information available at http://www.waismed.com/unique-79.htm

17. FAST1™ • Approved for use in adult patients • Allows for sternal access • Futher information available at http://www.pyng.com/

18. Adult Intraosseous Access • Indications: • Patients who require IV access and a peripheral IV cannot be established in 2 attempts or 90 seconds and in patients who exhibit 1 or more of the following: • An altered mental status (GCS of 8 or less) • Hemodynamic instability (Systolic BP <90) • Patients requiring sedation/paralysis for airway management

19. Adult Intraosseous Access • The Adult IO is Optional Equipment for the CNYEMS Region. • Agencies that elect to carry this equipment must provider didactic and skill instruction on the device per manufacturer’s guidelines. • This instruction must be completed prior to the device being used in the field.

20. Adult Intraosseous Access • IO may be considered prior to peripheral IV attempts in the following situations: • Cardiac arrest • Evidence of profound hypovolemia with alteration in mental status

21. Adult Intraosseous Access • Contraindications: • Evidence of fracture in bone of insertion site • Known previous orthopedic procedures/hardware in bone of insertion site • Known pre-existing medical condition such as tumor near insertion site or sternotomy • Infection or vascular compromise at insertion site • Inability to locate landmarks

22. Adult Intraosseous Access • Steps: • Routine Medical Care • Prepare equipment, to include: IO driver, IO needle of appropriate size, Alcohol swab, IV and/or extension set, 10 ml syringe, Tape, Pressure bag, Sharps container • Locate and cleanse FDA approved insertion site • Stabilize and insert the IO needle set • Remove driver while stabilizing catheter hub

23. Adult Intraosseous Access • Steps (Continued): • Remove stylet and secure in a sharps container • Confirm proper placement • Consider Lidocaine 20-50 mg IO slow in conscious patient • Flush catheter rapidly with 10 ml of normal saline • Place pressure bag and inflate; Begin infusion • Dress site and secure tubing • Continue to monitor patient and infusion site

24. Protocol Additions • All ALS providers must successfully complete the quiz in order to maintain their ALS privileges in Central New York. You will be directed from the next slide to take the test. • Inserts for the protocol books will be provided to agencies. • Click on the link for the three protocols. • New ALS Protocols • Protocols go into effect February 1, 2008.

25. Protocol Additions Test Click appropriate link below to take test – you will be directed to login to your CNYEMS account in an Internet browser. Login and proceed from there with the test. (You may have to close the presentation). Protocol AdditionsTest