Sierra – Sacramento Valley EMS Agency 2016/2017 Regional Training Module

S-SV EMS 2016/2017 Regional Training Module Agenda/Objectives Naloxone Utilization Prehospital Pain Management Prehospital Documentation Trauma Triage Criteria

S-SV EMS 2016/2017 Regional Training Module Agenda/Objectives Training Module Objectives Participants in this course will learn the following: Opioid abuse epidemic background and information Naloxone administration indications, contraindications, onset/duration, adverse reactions, warnings, notes and S-SV EMS protocol requirements Background, concerns and trial/retrospective study information related to prehospital pain management S-SV EMS protocol requirements for prehospital pain management of adult and pediatric patients S-SV EMS prehospital documentation policy requirements

S-SV EMS 2016/2017 Regional Training Module Agenda/Objectives Training Module Objectives Participants in this course will learn the following: S-SV EMS prehospital anatomic, physiologic, mechanism of injury and special considerations trauma triage criteria and patient destination Special considerations related to trauma in older adults

Naloxone Utilization

S-SV EMS 2016/2017 Regional Training Module Naloxone Utilization Background Opioid abuse is a major public health epidemic 16,325 prescription opioid-related deaths in the US in 2013 (4x the number of deaths that occurred in 1999) 8,257 deaths in the US from heroin in 2013 7,428 prescription opioid-related deaths in California from 2008 to 2012 (16.5% increase from 2006) 1,800 opioid-related deaths in California in 2012 alone (72% involved prescription pain medications)

S-SV EMS 2016/2017 Regional Training Module Naloxone Utilization Background Efforts undertaken to combat the crisis Calls to improve opioid prescription practices Greater access to addiction treatment

S-SV EMS 2016/2017 Regional Training Module Naloxone Utilization Background Efforts undertaken to combat the crisis Additional tools for the public and first responders Public naloxone distribution programs – 2015 California State Board of Pharmacy emergency regulations allow pharmacists to dispense naloxone without a prescription Increased first responder naloxone utilization – multiple BLS fire and law enforcement agencies have been approved to administer IN naloxone

S-SV EMS 2016/2017 Regional Training Module Naloxone Utilization S-SV EMS Data (10/1/2015 – 12/31/2015) Total 911 responses: 29,607 Total transports: 22,102 (74.65%) Total number of patients receiving naloxone: 223 (1%) Adult: 223 Pediatric: 0

S-SV EMS 2016/2017 Regional Training Module Naloxone Utilization S-SV EMS Data (10/1/2015 – 12/31/2015) Cardiac Arrest Primary Impression – Naloxone Administration Dose 0.5 mg 1.0 mg 2.0 mg Patients 2 37 Unchanged 2 (100%) 37 (100%) Improved 0 (0%) All Other Non-Cardiac Arrest Primary Impressions – Naloxone Administration Dose 0.4 mg 0.5 mg 0.8 mg 1.0 mg 2.0 mg Patients 14 18 2 36 112 Unchanged 14 (100%) 18 (100%) 2 (100%) 22 (61%) 30 (27%) Improved 0 (0%) 14 (39%) 82 (73%)

S-SV EMS 2016/2017 Regional Training Module Naloxone Utilization Description Opioid antagonist Pharmacology Competitive narcotic antagonist which reverses all effects of opioids (morphine, fentanyl, etc.) such as respiratory depression and central and peripheral nervous system effects Indications To reverse respiratory depression caused by presumed opiate intoxication

S-SV EMS 2016/2017 Regional Training Module Naloxone Utilization Contraindications Patient hypersensitivity to naloxone Onset/Duration Onset of action is within a few minutes Duration of action is approximately 30 – 60 minutes Adverse reactions May include tachycardia, hypertension, dysrhythmias, nausea, vomiting, and/or diaphoresis

S-SV EMS 2016/2017 Regional Training Module Naloxone Utilization Warnings May introduce opiate withdrawal in patients who are physically dependent Certain drugs such as Darvon may require much higher doses of naloxone for reversal

S-SV EMS 2016/2017 Regional Training Module Naloxone Utilization Notes Naloxone should not be given for any reason other than inadequate ventilatory drive and/or oxygenation associated with ALOC ALOC or cardiac arrest alone, without indication of opioid use/overdose does not warrant naloxone administration Appropriate prehospital documentation indicating suspected opioid overdose is required for all patients receiving naloxone Naloxone administration should be titrated to allow gradual improvement of respiratory drive and oxygenation

