1. Presentation Prepared By James L. Dean, AEMT-P and Sean J. Britton, NREMT-P Benjamin J. Krakauer, MPA, NREMT-P

2. SREMS ALS Protocol Update Questions arising from the application of the protocols should be addressed to your medical control physician, Agency Medical Director, or to the Susquehanna Regional Medical Emergency Advisory Committee (SREMS REMAC).

3. Definitions “Infant” is considered up to 1 year of age. “Child” is considered 1 year of age to the onset of puberty (12-14 year old). “Adult” is considered the age of puberty (12-14 years old) and upwards.

7. Prepare for success: Identify if the patient will be a difficult intubation. Position the patient. Have suction turned on and well within reach. Ensure your IV access is patent. Have a King airway ready. Practice intubation on a manikin regularly to maintain competency.

8. Versed (Midazolam) Class: short acting benzodiazepine, CNS depressant Description: benzodiazepine frequently used for conscious sedation Mechanism of action: suppresses the spread of electrical activity through the cortex of the brain. Reduces anxiety/stress and induces amnesia. Administration: Adult – 2.5mg slow IV Indications: premedication for intubation, maintenance of sedation Contraindications: Hypersensitivity Hypotension Glaucoma Respiratory depression Side Effects: Respiratory depression Nausea/vomiting Headache Blurred vision Cough Hypotension Precautions/Interactions: sedative effect increases with concomitant use of barbiturates, alcohol, and narcotics

9. Recordable Waveform Capnography Verify placement on all adult and pediatric patients with direct visualization, auscultation, and waveform capnography. Waveform Capnography is considered to be the “Gold Standard” method of verifying ETT placement.

10. Definitive Confirmation & Continuous Monitoring – Continuous End Tidal CO2 waveform capnography monitoring. The capnography device must have the ability to print and/or store the data of the continuous waveform monitoring documentation as well as QA/QI purposes. The ability to print the data should be accomplished at the hospital when ever possible. – Print a copy of the strip from the LP12 and scan this into your e-pcr for documented proof.

11. This protocol has been changed to allow Ondansetron (Zofran) to be administered IV or IM This was a change from IV only.

14. Altered Mental Status causes: Alcohol Epilepsy Insulin Overdose Uremia Trauma Infection Psychoses Stroke: There has been a separate Stroke Protocol added.

15. Remember to ascertain time of onset of symptoms. Consider air transport based on location and time of onset.

16. Albuterol Sulfate 0.083%, 2.5 mg in 3ml mixed with Ipratropium 0.5mg (one unit dose) via nebulizer at a flow rate of 6 LPM. (EMT-CC/EMT-P) may repeat x1 IV Epinephrine 1:10,000 dose is now 1mg.

21. Albuterol Sulfate0.083%, 2.5 mg in 3ml mixed with Ipratropium 0.5mg(one unit dose) via nebulizer at a flow rate of 6 LPM O2 (EMT-CC/EMT-P) first nebulizer treatment.

22. Albuterol Sulfate 0.083%, 2.5 mg in 3ml mixed with Ipratropium 0.5mg (one unit dose) via nebulizer at a flow rate of 6 LPM O2 for first nebulizer treatment. Medical Control Options. Nitro Paste has been added as a Med Control option for CHF.

23. Atrovent (Ipratropium) Class: Bronchodilator Description: Anticholinergic used in the treatment of asthma/COPD Mechanism of action: Antagonizes acetylcholine receptor producing bronchodilatation Administration: Administer via nebulization along with Albuterol Indications: Treatment of bronchospasm from asthma, anaphylaxis, or COPD Contraindications: Hypersensitivity Acute glaucoma Caution if prostatic hypertrophy Side Effects: Glaucoma Tachycardia Dizziness Headache Dry mouth Precautions/Interactions: caution with bladder obstruction

29. MORPHINE is a standing order for Pain Management due to Burns: Morphine Sulfate IV/IM 5mg may repeat to a max of 10mg Med Control Signature REQUIRED!!!

30. MORPHINE is a standing order for Pain Management due to Fractures/Dislocations Morphine Sulfate IV/IM 5mg may repeat to a max of 10mg Med Control Signature REQUIRED!!! Toradol has been REMOVED!!!

31. Spinal shock causes hypotension which may require a large amount of fluid infusion.

32. The dose of Lidocaine prior to intubation with signs of increased ICP is: 1 – 1.5 mg/kg with a Maximum of 100mg.

39. 100 ml over 10 minutes = 10 gtts/sec with 60 gtts/ml set.

49. 12 Lead ECG is now a separate protocol!!

65. Albuterol Sulfate 0.083%, 2.5 mg in 3ml mixed with Ipratropium 0.5mg (one unit dose) via nebulizer at a flow rate of 6 LPM O2 EMT-CCT, EMT-P

66. Diazepam dose is per Broselow Tape recommendation Medical Control signature is REQUIRED