1. Buncombe/Madison/Yancey EMS System 2012 Protocol Changes Keith Owens, Ned Fowler, Jamie Judd, Stace Horine, DO April 2013

2. NCCEP now allows agencies to modify protocols to reflect local practice – Medications listed in protocols match those in our local Drug List – Local agencies now have greater ownership of protocols Changes in Table of Content – 13 Categories compared to 4 previous categories – Each category has specific color around the border New appearance of each protocol - Protocol is on one page, Pearls are located on second page including local comments in purple section Buncombe/Madison/Yancey EMS 2012 Protocol Changes

3. Previous “Legend” block has been removed – Color coding has changed per level White with no lettering – Medical Responder White with “B” – EMT-Basic Yellow with “I” – Intermediate Blue with “P” – Paramedic Buncombe/Madison/Yancey EMS 2012 Protocol Changes

4. Hexagon illustrates Assessment or Decision points Terminator Oval exits to another protocol Information Boxes Procedures / Actions

5. GENERAL SECTION – Black Border – Protocol #1: Universal Patient Care No significant changes ADULT GENERAL SECTION – Light Green – Protocol #3: Adult, Failed Airway Ventilatory rate 8-10 breaths/minute Addition of Gum Elastic Bougie (refer to procedure #7) – Protocol #4: Rapid Sequence Intubation (name change) New medications – Ketamine, Rocuronium, Fentanyl Buncombe/Madison/Yancey EMS 2012 Protocol Changes

6. ADULT GENERAL SECTION – Light Green – Protocol #6: Behavioral Excited Delirium Syndrome with treatment guidelines – Protocol #7: Pain Control, Adult New medication – Fentanyl – Protocol #8: Scene Rehabilitation (New Protocol) New Protocol to be utilized when ALS transport agencies establish a formal rehab section Follows NFPA recommendations Buncombe/Madison/Yancey EMS 2012 Protocol Changes

7. ADULT CARDIAC SECTION – Dark Blue – Protocol #13: Cardiac Arrest, Adult Emphasis on continuous CPR compressions Breathing / Airway management after 2 nd shock and/or 2 rounds of compressions Do not interrupt compressions to place endotracheal tube, consider BIAD first to limit interruptions – Protocol #11: Adult Asystole / PEA Previous separate protocols Atropine has been removed TCP removed unless advised by Medical Control Buncombe/Madison/Yancey EMS 2012 Protocol Changes

8. ADULT CARDIAC SECTION – Dark Blue – Protocol #14: Chest Pain, Cardiac and STEMI Scene time ≤ 10 minutes New Medications – NTG SL with BP > 100, NTG Paste with guidelines, Fentanyl Normal Saline Bolus – Maximum 2 liters If N&V presents, continue utilizing anti-emetics (protocol #35) – Protocol #15: CHF / Pulmonary Edema New Medications – NTG SL with BP > 100, NTG Paste with guidelines, Dopamine in Cardiogenic Shock Consider Furosemide with transport time > 30 minutes

9. Buncombe/Madison/Yancey EMS 2012 Protocol Changes ADULT CARDIAC SECTION – Dark Blue – Protocol #16: Adult Tachycardia, Narrow Complex Note extensive Pearls list – Protocol #17: Adult Tachycardia, Wide Complex Three options for stable patients New Medications – Adenosine, Mag. Sulfate Note extensive Pearls list – Protocol #18: Vent. Fib / Pulseless Vent. Tach Amiodarone -vs- Lidocaine

10. Buncombe/Madison/Yancey EMS 2012 Protocol Changes ADULT CARDIAC SECTION – Dark Blue – Protocol #19: Post Resuscitation Consider Sedation / Paralysis with definitive airway in place – Protocol #20: Induced Hypothermia New Medications – Etomidate, Fentanyl New Target Temp. – 91.4F (33C) – Protocol #21: Team Focused CPR (New Protocol) To be implemented as agencies complete training

11. Buncombe/Madison/Yancey EMS 2012 Protocol Changes ADULT MEDICAL SECTION – Light Blue – Protocol #23: Abdominal Pain New formatting, treatment guidelines similar – Protocol #24: Allergic Reaction Three new categories (Mild, Moderate & Severe) (Intermediate Level) Epi 1:1000 IM dosage may be repeated in 5 minutes without contacting MC – Protocol #25: Altered Mental Status Assessment leads to specific protocols for treatment

