PROTOCOL UPDATE ALABAMA EMS PROTOCOLS EDITION 5 JUNE, 2009 UPDATE 1

PROTOCOL UPDATE IF YOU IDENTIFY MISTAKES IN THE PROTOCOLS OR IF YOU HAVE SUGGESTIONS FOR PROTOCOL CHANGES IF YOU IDENTIFY MISTAKES IN THE PROTOCOLS OR IF YOU HAVE SUGGESTIONS FOR PROTOCOL CHANGES 2

PURPOSE OF PROTOCOLS IMPROVE PATIENT CARE IMPROVE PATIENT CARE PROVIDE OFF-LINE MEDICAL DIRECTION PROVIDE OFF-LINE MEDICAL DIRECTION REPRESENT STANDARD OF CARE REPRESENT STANDARD OF CARE PROVIDE QI STANDARDS PROVIDE QI STANDARDS PROVIDE EDUCATION STANDARDS PROVIDE EDUCATION STANDARDS 3

GENERAL CHANGE CHANGED THE WORD DRUG TO MEDICATION THROUGHOUT THE PROTOCOLS CHANGED THE WORD DRUG TO MEDICATION THROUGHOUT THE PROTOCOLS 4

TITLE PAGE & TABLE OF CONTENTS CHANGED TO 5 TH EDITION CHANGED TO 5 TH EDITION TABLE OF CONTENTS UPDATED WITH CHANGES TABLE OF CONTENTS UPDATED WITH CHANGES –Has been alphabetized and renumbered (except General Patient Care and Communications were left as 4.1 & 4.2 –Deleted Coma, 4.15 and combined it with Altered Mental Status, 4.5 –No new Patient Care Protocols added Two protocols were extensively rewritten –Added one new medication (Ondansetron) 5

PREFACE Dr. Campbells address corrected Dr. Campbells address corrected Clarified the EMTs responsibility to refuse to accept orders that are not in his/her scope of privilege Clarified the EMTs responsibility to refuse to accept orders that are not in his/her scope of privilege Added that a pediatric patient is defined as someone aged 15 years or younger unless otherwise noted in the protocols Added that a pediatric patient is defined as someone aged 15 years or younger unless otherwise noted in the protocols Noted that anything referring to a pediatric patient will be in Tahoma font, in bold, and colored green Noted that anything referring to a pediatric patient will be in Tahoma font, in bold, and colored green 6

SECTION 2 PATIENTS RIGHTS #6:Corrected to explain that families of patients do not have the same rights as the patients themselves. While as a general rule the EMT should take the patient to the hospital the patients family wants, if the hospital is inappropriate or is on diversion, OLMD must be called and his/her orders followed #6:Corrected to explain that families of patients do not have the same rights as the patients themselves. While as a general rule the EMT should take the patient to the hospital the patients family wants, if the hospital is inappropriate or is on diversion, OLMD must be called and his/her orders followed 7

SECTION 2 PATIENTS RIGHTS #7: Added that, while an ambulance service does not have to take a patient out of town if it leaves the community without ambulance service, that is not a license to ignore the trauma system and always take the trauma patient to the local hospital. #7: Added that, while an ambulance service does not have to take a patient out of town if it leaves the community without ambulance service, that is not a license to ignore the trauma system and always take the trauma patient to the local hospital. –If the ambulance service is unable to comply with the regional trauma plan, the service must contact the office of EMS & Trauma to develop a plan to correct this. 8

SECTION 3.3 PHYSICIAN MEDICAL DIRECTION Clarifies that medication orders may be signed by an OLMD physician or by the services medical director. Clarifies that medication orders may be signed by an OLMD physician or by the services medical director. 9

SECTION 3.4 MEDICATION AND PROCEDURE CLASSIFICATION Added list of pediatric Category A and Category B medications since they are not the same as the adult Category A and Category B medications Added list of pediatric Category A and Category B medications since they are not the same as the adult Category A and Category B medications 10

SECTION 3.4 MEDICATION AND PROCEDURE CLASSIFICATION Added Hemostatic Agents, CPAP, and Ondansetron to the list of required medications and procedures. Added Hemostatic Agents, CPAP, and Ondansetron to the list of required medications and procedures. –All are Category A –CPAP is optional for ALS nontransport services 11

SECTION 3.5 OPTIONAL MEDICATIONS AND PROCEDURES Removed CPAP and Hemostatic Agents from the list of optional medications and procedures Removed CPAP and Hemostatic Agents from the list of optional medications and procedures –CPAP remains optional to ALS nontransport services 12