S-SV EMS 2016/2017 Regional Training Module Naloxone Utilization S-SV EMS protocols (R-2, M-5, N-1, P-12, P-22, P-24) Administer only if RR < 12 or respiratory efforts are inadequate Adult patients (≥ 15 years old) 1 – 2 mg slow IV/IO, may give IM/IN if no IV/IO and/or SBP > 90 Pediatric patients (≤ 14 years old) 0.1 mg/kg slow IV/IO or IM/IN (maximum dose 2 mg) May repeat dose every 2 – 3 minutes x 2 if improvement inadequate Do not administer naloxone if advanced airway is in place and the patient is being adequately ventilated

Prehospital Pain Management

S-SV EMS 2016/2017 Regional Training Module Prehospital Pain Management Background Pain is a common complaint of EMS patients 2.9 million patients are transported by EMS annually with a complaint of moderate to severe pain (represents 20% of all EMS transported patients)1 1Mclean, Maio & Domeier, 2002, pp. 402- 405

S-SV EMS 2016/2017 Regional Training Module Prehospital Pain Management Concerns “Pain measurement and relief is complex and should be a priority for prehospital providers and supervisors. The literature continues to prove that we are poor pain relievers, despite the high prevalence of pain in the out-of-hospital patient population.”1 “Significant disparity exists between EMT-P’s perceptions of acute pain assessment and the frequency of providing analgesia and their actual practice. Children and adolescents had less documentation of pain assessment and received less analgesic interventions compared with adults.”2 1 Emergency Medicine Clinics of North America. 2005 May;23(2):415-31 2 Prehospital Emergency Care. 2005 Jan-Mar;9(1)32-9

NAEMSP Pain Management Position S-SV EMS 2016/2017 Regional Training Module Prehospital Pain Management NAEMSP Pain Management Position “The National Association of EMS Physicians (NAEMSP) believes that the relief of pain and suffering of patients must be a priority for every emergency medical services (EMS) system.” “NAEMSP believes that every EMS system should have a clinical care protocol to address prehospital pain management. Adequate training and education of prehospital personnel and EMS physicians should support this pain management protocol.”

EMS Trial & Retrospective Studies S-SV EMS 2016/2017 Regional Training Module Prehospital Pain Management EMS Trial & Retrospective Studies “IV fentanyl can be used safely and effectively in the prehospital arena without causing significant hypotension, respiratory depression, hypoxemia, or sedation.”1 “Morphine and fentanyl provide similar degrees of out-of-hospital analgesia, although this was achieved with a higher dose of fentanyl. Both medications had low rates of adverse events, which were easily controlled.”2 1Alameda EMS Trial Study The Prehospital Use of Fentanyl, March, 2009 2Multnomah County, OR EMS trial study Effectiveness and Safety of Fentanyl Compared with Morphine for Out-of-Hospital Analgesia, 2007

EMS Trial & Retrospective Studies S-SV EMS 2016/2017 Regional Training Module Prehospital Pain Management EMS Trial & Retrospective Studies 9.9% of patients who received morphine and 6.6% of patients who received fentanyl experienced an adverse event in the prehospital setting1 The most common event was nausea, with a rate of 7.0% for morphine vs. 3.8% for fentanyl1 1Multnomah County, OR EMS trial study Effectiveness and Safety of Fentanyl Compared with Morphine for Out-of-Hospital Analgesia, 2007

EMS Trial & Retrospective Studies S-SV EMS 2016/2017 Regional Training Module Prehospital Pain Management EMS Trial & Retrospective Studies Fentanyl is a more rapid acting narcotic than morphine (2 – 3 minutes vs. 15 minutes) 1 Fentanyl is shorter acting than morphine (30 minutes versus 3 – 4 hours) 1 Fentanyl does not induce hypotension from histamine response as does morphine1 Fentanyl is less likely to induce nausea or vomiting than morphine1 1Alameda EMS Trial Study The Prehospital Use of Fentanyl, March, 2009

