2010 EMS Protocols for Adult and Pediatric Care: Enhancements and Standards

1. 2009-2010 Protocol Rollout

2. Protocols 2010 Edition Philosophy Expectations Format Adult Reference Pages Adult Cardiac Adult General Pediatric Reference

3. Protocols 2010 Edition • Pediatric Cardiac • Pediatric General • Appendices

4. Philosophy • Goals • To establish minimum expectations for appropriate patient care • To relieve pain and suffering, improve patient outcomes and do no harm • To ensure a structure of accountability for operational medical directors, facilities, agencies and providers

5. Philosophy • Protocols are derived from a variety of sources • Final decision rests with the OMD committee • “In situations where an approved medical protocol conflicts with other recognized care standards, the medical provider shall adhere to the Tidewater EMS Regional Medical Protocol.”

6. Philosophy • Protocols are designed to be used in conjunction with each other- it is acceptable to use more than one protocol at a time.

7. Expectations • Providers will maintain a working knowledge of the protocols • Each patient should have a thorough assessment performed • BLS providers should request ALS assistance if any deficiencies are found on the initial assessment

8. Expectations • ALS providers may request additional ALS assistance for critical patients • Make early contact with receiving facilities • If providers are truly unable to make contact, they are permitted to perform LIFE SAVING PROCEDURES as standing orders • DO NOT EXCEED SCOPE OF PRACTICE • NOTIFY AGENCY AND TEMS

9. Format • Flowcharts were getting too wordy and too hard to see in pocket guides • Split each protocol into two • Flowchart • Information page • Added a Warnings and Alerts section • The important stuff that will get you into trouble

10. Reference Pages • Burn Chart • Dopamine drip chart • Magnesium sulfate drip chart • Epinephrine drip chart • Glascow Coma Scale • Adult Trauma Transport Criteria • Wong-Baker FACES pain rating scale

11. Airway / Oxygenation/ Ventilation • Enhanced providers may still use laryngoscope and Magill forceps to relieve airway obstruction • Indications for plural decompression (serious signs/symptoms of tension pneumothorax) • Respiratory distress with cyanosis • Loss of radial pulse (hypotension) • Decreased level of conciousness

12. Airway / Oxygenation/ Ventilation • In the 2010 edition of the protocols, EMT-Intermediate will have standing orders for: • Plueral decompression • Nasal intubation • Post-intubation sedation

13. Adult Cardiac Protocols • No major Changes • Consistent with ACLS • Information added about cardiac arrest in dialysis patients • More detailed information in Dialysis/Renal Failure protocol

14. Adult Cardiac Protocols • Adult Emergency Cardiac Care • Adult Asytole and Pulseless Electrical Activity • Adult Bradycardia • Adult Tachycardia – Narrow Complex • Adult Tachycardia – Wide Complex

15. Adult Cardiac Protocols • Adult Ventricular Fibrillation and Pulseless Ventricular Tachycardia • ROSC (Return of Spontaneous Circulation) • Name changed from post resuscitation • Moving to the adult cardiac section • Termination of Resuscitation

16. Termination of Resuscitation • Reworded to clarify • Allows EMS providers to stop resuscitation in cases where CPR started inappropriately • Once any ALS procedure is initiated, provider must contact medical control for an order to cease resuscitation efforts

17. Allergic/Anaphylactic Reaction • In the 2010 edition, EMT-Intermediate may administer Solu-medrol on standing orders if patient is hemodynamically unstable or in respiratory distress • Epinephrine will be given IM instead of SQ with maximum dose of 0.5mg • Physician may order IV 1:10,000 epinephrine in severe cases

18. Altered Mental Status • Need to assess patient to determine cause of altered mental status • No more “coma cocktail”

19. Breathing Difficulty • Added Nitroglycerin Paste ONLY when using CPAP • Providers will apply one inch of paste to patient’s chest and cover with occlusive dressing • WEAR GLOVES when handling paste • Paste onset: at least 30 minutes so SL NTG should be given every 3-5 minutes

20. Burns • Morphine dose changed to 2 mg • Waiting 5 minutes between doses removed • Allows EMT-Intermediate and EMT-Paramedic to give up to 10 mg morphine on standing orders • Can call medical control for more if needed

21. Cerebral Vascular Accident • Minor changes to implement the hyper/hypoglycemia protocol if the blood sugar is <60 mg/dL or >500 mg/dL

22. Chemical Exposure • New name for the poisoning protocol • Simplified from 6 pages into 1 page • Focuses on chemical exposures that can be treated by EMS providers • If it cannot be treated by EMS providers, decontaminate and transport while providing supportive care

23. Chest Pain/AMI • Nitroglycerin paste added • Only if pain persists after 3 SL NTG and morphine

24. Combative Patient • Added Ativan • Should be given with Haldol • In the 2010 edition EMT-Paramedics have standing orders for Haldol and Ativan • In the 2010 edition EMT-Intermediates and EMT-Paramedics may administer Benadryl on standing orders for dystonic reactions