SECTION 4 TREATMENT PROTOCOLS 13

GENERAL PATIENT CARE 4.1 Clarified that when filling out the ePCR, the General Patient Care protocol can be listed if there is no specific protocol for use in treating the patient Clarified that when filling out the ePCR, the General Patient Care protocol can be listed if there is no specific protocol for use in treating the patient 14

COMMUNITCATIONS 4.2 For stable patients and patients only requiring Cat. A treatment, added that the EMT may notify the nurse or paramedic at the receiving hospital For stable patients and patients only requiring Cat. A treatment, added that the EMT may notify the nurse or paramedic at the receiving hospital –Some hospitals have paramedics answer the phone 15

ALTERED MENTAL STATUS 4.5 Combined COMA 4.15 with this protocol Combined COMA 4.15 with this protocol You should review this entire protocol as there are so many changes You should review this entire protocol as there are so many changes 16

BURNS 4.7 For burn patients with wheezing, changed albuterol to Category A for adults For burn patients with wheezing, changed albuterol to Category A for adults 17

CARDIAC ARREST 4.8 Added that if the patient is in cardiac arrest, and has a venous port, you may access the port if you have been trained and have the proper equipment Added that if the patient is in cardiac arrest, and has a venous port, you may access the port if you have been trained and have the proper equipment –This requires your medical director to see what type of ports are being used in your area and see that you are trained how to access that particular port –Some ports require special needles to access 18

QUICK REFERENCE TO CARDIAC MEDICATIONS 4.9 INFANTS AND CHILDREN (Age one month t 8 years) INFANTS AND CHILDREN (Age one month t 8 years) –Under Sodium Bicarbonate changed Dilute 50% with D5W to Dilute 50% with NS –Also changed dose from 1 mEq/dose to 1mEq/kg initial dose 19

CARDIAC SYMPTOMS/ACUTE CORONARY SYNDROME 4.10 Added note that this protocol is for adults only. you should contact OLMD for chest pain in pediatric patients (age 15 or less). Added note that this protocol is for adults only. you should contact OLMD for chest pain in pediatric patients (age 15 or less). Aspirin to be given to adults unless 324mg or more has already been given in the last 24 hours Aspirin to be given to adults unless 324mg or more has already been given in the last 24 hours –If the patient has only had a baby aspirin (81 mg) you should give another four baby aspirin Aspirin is almost never given to pediatric patients (CAT. B) because of danger of Reyes syndrome Aspirin is almost never given to pediatric patients (CAT. B) because of danger of Reyes syndrome 20

PEDIATRIC BRADYCARDIA 4.11 Added that epinephrine and atropine are CAT A Added that epinephrine and atropine are CAT A –Epinephrine may be repeated every 3-5 minutes until heart rate is 80 or above –Atropine may be repeated once in 5 minutes if heart rate is not 80 or above (maximum total dose of 1 mg) Added that external pacing is for age 14 and above and is CAT B Added that external pacing is for age 14 and above and is CAT B 21

CHILDBIRTH 4.12 Changed the order of clamping and cutting the cord to the correct place in the sequence of care Changed the order of clamping and cutting the cord to the correct place in the sequence of care –It was originally listed after wrapping the baby in a blanket and taking the vital signs 22

CONGESTIVE HEART FAILURE 4.14 Added that the patient should be put in the upright sitting position Added that the patient should be put in the upright sitting position Made nitroglycerin and CPAP Cat. A Made nitroglycerin and CPAP Cat. A Kept lasix and morphine as CAT. B Kept lasix and morphine as CAT. B –This was to bring our protocols in line with current treatment of CHF 23

COMA 4.15 Deleted this protocol and combined its content with ALTERED MENTAL STATUS 4.5 Deleted this protocol and combined its content with ALTERED MENTAL STATUS

NEAR DROWNING 4.22 Added near drowning as a CAT. A indication for use of CPAP Added near drowning as a CAT. A indication for use of CPAP 25

POISONS AND OVERDOSES 4.23 Since paramedics no longer carry syrup of ipecac, deleted the list of conditions in which you should not induce vomiting Since paramedics no longer carry syrup of ipecac, deleted the list of conditions in which you should not induce vomiting The protocol now simply states DO NOT INDUCE VOMITING The protocol now simply states DO NOT INDUCE VOMITING 26

RESPIRATORY DISTRESS 4.25 Added that for pulmonary edema, nitroglycerin and CPAP are CAT. A and all other treatments (lasix and morphine) are CAT B. Added that for pulmonary edema, nitroglycerin and CPAP are CAT. A and all other treatments (lasix and morphine) are CAT B. –This reflects current treatment of pulmonary edema 27

SEIZURES 4.26 Protocol has been changed to allow either diazepam or lorazepam for treatment of seizures Protocol has been changed to allow either diazepam or lorazepam for treatment of seizures –Some doctors prefer lorazepam –The only drawback to lorazepam is that it has only a 60-day unrefrigerated shelf-life 28