Opioid Administration Notes S-SV EMS 2016/2017 Regional Training Module Prehospital Pain Management Opioid Administration Notes Both morphine and fentanyl are approved for use by paramedic personnel in the S-SV EMS region Either opioid may be utilized for pain management based on availability and specific patient factors Paramedics may administer one opioid and switch to the other if necessary based on patient response and other factors Maximum total opioid dosing allowed per patient without base hospital order = 20 mg morphine equivalent (20 mg morphine, 200 mcg fentanyl, or a combination of the two), or four (4) total doses for pediatric patients (whichever is less)

S-SV EMS Pain Management Protocols S-SV EMS 2016/2017 Regional Training Module Prehospital Pain Management S-SV EMS Pain Management Protocols General considerations/requirements (M-8 & P-34) Acute injuries: Isolated extremity injuries Multi-system trauma Burns Frostbite Bites/envenomations Other causes of pain: Non-acute injuries Abdominal pain Back pain Sickle cell crisis Cancer

S-SV EMS Pain Management Protocols S-SV EMS 2016/2017 Regional Training Module Prehospital Pain Management S-SV EMS Pain Management Protocols General considerations/requirements (M-8 & P-34) Asses/document initial pain score, and reassess/document pain score after each pain management intervention Utilize non-pharmacological pain management as appropriate (psychological coaching, ice packs, immobilization/splinting)

S-SV EMS Pain Management Protocols S-SV EMS 2016/2017 Regional Training Module Prehospital Pain Management S-SV EMS Pain Management Protocols General considerations/requirements (M-8 & P-34) Continuous cardiac and SpO2 monitoring required for all patients receiving pain medication Titrate pain medication to a tolerable pain level Use caution when administering both opioids and midazolam to the same patient Each individual medication dose and patient response (including pain score) must be documented on the PCR

S-SV EMS Pain Management Protocols S-SV EMS 2016/2017 Regional Training Module Prehospital Pain Management S-SV EMS Pain Management Protocols Adult Pain Management (M-8) Pain from acute injuries – standing order pharmacological management may be utilized if all the following are present: Significant pain RR > 12 SBP > 100 GCS 15 or baseline mental status and no evidence of a head injury

S-SV EMS Pain Management Protocols S-SV EMS 2016/2017 Regional Training Module Prehospital Pain Management S-SV EMS Pain Management Protocols Adult Pain Management (M-8) Other causes of pain – base hospital order required for pharmacological management unless documented communication failure and all the following are present: Significant pain RR > 12 SBP > 100 GCS 15 or baseline mental status and no evidence of a head injury

S-SV EMS Pain Management Protocols S-SV EMS 2016/2017 Regional Training Module Prehospital Pain Management S-SV EMS Pain Management Protocols Adult Pain Management (M-8) Opioid pharmacological pain management Morphine: 2 – 10 mg IV/IO or IM/SQ every 5 minutes OR Fentanyl: 25 – 100 mcg IV/IO or IM/SQ, or 1.5 mcg/kg IN (maximum 100 mcg) every 5 minutes Maximum total opioid dosing for adult patients without base hospital order = 20 mg morphine equivalent

S-SV EMS Pain Management Protocols S-SV EMS 2016/2017 Regional Training Module Prehospital Pain Management S-SV EMS Pain Management Protocols Adult Pain Management (M-8) Additional pharmacological pain management for acute isolated extremity injuries only (if necessary) Midazolam: 1 – 2 mg IV/IO every 5 minutes Maximum total midazolam dosing per adult patient without base hospital order = 4 mg

S-SV EMS Pain Management Protocols S-SV EMS 2016/2017 Regional Training Module Prehospital Pain Management S-SV EMS Pain Management Protocols Pediatric Pain Management (P-34) Pain from acute injuries – standing order pharmacological management may be utilized if all the following are present: Age ≥ 4 years old with significant pain RR > 12 and SBP age appropriate GCS 15 or baseline mental status and no evidence of a head injury Pharmacological management for other causes of pain in pediatric patients requires a base hospital order Midazolam pharmacological pain management for pediatric patients requires a base hospital order