12. Buncombe/Madison/Yancey EMS 2012 Protocol Changes ADULT MEDICAL SECTION – Light Blue – Protocol #26: Adult COPD / Asthma Title change from previous “Respiratory Distress “ New Medication – Magnesium Sulfate – Protocol #27: Diabetic; Adult New Protocol from previous “Altered Mental Status” Normal Saline Bolus – Maximum 2 liters Additional information in Pearls – Protocol #28: Dialysis / Renal Failure New Protocol Normal Saline Bolus – Maximum “1” liter

13. Buncombe/Madison/Yancey EMS 2012 Protocol Changes ADULT MEDICAL SECTION – Light Blue – Protocol #29: Hypertension Systolic BP 220 or greater Diastolic BP 120 or greater New Medication – Labetalol after contacting MC Assessment leads to specific protocols for treatment – Protocol #30: Hypotension / Shock Four New Categories (Hypovolemic, Cardiogenic, Distributive & Obstructive) Complex to read

14. Buncombe/Madison/Yancey EMS 2012 Protocol Changes ADULT MEDICAL SECTION – Light Blue – Protocol #31: Overdose / Toxic Ingestion Five New Categories (Beta Blocker / Ca Channel Blocker, Tricyclic Antidepressant, Organophosphate & Cyanide / Carbon Monoxide OD) New Medications - Glucagon, Calcium Chloride & Dopamine New Acronym – D.U.M.B.B.E.L.S – Protocol #32: Seizure New Medication – Magnesium Sulfate

15. Buncombe/Madison/Yancey EMS 2012 Protocol Changes ADULT MEDICAL SECTION – Light Blue – Protocol #33: Suspected Stroke New Medication – Labetalol after contacting MC – Todd’s Paralysis – Protocol #34: Syncope Assessment leads to specific protocols for treatment – Protocol #35: Vomiting and Diarrhea Assessment leads to specific protocols for treatment

16. Buncombe/Madison/Yancey EMS 2012 Protocol Changes ADULT OBSTETRICAL SECTION – Purple – Protocol #37: Childbirth / Labor Two New Categories (Prolapsed Cord / Shoulder Dystocia & Breech Birth) New Information Box (Unable to Deliver) – Protocol #38: Newly Born New formatting, treatment guidelines similar Normal Saline Bolus – 10ml/kg, may repeat x 1 Additional information in Pearls – Protocol #39: Obstetrical Emergency New formatting, treatment guidelines similar Additional information in Pearls

17. Buncombe/Madison/Yancey EMS 2012 Protocol Changes ADULT TRAUMA and BURN SECTION – Red – Protocol #40: Adult Thermal Burn Refers to New Carbon Monoxide / Cyanide Protocol Additional Information in Pearls – Protocol #41: Head Trauma New Information Boxes (Do Not Hyperventilate), (Brain Herniation) – Protocol #42: Multiple Trauma New formatting, treatment guidelines similar

18. Buncombe/Madison/Yancey EMS 2012 Protocol Changes PEDIATRIC GENERAL SECTION – Olive Green – Protocol #44: Pediatric Airway New Procedure (Chest Decompression) – Protocol #45: Pediatric Failed Airway SP02 saturation ≥ 90% – Protocol #46: Pediatric Pain Control New Medication – Ketorolac & Fentanyl

19. Buncombe/Madison/Yancey EMS 2012 Protocol Changes PEDIATRIC CARDIAC SECTION – Dark Blue – Protocol #48: Pediatric Asystole / PEA New Protocol – Protocol #49: Pediatric Bradycardia New formatting, treatment guidelines similar – Protocol #50: Pediatric Pulmonary Edema / CHF New Protocol – Protocol #51: Pediatric Pulseless Arrest Assessment leads to specific protocols for treatment

20. Buncombe/Madison/Yancey EMS 2012 Protocol Changes PEDIATRIC CARDIAC SECTION – Dark Blue – Protocol #52: Pediatric Tachycardia New Protocol – Protocol #53: Pediatric VF / Pulseless VT New Protocol – Protocol #54: Pediatric Post Resuscitation New Protocol

