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

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

3. 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

4. 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

5. Naloxone Utilization

6. 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 (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 to 2012 (16.5% increase from 2006)
1,800 opioid-related deaths in California in 2012 alone (72% involved prescription pain medications)

7. 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

8. 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 – 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

9. 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

10. 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%)

11. 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

12. 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

13. 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

14. 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

15. 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

16. Prehospital Pain Management

17. 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

18. 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 May;23(2):415-31
2 Prehospital Emergency Care Jan-Mar;9(1)32-9

19. 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.”

20. 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

21. 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

22. 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

23. 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)

24. 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

25. 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)

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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)

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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)

39. 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.)

40. 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

41. Trauma Triage Criteria

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

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

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