SHOCK 4.27 Added that if external bleeding from an extremity cannot be controlled by pressure, application of a tourniquet is the reasonable next step in hemorrhage control Added that if external bleeding from an extremity cannot be controlled by pressure, application of a tourniquet is the reasonable next step in hemorrhage control –This reflects current treatment and current National Registry testing 29

SHOCK 4.27 Added to use a hemostatic agent if unable to stop severe bleeding with pressure or a tourniquet Added to use a hemostatic agent if unable to stop severe bleeding with pressure or a tourniquet Added that if the patient is in hypovolemic shock and the patient has a venous port, you may access the port if you have been trained and have the proper equipment Added that if the patient is in hypovolemic shock and the patient has a venous port, you may access the port if you have been trained and have the proper equipment 30

STROKE 4.28 Protocol has been rewritten to reflect the current national guidelines for diagnosis and treatment of the stroke patient Protocol has been rewritten to reflect the current national guidelines for diagnosis and treatment of the stroke patient You should review the entire protocol since so many changes have been made You should review the entire protocol since so many changes have been made 31

VOMITING 4.32 Deleted NAUSEA Deleted NAUSEA Changed treatment of vomiting from diphenhydramine to ondansetron (Zofran) Changed treatment of vomiting from diphenhydramine to ondansetron (Zofran) –The cost of injectable ondansetron is now reasonable 32

SECTION 5 MEDICATIONS 33

ALBUTEROL 5.3 Added burns and CHF as adult CAT. A use of albuterol Added burns and CHF as adult CAT. A use of albuterol –Still CAT B for pediatric burns with wheezing 34

ASPIRIN 5.5 Added that aspirin is CAT. B for pediatric patients because it may be associated with Reyes syndrome Added that aspirin is CAT. B for pediatric patients because it may be associated with Reyes syndrome 35

DIPHENHYDRAMINE 5.10 Changed diphenhydramine to a secondary medication for treating vomiting Changed diphenhydramine to a secondary medication for treating vomiting 36

FUROSEMIDE 5.13 Added a pediatric dose (CAT. B) Added a pediatric dose (CAT. B) –0.5 to 1mg/kg IV given slowly over 2 minutes 37

LORAZEPAM 5.17 Added that lorazepam may be used in place of diazepam Added that lorazepam may be used in place of diazepam –Rather than only if you cant get diazepam Lorazepam was originally added to the protocols because for a time diazepam was unavailable Lorazepam was originally added to the protocols because for a time diazepam was unavailable 38

MAGNESIUM SULFATE 5.18 added pediatric dose for treating torsade (CAT. B) added pediatric dose for treating torsade (CAT. B) –25 to 50mg/kg IV or IO Maximum dose is 2 grams 39

NITROGLYCERIN 5.21 Added that nitroglycerin is contraindicated for pediatric patients in the EMS setting Added that nitroglycerin is contraindicated for pediatric patients in the EMS setting 40

NITROUS OXIDE 5.22 Added that use of nitrous oxide is CAT. B for pediatric patients Added that use of nitrous oxide is CAT. B for pediatric patients 41

ONDANSETRON 5.24 Added new medication, ondansetron (Zofran) for treatment of vomiting Added new medication, ondansetron (Zofran) for treatment of vomiting –Ondansetron is non-sedating but has been too expensive to use in the past It is now generic and inexpensive It is now generic and inexpensive 42

SODIUM BICARBONATE 5.26 Added that for children between the ages of one month and 8 years of age the sodium bicarbonate should be diluted 50% with NS Added that for children between the ages of one month and 8 years of age the sodium bicarbonate should be diluted 50% with NS 43

THIAMINE 5.27 Added that there is almost no indication for thiamine (CAT. B) use in a child Added that there is almost no indication for thiamine (CAT. B) use in a child –Only use is for treatment of Beriberi, a disease caused by a lack of thiamine (not an emergency condition) 44

VASOPRESSIN 5.28 Added that vasopressin use is contraindicated for pediatric cardiac arrest Added that vasopressin use is contraindicated for pediatric cardiac arrest 45

SECTION 6 PROCEDURES 46

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) 6.3 Added near drowning as an indication for use of CPAP Added near drowning as an indication for use of CPAP Added a note that CPAP is not used in children under the age of 12 because of lack of complete development of their respiratory system Added a note that CPAP is not used in children under the age of 12 because of lack of complete development of their respiratory system 47

ENDOTRACHEAL INTUBATION 6.5 Added that orotracheal intubation is CAT. B for children and nasotracheal intubation is contraindicated in children Added that orotracheal intubation is CAT. B for children and nasotracheal intubation is contraindicated in children 48