21. Buncombe/Madison/Yancey EMS 2012 Protocol Changes PEDIATRIC MEDICAL SECTION – Light Blue – Protocol #56: Pediatric Allergic Reaction New Protocol – Protocol #57: Pediatric Altered Mental Status New Protocol – Protocol #58: Pediatric Diabetic New Protocol – Protocol #59: Pediatric Hypotension / Shock Four New Categories (Hypovolemic, Cardiogenic, Distributive & Obstructive)

22. Buncombe/Madison/Yancey EMS 2012 Protocol Changes PEDIATRIC MEDICAL SECTION – Light Blue – Protocol #60: Pediatric Overdose / Toxic Ingestion New Protocol – Protocol #61: Pediatric Respiratory Distress EMT-I’s, Epi 1:1000 IM administered prior to contacting MC – Protocol #62: Pediatric Seizure Lorazepam preferred first-line medication Refer to Protocol #72 Fever/Infection Control

23. Buncombe/Madison/Yancey EMS 2012 Protocol Changes PEDIATRIC MEDICAL SECTION – Light Blue – Protocol #63: Pediatric Vomiting / Diarrhea New Protocol PEDIATRIC TRAUMA and BURN SECTION – Brown – Protocol #65: Pediatric Head Trauma Assessment leads to specific protocols for treatment Additional information in Pearls – Protocol #66: Pediatric Multiple Trauma New formatting, treatment guidelines similar Additional information in Pearls

24. Buncombe/Madison/Yancey EMS 2012 Protocol Changes PEDIATRIC TRAUMA and BURN SECTION – Brown – Protocol #67: Pediatric Thermal Burn New Protocol ADULT / PEDIATRIC GENERAL SECTION – Green – Protocol #69: Triage New Protocol – Protocol #70: Dental Problems New formatting, treatment guidelines similar – Protocol #71: Epistaxis Ice Packs no longer recommended

25. Buncombe/Madison/Yancey EMS 2012 Protocol Changes ADULT / PEDIATRIC GENERAL SECTION – Green – Protocol #72: Fever / Infection Control New formatting, treatment guidelines similar – Protocol #73: Police Custody No Change – Protocol #74: Emergencies Involving Indwelling Central Lines New Protocol

26. Buncombe/Madison/Yancey EMS 2012 Protocol Changes ADULT / PEDIATRIC GENERAL SECTION – Green – Protocol #75: Respiratory Distress With a Tracheostomy Tube New Protocol Refer to Procedure #18, Tracheostomy Tube Change – Protocol #76: Emergencies Involving Ventilators New Protocol Refer to Procedure #19, Ventilator Operation

27. Buncombe/Madison/Yancey EMS 2012 Protocol Changes ADULT / PEDIATRIC ENVIRONMEMTAL SECTION – Salmon – Protocol # 78: Bites and Envenomations Assessment leads to other protocols for some treatment Three new categories (Spider/Bee, Snake, Dog/Cat/Human) New medication Midazolam for Spider/Bee – Protocol # 79: Carbon Monoxide/Cyanide New Protocol New Medication – Hydroxocobalamin (CyanoKit)

28. Buncombe/Madison/Yancey EMS 2012 Protocol Changes ADULT / PEDIATRIC ENVIRONMEMTAL SECTION – Salmon – Protocol # 80: Drowning / Submersion Injury Three new categories (Awake/Alert, Awake/AMS, Unresponsive) – Protocol # 81: Hyperthermia Three new categories (Heat Cramps, Heat Stroke, Heat Exhaustion) Note description of cooling measures on page 2 – Protocol # 82: Hypothermia / Frostbite Three new categories (Localized Cold Injury, Awake, Unresponsive) Note description of warming measures on page 2 Note CPR guidelines in PEARLS (<86 degrees F/30 degrees C)

29. Buncombe/Madison/Yancey EMS 2012 Protocol Changes ADULT / PEDIATRIC ENVIRONMEMTAL SECTION – Salmon – Protocol # 83: Marine Envenomations / Injury New Protocol Calcium Chloride – Protocol # 84: WMD Nerve Agent Three new categories (Asymptomatic, Minor, Major) Pralidoxime now prior to contact with Medical Control