25. Dialysis/Renal Failure • New protocol • EMT-Intermediates and EMT-Paramedics have standing orders for calcium chloride and sodium bicarbonate for dialysis patients in cardiac arrest • Physician order if not in arrest • ALWAYS FLUSH thoroughly (40ml) between calcium and sodium to prevent precipitation

26. Dialysis/Renal Failure • Also includes instructions for bleeding shunt/fistula • Firm fingertip pressure (may have to hold for 20+ minutes) • Pressure bandages do not work • Tourniquet above fistula site if life threatening bleed

27. Commercially Available Tourniquets

28. Drowning/Near Drowning • ALL patients involved in a submersion incident should be encouraged to accept transport- they are at high risk for secondary drowning (development of life-threatening pulmonary edema) • NG/OG tubes are not appropriate for non-intubated patients

29. Electrical/Lightning Injuries • Not all lightning strike victims need to be transported to a Trauma Center

30. Extraordinary Measures • Not just for trauma anymore! • No other major changes

31. Hyper/Hypoglycemia • New protocol • Emphasizes patient must be conscious and able to swallow to receive oral glucose • Thiamine ONLY if patient is known alcoholic or malnourished • 250 ml NS bolus for hyperglycemic patients- may repeat up to 1000 ml total

32. Hypothermia • No major changes

33. Nausea/Vomiting • New protocol • Zofran replacing Phenergan in the drug box • Dose is 4 mg slow IV push • EMT-Intermediates and EMT-Paramedics have standing orders • Should not be given with Amiodorone or Haldol

34. OB/GYN Pregnancy/Vaginal Bleeding • Renamed since not all vaginal bleeding is related to pregnancy • Added transport guidelines for high-risk maternity patients • Not new- has been a part of appendix H for multiple years • May not apply to the rural agencies

35. OB/GYN Pregnancy/(Pre-) Eclampsia • Eclampsia may occur post delivery • The order in which medications are given has changed • Ativan given first to stop current seizure • Magnesium Sulfate given to prevent further seizures

36. Pain Management / Non-Cardiac • Morphine dose changed to 2 mg • Removed the 5 minute wait time between doses • May implement Nausea/Vomiting protocol as needed

37. RSI • This is an agency specific protocol

38. Rehabilitation • Clarification of mixing sports drinks • Single serve taken at normal strength • Powdered dry mixes are mixed at half-strength, due to ice displacing the water • Changes made in an effort to be consistent with current NFPA guidelines • Hyperthermia protocol may be needed

39. Seizures • Ativan is the first drug of choice for seizures • Dose is 2 MG IV/IM • Works best when given IV • Do not give Ativan rectally- use Valium instead • Not harmful just ineffective when given • IO is the ABSOLUTE last resort to give medications for seizures

40. Shock/Non-Traumatic • New Protocol • Pressors for vasogenic or cardiogenic shock- Physician Order Only • Dopamine contraindicated for hypovolemic patients • Tourniquets are coming back • Not the same as IV tourniquets • Commercially available tourniquets (examples on next slide)

41. Commercially Available Tourniquets

42. Spinal Immobilization • No longer in “Trauma” section • Medical patients may need spinal immobilization as well • Protocol as listed needed clarification in some areas • Age extreme patients • Unknown • If unable to explain how patient ended up on the floor, then IMMOBILIZE!

43. Spinal Immobilization(Reliable Patient) • Calm • Cooperative • Not impaired by drugs, medications, alcohol or existing medical conditions • Awake, alert and oriented to person, place, time and event • Without any distracting injuries

44. Spinal Immobilization Criteria • Signs and Symptoms of possible Spinal Cord Injury • Extreme pain or pressure in head, neck or back • Tingling or loss of sensation in hand, fingers, feet or toes • Partial or complete loss of control over any part of the body • Urinary or bowel urgency, incontinence or retention • Difficulty with balance and walking

45. Spinal Immobilization Criteria • Signs and Symptoms of possible Spinal Cord Injury continued • Abnormal band like sensations in the thorax- pain, pressure • Impaired breathing after injury • Unusual lumps on the head or spine

46. Spinal Immobilization Criteria • The EMS provider may conclude that a spinal cord injury is unlikely if they do not exhibit any S and S listed and meet the following criteria • Unaltered mental status • No neurological deficits • No intoxication from alcohol, drugs or medications • No other painful distracting injuries

47. Spinal Immobilization Criteria • Distracting injuries • Reliable patient • Special needs patients • Age extremes • Pediatrics • Geriatrics • Kyphosis

48. Toxicological Emergencies • New name for overdose • Focuses on toxicological emergencies that EMS can treat • Does not cover every possible drug/medication • Narcan is used to treat respiratory depression • Not given just because pt is unconscious

49. Trauma: Crush Syndrome • No major changes • Remember this protocol exists and review it

50. Trauma • Simplified • Removed morphine • May implement Pain Management: Non-Cardiac protocol as needed • Includes trauma transport criteria