S-SV EMS Pain Management Protocols S-SV EMS 2016/2017 Regional Training Module Prehospital Pain Management S-SV EMS Pain Management Protocols Pediatric Pain Management (P-34) Opioid pharmacological pain management Morphine: 0.1 mg/kg IV/IO or 0.2 mg/kg IM/SQ (maximum 5 mg) every 5 minutes OR Fentanyl: 1 mcg/kg IV/IO or IM/SQ (max 50 mcg), or 1.5 mcg/kg IN (maximum 75 mcg) every 5 minutes Maximum total opioid dosing for pediatric patients without base hospital order = 20 mg morphine equivalent or 4 doses (whichever is less)

Prehospital Documentation Note: This module contains minimum S-SV EMS prehospital documentation requirements – your provider agency may have more stringent documentation requirements which must be followed if applicable

S-SV EMS 2016/2017 Regional Training Module Prehospital Documentation S-SV EMS Prehospital Documentation Policy (605) ALS PCR completion requirements PCR documentation is not required to be completed under the following circumstances: Cancellation prior to arrival at scene No patient contact is established by a subsequent arriving ALS unit If an ALS non-transport or transport provider arrives on scene after another ALS provider and no patient contact is established by the subsequent provider, only the initial provider that established patient contact is required to complete PCR documentation

S-SV EMS 2016/2017 Regional Training Module Prehospital Documentation S-SV EMS Prehospital Documentation Policy (605) ALS PCR completion requirements If ALS units arrive at scene and no patient is identified, a single PCR by one of the ALS providers (as agreed to by on scene personnel) indicating the following information is required: Reported incident location Pertinent incident times Reason why no patient was identified

S-SV EMS 2016/2017 Regional Training Module Prehospital Documentation S-SV EMS Prehospital Documentation Policy (605) ALS PCR completion requirements If an ALS non-transport provider establishes patient contact prior to the transport provider, the ALS non-transport provider shall complete a PCR for each patient If transfer of care is done within the same agency, a single PCR documenting the care provided by all personnel on scene is sufficient

S-SV EMS 2016/2017 Regional Training Module Prehospital Documentation S-SV EMS Prehospital Documentation Policy (605) ALS PCR completion requirements If an ALS non-transport provider establishes patient contact simultaneously or after the transport provider, a single PCR documenting the care provided by all personnel on scene is sufficient The ALS transport provider shall complete a PCR for each patient where patient contact/transport is established. If patient care is maintained by a non-transport provider and both units are from the same agency, a single PCR documenting the care provided by all personnel on scene is sufficient

S-SV EMS 2016/2017 Regional Training Module Prehospital Documentation S-SV EMS Prehospital Documentation Policy (605) Multiple patient incidents The initial ALS provider who establishes patient contact shall complete a PCR on each patient unless one or more of the following special circumstances apply: Patient contact was limited to triage/basic assessment only, and all pertinent patient assessment and treatment information is documented by the transporting provider Patient care was transferred to another provider from the same agency, and all pertinent patient assessment and treatment information is documented by the transporting unit The provider receives approval from S-SV EMS not to complete full PCR documentation on each patient (i.e. – large MCI)

S-SV EMS 2016/2017 Regional Training Module Prehospital Documentation S-SV EMS Prehospital Documentation Policy (605) Multiple patient incidents If the initial ALS provider is not required to complete a PCR on each patient, they must complete a minimum of one PCR containing pertinent incident information (incident nature, details, patient count/triage categories, etc.)

S-SV EMS 2016/2017 Regional Training Module Prehospital Documentation S-SV EMS Prehospital Documentation Policy (605) A PCR is a legal medical record, it must be complete and accurate Minimum patient care documentation (e.g. an interim patient care report) must be left at the receiving facility at time of patient delivery An approved ePCR must be completed and provided to the receiving hospital within 24 hours

Trauma Triage Criteria

S-SV EMS 2016/2017 Regional Training Module Trauma Triage Criteria S-SV EMS Trauma Triage Policy (860) Patients meeting trauma triage criteria should be transported as soon as possible On scene procedures should be limited to: Triage/assessment Airway management External hemorrhage control Immobilization

S-SV EMS 2016/2017 Regional Training Module Trauma Triage Criteria S-SV EMS Trauma Triage Policy (860) Physiologic Trauma Triage Criteria (one or more): Respiratory rate < 10 or > 29 breaths per minute (< 20 in infants < 1 year of age), or need for ventilatory support Glasgow Coma Score (GCS) ≤ 13 Systolic blood pressure < 90

