1. Snohomish County Protocol Update July 2006 Ron Brown, MD, FACEP

2. Effective Date These protocols will go into effect September 01, 2006 If your protocols do not say “effective 09/01/06” discard them The most current copy of the protocols can always be found at http://www.snocountyems.org/emshome.html http://www.snocountyems.org/emshome.html

3. Process Thank you all for being patient The Protocol Committee was started by Dr. Cozzetto Those protocols were finished by committee and adopted in early 2005 Various changes were needed, to provide internal consistency and to stay abreast with prehospital medical care

4. Process Protocol Committee reconvened 2006 Since then we’ve been working through the entire document The new 2006 AHA guidelines came out and those were integrated immediately to be concurrent with recertification training (you all should be working off the new standard already)

5. Implementation It is required of ALL providers in Snohomish County to review the new protocols during the months of July and August This PowerPoint reviews some of the changes ALL providers must take a protocol test BEFORE September 30, 2006 Failure to pass the exam may result in inability to practice medicine in Snohomish County

6. Implementation A passing score of 80% must be achieved If less, the provider must retake the exam ALL providers must have a passing score by December 1, 2006

7. Future Updates Updates to the protocols will happen yearly unless more immediate changes are needed If the protocols are changed a copy of that Section will be sent out along with the Table of Contents and Index These sections will reflect a “revised date” in the footer A short explanation of the changes will accompany the document

8. Errors Please notify me of any errors in the protocols (including typographical) via email (rbrownmd@snocountyems.org) or through the Snohomish County EMS Office (425) 259-4172rbrownmd@snocountyems.org

9. Section 1 Introduction

10. No major changes in this section

11. Section 2 EMS System

12. Transfer of Care Responsibility and Delegation The assessment and decision for transfer of care shall be documented If an ALS provider performs an exam (at any level) and determines BLS transport is appropriate, documentation of their assessment must be completed This is not to say that if a paramedic is on scene acting in a supporting role (taking VS, etc) that they must document their presence Rather this is to ensure if an ALS assessment is performed, that assessment is clearly documented on the MIR

13. Section 3 EMS Protocols

14. No major changes

15. Section 4 Cardiac Emergencies – Adult

16. Order Most of the protocols are alphabetic by section This did not flow well in either the adult or pediatric cardiac sections The protocols have been re-ordered to make better sense

17. Cardiac Chest Pain Designation of Condition As a system we are still having cardiac chest pain patients sent in BLS While not every chest pain requires ALS transport the following line was added: Providers should recognize that there are many types of chest pain and it may be difficult to distinguish between cardiac chest pain and other forms. Caution should be given and err on the side of cardiac in origin

18. Cardiac Chest Pain BLS Providers This is not new but a reminder that EMT- Basic should give Aspirin to a patient suspected of having cardiac chest pain ALS Providers Medical Control must be contacted for use of nitro paste (only in long transport situations) Metoprolol cannot be used in inferior MI’s

19. Cardiac Arrest – Universal Algorithm This was a new protocol created with the new AHA changes If down time is less than 4 minutes then CPR should be performed only until AED is applied and ready to analyze The goal is this situation is rapid defibrillation

20. Cardiac Arrest – Universal Algorithm If down time is greater than 4 minutes 2 minutes of CPR (30:2) should be performed without interruption The goal is to perfuse the heart and attempt to rectify the acidic environment During this time ILS/ALS personnel can be establishing IV/IO access

21. Asystole Vasopressin was added to reflect current ACLS guidelines

22. PEA The algorithm was changed to highlight the causes Vasopressin was added to reflect current ACLS guidelines

23. VF/Pulseless VT Updated to reflect current ACLS guidelines

24. Bradycardia – Symptomatic Atropine dose 0.5 mg Decreased from previous

25. Anti-Emetic Use This protocol was removed Use anti-emetics in chest pain patients that are vomiting, as needed

26. Cardiac Arrest – Non- Traumatic/Medical Origin Removed

27. Cardiac Emergencies Removed

28. Section 5 Cardiac Emergencies – Pediatric

29. General These were updated to reflect new AHA standards

30. Section 6 Medical Emergencies

31. Allergic Reaction and Anaphylaxis Epinephrine drip (2-10 mcg/min) is now the preferred vasopressor in anaphylactic shock for refractory hypotension instead of Dopamine

32. Carbon Monoxide Poisoning Somehow or other oxygen therapy was being based off pulse oximetry saturation?! Obviously, pulse oximetry is ineffective during CO poisoning

33. Cerebrovascular Accident (CVA) The goal is rapid transport to a facility with a CT scanner This may be sent BLS If symptoms are less than 2 hours, emergent (Code Red) transport should be initiated ALS Providers Dextrose administration was reduced to 12.5 GM increments Clarification of EtCO2 numbers were added for intubated patients

34. Chemical/Substance Abuse Removed Addressed under psychological/behavioral section

35. Croup/Epiglottitis Epiglottitis was removed This protocol now only addresses croup

36. Fainting/Syncope Reference to fainting removed ALS providers Cardiac monitoring should be performed on all syncopal patients

37. Hyperthermia Changed to “Heat Related Illnesses”

38. Increased Intracranial Pressure Removed It was felt this issue was addressed in each individual protocol (CVA, TBI, etc) and was not required

39. Toxic Substance Exposure Removed

40. Tricyclic Antidepressant Overdose ALS Providers Indications for Sodium Bicarbonate have changed Heart rate as an indication is removed