30. Buncombe/Madison/Yancey EMS 2012 Protocol Changes ADULT / PEDIATRIC TRAUMA and BURN – Red – Protocol # 86: Blast Injury / Incident New Protocol – Protocol # 87: Chemical and Electrical Burn Three categories (Minor, Serious, Critical) New formatting, treatment guidelines similar – Protocol # 88: Crush Syndrome New Protocol

31. Buncombe/Madison/Yancey EMS 2012 Protocol Changes ADULT / PEDIATRIC TRAUMA and BURN – Red – Protocol # 89: Extremity Trauma New formatting, treatment guidelines similar New box for open fracture with exposed bone – Protocol # 90: Selective Spinal Immobilization New title: Former Protocol 12 – Spinal Immobilization Clearance – Protocol # 91 Radiation Incident New Protocol Extensive information

32. Buncombe/Madison/Yancey EMS 2012 Protocol Changes Drug List – Atropine No longer indicated in Asystole – Calcium Chloride New protocols: Dialysis/Renal Failure, Marine Envenomation, Crush Injury – Dextrose 10% Now only in Peds Diabetic protocol (still indicated CBG <60) – Dextrose 50% Now only in Adult Diabetic protocol (still indicated CBG <60)

33. Buncombe/Madison/Yancey EMS 2012 Protocol Changes Drug List – Diltiazem (Cardizem) New Adult dosing guidelines 20 mg IV/IO over 2 min, repeat 25 mg in 15 min if needed If age ≥ 60 reduce dosage according to protocol – Diphenhydramine (Benadryl) New Adult dosing guidelines 25 – 50 mg IV/IO/IM/PO – Epi 1:1000 Now IM route only – Epi 1:10,000 Maximum Pediatric dose now 1 mg – Fentanyl (Sublimaze)– New Medication Narcotic analgesic, with vasodilatation Avoid in BP < 110 50-75 mcg IM/IV/IO Adult, repeat 25 mcg every 20 min, Max 200 mcg 1 mcg/kg IM/IV/IO Peds, repeat 0.5 mcg/kg every 5 min, Max 2 mcg/kg

34. Buncombe/Madison/Yancey EMS 2012 Protocol Changes Drug List – Furosemide (Lasix) New Adult dose 40 mg IV or equal to patient normal PO dose – Glucagon Now in fewer protocols (still indicated CBG <60) – Hydroxocobalamin (CyanoKit) – New Medication 70 mg/kg IV/IO – Requires reconstitution – Max 5 grams – Ketamine (Ketalar) – New Medication Sedative in RSI if Etomidate not available 1.5 mg/kg IV/IO Do not use if suspected coronary ischemia

35. Buncombe/Madison/Yancey EMS 2012 Protocol Changes Drug List – Ketorolac (Toradol) Adult Dose 30 mg IV/IO, 60 mg IM Peds dose 0.5 mg/kg IV/IO/IM, Max 30 mg – Labetalol (Normodyne) – New Medication Persistent Symptomatic High BP (<220 systolic or 120 diastolic) Requires online order from Med Control 10 mg IV/IO – Lorazepam (Ativan) New adult dose 1 -2 mg IV/IM, May repeat every 5 min until seizure controlled – Magnesium Sulfate New adult dosing guideline spelling out how fast to push Over 10 min in Resp Distress, Over 2 – 3 min in OB Seizures

36. Buncombe/Madison/Yancey EMS 2012 Protocol Changes Drug List – Midazolam (Versed) Usual Adult Dose 2.5 – 5 mg IV/IO/IM (Max single dose 5 mg) May repeat as needed (No total maximum dose in Adult) Usual Peds Total Dose 0.1 - 0.2 mg/kg IV/IO/IM – Normal Saline Adult Fluid Bolus 500 mL, may repeat up to 2 Liters per individual protocol Peds Fluid Bolus 20mL/Kg, may repeat up to 60 mL/kg (except Cardiogenic Shock) Infant <28 days Fluid Bolus 10 mL/kg, may repeat X1 – Nitroglycerin No longer used in Hypertensive Crisis Paste dosing guideline – BP >100 = 1 Inch – BP >150 = 1.5 inches – BP >200 = 2 inches