S-SV EMS 2016/2017 Regional Training Module Trauma Triage Criteria S-SV EMS Trauma Triage Policy (860) Anatomic Trauma Triage Criteria (one or more): All penetrating injuries to the head, neck, chest, torso, and/or extremities proximal to the elbow or knee Chest wall instability or deformity (e.g. flail chest) Two or more proximal long-bone fractures Paralysis Pelvic fractures Amputation proximal to the wrist or ankle Crushed, degloved, mangled, or pulseless extremity Open or depressed skull fracture

S-SV EMS 2016/2017 Regional Training Module Trauma Triage Criteria S-SV EMS Trauma Triage Policy (860) Mechanism of Injury Trauma Triage Criteria (any): High-risk auto crash (one or more of the following): Ejections (partial or complete) from automobile Death in the same passenger compartment Intrusions, including roof: > 12 inches at occupant site or > 18 inches at any site

S-SV EMS 2016/2017 Regional Training Module Trauma Triage Criteria S-SV EMS Trauma Triage Policy (860) Mechanism of Injury Trauma Triage Criteria (any): Non-automotive crash > 20 mph (motorcycle, ATV, go-cart, bicycle, skateboard, watercraft, aircraft, etc.) Auto vs pedestrian/bicycle: thrown, run over, or with significant impact (> 20 mph) Adults who fall > 20 feet Children who fall > 10 feet or three (3) times their height Other high energy impact

S-SV EMS 2016/2017 Regional Training Module Trauma Triage Criteria S-SV EMS Trauma Triage Policy (860) Special Considerations Trauma Triage Criteria (any): Adults ≥ 65 years of age: Low impact mechanism (e.g. ground level falls) might result in severe injury SBP < 110 might represent shock Current patient use of anticoagulation or antiplatelet medication, or history of bleeding disorder Pregnancy > 20 weeks

S-SV EMS 2016/2017 Regional Training Module Trauma Triage Criteria S-SV EMS Trauma Triage Policy (860) Special considerations (adults ≥ 65 years of age) “Ample evidence demonstrates that injured elderly patients are less likely to receive care at trauma centers despite ample evidence that they are at increased risk for adverse outcomes after injury because of limited cardiovascular reserve, comorbidities, and general frailty.”1 “A retrospective analysis of 10 years (1995 – 2004) of the Maryland Ambulance Information System in 2008 found that among 26,565 patients, the risk for under-triage was significantly higher among those older than 65 years (49.9 vs. 17.8%; p G 0.001).”1 1Journal of Trauma and Acute Care Surgery 2012;73:5:4

S-SV EMS 2016/2017 Regional Training Module Trauma Triage Criteria S-SV EMS Trauma Triage Policy (860) Special considerations (adults ≥ 65 years of age) “In general, a lower threshold for trauma activation should be used for injured patients aged 65 years or older who are evaluated at trauma centers.”1 “Preexisting conditions and/or severe anatomic injuries dramatically increase the risk of poor outcome in elderly patients. Age and anticoagulants and antiplatelet agents increase the risk for post injury hemorrhage.”1 1Journal of Trauma and Acute Care Surgery 2012;73:5:4

S-SV EMS 2016/2017 Regional Training Module Trauma Triage Criteria S-SV EMS Trauma Triage Policy (860) Special considerations (all trauma patients) Thorough evaluation/documentation of the scene conditions, mechanism of injury, patient presentation and other factors are extremely important on any trauma related incident Prehospital personnel should pay special attention to: Any change in patient’s baseline mentation (especially older adults) Current patient use of anticoagulation or antiplatelet medication or history of a bleeding disorder

S-SV EMS 2016/2017 Regional Training Module Trauma Triage Criteria S-SV EMS Trauma Triage Policy (860) Special considerations (all trauma patients) The primary goal is to transport trauma patients to the most appropriate facility in a timely manner S-SV EMS regional data indicates that interfacility transfers of trauma patients from a non-trauma center to a trauma center are sometimes significantly delayed due to various patient and system factors Patients with a high suspicion of serious traumatic injuries should be transported directly from the field to a designated trauma center whenever possible

S-SV EMS 2016/2017 Regional Training Module Trauma Triage Criteria EMS Trauma Patient Destination

S-SV EMS 2016/2017 Regional Training Module Trauma Triage Criteria EMS Trauma Patient Destination