41. Section 7 Obstetric & Gynecologic Emergencies

42. General This section has been re-organized to achieve better flow

43. Neonatal Resuscitation Do not stop delivery to suction the baby in the perineum if meconium stained Instead deliver the entire baby and then suction for meconium

44. Vaginal Hemorrhage – Post Delivery One dose and indication for Oxytocin (20 units/1000 ml wide open) Don’t forget fundal massage

45. Spontaneous Rupture of Membranes Removed

46. Section 8 Psychological/Behavioral

47. General Revised this entire section Please review entire section thoroughly

48. General Main issues addressed: Use of restraints-verbal, physical, chemical Evaluating patients to screen for “excited delerium” or Sudden Unexpected Death Syndrome while in Law Enforcement custody

49. Section 9 Trauma

50. Trauma (Blunt and Penetrating) Removed and replaced with a Shock protocol

51. Spinal Motion Restriction Simplified ALL EMS providers are now able to NOT backboard patients under certain conditions Old protocols allowed only ALS providers to do this This is an important protocol Please review thoroughly!

52. Spinal Motion Restriction The concept is that as long as the patient is c/a/o without distracting injuries or significant MOI they do not have to be backboarded When evaluating the next for pain remember it is only POSTERIOR C- SPINE pain that counts

53. Spinal Motion Restriction Lateral neck pain (not directly over the c- spine) does not warrant LSB use SMR is not a benign procedure I will inform the local hospitals so you are not questioned by the ED staff for not having a patient backboarded with lateral neck pain (make sure you document your assessment well)

54. Trauma Triage Criteria Replaced this protocol with Trauma Team Activation Criteria Please review

55. Section 10 Communication & Notification Issues

56. General Keep reports brief When to speak to a physician Giving report in special situations Requesting medical control

57. Section 11 Appendix A – Procedures

58. General This section was significantly revamped Please review entire section closely Main emphasis on Low Frequency-High Risk procedures Indications Contraindications

59. Airway Management New protocols Includes Recognizing approved management tools, from All Provider maneuvers to advanced ALS interventions Protocol on Drug-Assisted Intubation (DAI) Sedation only Rapid Sequence Intubation

60. Airway Management Includes Difficult Airway Algorithm Failed Airway Algorithm Note ALS Providers should avoid transporting a patient with a failed airway using BVM ventilation, particularly after failed DAI

61. Assisting with Medications Removed Felt this was standard information and did not need to be included

62. AED Updated to reflect new AHA changes

63. Cardioversion Removed It was felt this is common knowledge (standard ACLS)

64. Central Venous Catheter Added to clarify options available to ALS providers Accessing preexisting catheter Placing a new central line

65. CPAP Condensed some information Note indications and contraindications

66. Cricothyrotomy The vertical skin incision is the only approved method for this procedure

67. Intraosseous Access This is a new skill in Snohomish County There have been some concerns raised by physicians about their use (started on patients that had peripheral access, or did not have a need for life-saving IVF/meds) Clarifies when IO access may be considered First line in cardiac arrest only Otherwise all other patients should have peripheral access attempted first

68. Intraosseous Access If you think of placing a central line, you can think of placing an intraosseous line

69. Thoracostomy New protocol, old procedure (chest decompression) Outlines procedure Note approach

70. Post Intubation Sedation… This protocol was removed, felt to be redundant

71. RSI Incorporated into Airway Protocol

72. Transthoracic Pacing Felt to be a basic ACLS skill and not required in the protocols

73. Section 12 Special Situations

74. Blood Draws Still up to each service I do not believe EMS should be drawing blood Legal Blood draws by EMS in the field are NOT currently allowed per protocol I addressed this with Law Enforcement countywide in 2005

75. Inter-Facility Transport Patient should be stabilized by sending facility prior to transport EMS crews may refuse to transport the patient if they believe the patient has not been adequately stabilized

76. Non-Transport and Refusals These two protocols were revised and combined Please review this protocol carefully! Not all Non-transports are refusals EMS-initiated no-transports have much higher liability Good documentation in necessary Each agency should maintain a release form

77. Relationship Between ALS Team and Private Physician Addressed elsewhere Removed

78. Trauma Triage Tool Washington State DOH Document Note the thrust of this document is to get the patient to the highest level trauma Center possible within thirty minutes transport time This will occasionally mean ground transport to Snohomish County hospitals

79. Section 13 Forms

80. General This section completely removed

81. Section 14 Paramedic Drug Supplement

82. Required Drugs Removed: Bretylium, Oxytocin, Procainamide from Required Drugs Added Etomidate and Oxygen to Required Drugs Removed all Required (Optional Substitutions) other than benzodiazepines

83. Allowed Drugs Changed “Alcaine” to “Topical Ophthalmic Drops (Proparacaine)” Removed Mannitol and Etomidate from Allowed Drugs. Mannitol is gone. Added Oxytocin, Procainamide, Ipratroprium Bromide, Metropolol, Terbutaline, and Fentanyl to the Allowed Drugs. Made Dexamethasone and Metaclopramide an optional substitution for Allowed Drugs.

84. Fentanyl Dose increased to 0.3 mg/kg dose Both pediatric and adult dose are the same

85. Protocols That outlines some of the main changes in the new versions This does not relieve you from reading the entire protocols The tests will reflect your level of care Paramedics may also have questions from the Drug Supplement Section (doses, indications, contraindications, etc)

86. Prehospital Care Thank you for your dedication to caring for the sick and injured in Snohomish County Continue to strive to educate yourselves and learn

87. Snohomish County EMS Thanks!