37. Buncombe/Madison/Yancey EMS 2012 Protocol Changes Drug List – Odansetron (Zofran) Added IO, PO and ODT (Oral Dissolving Tablet) routes – Pralidoxime (2-Pam) Adult dosing increases with major symptoms from 600 mg to 1800 mg over 30 minutes – Promethazine (Phenergan) Adult Dose 12.5 mg, May repeat X1, ≥ 60 yoa give ½ dose – Rocuronium – New medication Used in RSI when Succinylcholine is not available Onset longer than Succinylcholine – up to 3 minutes Patient will not defasciculate 1 mg/kg IV/IO

38. Buncombe/Madison/Yancey EMS 2012 Protocol Changes Drug List – Sodium Bicarbonate Repeat dose requires order from Medical Control – Succinylcholine No Adult IM dose – Vecuronium Now included in Post Resuscitation and Induced Hypothermia protocols

39. Buncombe/Madison/Yancey EMS 2012 Protocol Changes Procedures – New Procedures ET Tube Introducer – Procedure 7

40. Buncombe/Madison/Yancey EMS 2012 Protocol Changes Procedures – Modified Procedures Procedure 1 – 12 Lead ECG – Label ECG and provide hospital with patient full name and DOB Procedure 5 – Airway CPAP – Modified from 2009 Procedure 6 – Airway Cricothyrotomy - Surgical – Clarified incision technique – 1” vertical through skin, ½” horizontal through Cric membrane Procedure 12 – Nasotracheal Intubation – No longer included in system protocol

41. Buncombe/Madison/Yancey EMS 2012 Protocol Changes Procedures – Modified Procedures Procedure 28 - CPR – Follows current AHA guidelines Procedure 29 – Cardioversion – Note energy settings based on individual protocol Procedure 30 – Chest Decompression – Note catheter sizes for Adult and Pediatric (<12 yoa) Procedure 35 and 36 – Defibrillation – Emphasis on minimal interruption of chest compressions – Note energy settings for Manual Defibrillation

42. Buncombe/Madison/Yancey EMS 2012 Protocol Changes Procedures – Modified Procedures Procedure 37 – Gastric Tube Insertion – No longer included in system protocol Procedure 46 – Temperature Measurement – Format change only, procedure similar Procedure 50 – Venous Access: Existing Catheter – Do not attempt to access hemodialysis catheters (Perma Cath) – Added verbiage regarding use of non-coring needle for implanted ports Procedure 54 – Venous Access: Intraosseous – Procedure re-written to reflect EZ-IO and Manual IO devices

43. Buncombe/Madison/Yancey EMS 2012 Protocol Changes Procedures – Modified Procedures Procedure 55 Venous Access: Swan-Ganz Catheter Maintenance – No longer included in system protocol

44. Buncombe/Madison/Yancey EMS 2012 Protocol Changes Policies – New Policies Policy 21 – Rapid Sequence Intubation – New policy mandated by state – Requires Waveform Capnography and Pulse Oximetry – Establishes mandatory Airway Evaluation Form procedures Ventricular Assist Devices Policy 31 – Provides guidance for assessment and treatment of patients with VAD

45. Buncombe/Madison/Yancey EMS 2012 Protocol Changes Policies – Modified Policies Policy 1 – Air Transport – Added estimated weight to minimal information to provide Policy 6 – Discontinuation of Prehospital Resuscitation – Policy modified to reflect current practice Policy 7 – Disposition (Patient Instructions) – Added two items clarifying patient refusal practices Policy 12 – EMS Back In Service Time – Within 30 minutes (Previously 45 minutes) 90% of time Policy 13 – EMS Dispatch Center Time – Less than 90 seconds (Previously 120 seconds) 90% of time

46. Buncombe/Madison/Yancey EMS 2012 Protocol Changes Policies – Modified Policies Policy 14 – Wheels Rolling (Turn-out) Time – Less than 90 seconds (Previously 3 minutes) 90% of time Policy 22 – Care on Minors – Renumbered (Previously Policy 21) Policy 23 – Communications (Previously Policy 22) – Significant Revision Policy 24 – Conditions For Direction – Renumbered (Previously Policy 23)

47. Buncombe/Madison/Yancey EMS 2012 Protocol Changes Interfacility Transport Medications – No change Appendices – Age reference Clarifies age guidelines for procedures – Approved Medical Abbreviations Modified to remove non approved abbreviations