SECTION 8 ADMINISTRATIVE PROTOCOLS 49

DOCUMENTATON OF CARE 8.2 Added that ePCRs must be completed and transmitted to the office of EMS & Trauma within 168 hours (one week) of the provided medical care Added that ePCRs must be completed and transmitted to the office of EMS & Trauma within 168 hours (one week) of the provided medical care 50

TRAUMA SYSTEM PROTOCOL 8.5 Changed the protocol to reflect suggestions made by the pediatric workgroup and the State Trauma Advisory Council Changed the protocol to reflect suggestions made by the pediatric workgroup and the State Trauma Advisory Council Physiologic Criteria Physiologic Criteria –Added that a BP of <90mmHg refers to an adult or a child 6 years of age or older 51

TRAUMA SYSTEM PROTOCOL 8.5 Physiologic Criteria (cont.) Physiologic Criteria (cont.) –Added that respiratory distress rates in children are: 60 in a newborn 60 in a newborn 40 in a child three years or younger 40 in a child three years or younger 29 in a child four years or older 29 in a child four years or older –Added that head trauma with any neurologic changes in a child 5 years or younger puts the child in the trauma system 52

SECTION 9 ACCEPTABLE EMS EQUIPMENT AND DEVICES 53

BOUGIE FOR DIFFICULT INTUBATIONS 9.2 Added this optional equipment to the list of acceptable equipment Added this optional equipment to the list of acceptable equipment –Bougie, Endotracheal Tube Introducer 15 French by 60-70cm for 6.0 to 11.0 ET tubes 15 French by 60-70cm for 6.0 to 11.0 ET tubes 54

BOUGIE 55

DEVICES TO PERFORM CHEST DECOMPRESSION 9.4 Added: Becton Dickinson Angiocath 14 gauge by 3.25 inches long Added: Becton Dickinson Angiocath 14 gauge by 3.25 inches long 56

HEMOSTATIC AGENTS 9.5 Added QuikClot Combat Gauze Added QuikClot Combat Gauze –Kaolin based –Currently being used by military in combat in Iraq Added WoundStat Added WoundStat –Granular combination of smectite and polymer 57

SECTION 10 FORMS 58

REQUEST TO BE TAKEN TO A HOSPITAL ON DIVERSION 10.2 Removed the patients family as being able to sign to take the patient to a hospital on diversion Removed the patients family as being able to sign to take the patient to a hospital on diversion 59

STROKE CHECKLIST 10.4 Rewrote stroke checklist to reflect the new Stroke Protocol Rewrote stroke checklist to reflect the new Stroke Protocol 60

ALERT! BEFORE USING NEW PRTOTOCOLS: EACH SERVICE MUST NOTIFY AND PROVIDE YOUR SERVICE OFF-LINE MEDICAL DIRECTOR A COPY OF THE 5 TH EDITION PROTOCOLS (June 09 edition) AND A COPY OF THIS UPDATE PRESENTATION EACH SERVICE MUST NOTIFY AND PROVIDE YOUR SERVICE OFF-LINE MEDICAL DIRECTOR A COPY OF THE 5 TH EDITION PROTOCOLS (June 09 edition) AND A COPY OF THIS UPDATE PRESENTATION –It is OK for the medical director to download the material instead EACH SERVICE MUST BE SURE THE ON-LINE MEDICAL DIRECTORS AT YOUR MEDICAL DIRECTION HOSPITALS ARE AWARE THAT THE PROTOCOLS HAVE BEEN UPDATED AND WHERE TO GET THE MATERIAL EACH SERVICE MUST BE SURE THE ON-LINE MEDICAL DIRECTORS AT YOUR MEDICAL DIRECTION HOSPITALS ARE AWARE THAT THE PROTOCOLS HAVE BEEN UPDATED AND WHERE TO GET THE MATERIAL –The service is not responsible for furnishing copies of the protocols or update slide presentation 61

NEW PROTOCOLS CAN BE USED WHEN EVERYONE IN A SERVICE HAS BEEN UPDATED WHEN EVERYONE IN A SERVICE HAS BEEN UPDATED –TURNED ON SERVICE BY SERVICE NOT INDIVIDUAL BY INDIVIDUAL –TURN IN ROSTER TO REGIONAL EMS AGENCY NOT TO OFFICE OF EMS & TRAUMA Also acknowledge that you have updated your off-line medical director and provided copy of protocols Also acknowledge that you have updated your off-line medical director and provided copy of protocols –REGIONAL EMS AGENCY WILL NOTIFY YOU WHEN YOU CAN START USING NEW PROTOCOLS –EVERY SERVICE MUST BE UPDATED BY OCTOBER 1 ST,

QUESTIONS? 63