1. 2009-2010 Protocol Rollout

2. Protocols 2010 Edition 1.Philosophy 2.Expectations 3.Format 4.Adult Reference Pages 5.Adult Cardiac 6.Adult General 7.Pediatric Reference

3. Protocols 2010 Edition 8.Pediatric Cardiac 9.Pediatric General 10.Appendices

4. Philosophy Goals –To establish minimum expectations for appropriate patient care –To relieve pain and suffering, improve patient outcomes and do no harm –To ensure a structure of accountability for operational medical directors, facilities, agencies and providers

5. Philosophy Protocols are derived from a variety of sources Final decision rests with the OMD committee –“In situations where an approved medical protocol conflicts with other recognized care standards, the medical provider shall adhere to the Tidewater EMS Regional Medical Protocol.”

6. Philosophy Protocols are designed to be used in conjunction with each other- it is acceptable to use more than one protocol at a time.

7. Expectations Providers will maintain a working knowledge of the protocols Each patient should have a thorough assessment performed BLS providers should request ALS assistance if any deficiencies are found on the initial assessment

8. Expectations ALS providers may request additional ALS assistance for critical patients Make early contact with receiving facilities –If providers are truly unable to make contact, they are permitted to perform LIFE SAVING PROCEDURES as standing orders DO NOT EXCEED SCOPE OF PRACTICE NOTIFY AGENCY AND TEMS

9. Format Flowcharts were getting too wordy and too hard to see in pocket guides Split each protocol into two –Flowchart –Information page Added a Warnings and Alerts section –The important stuff that will get you into trouble

10. List of Changes

11. Reference Pages Burn Chart Dopamine drip chart Magnesium sulfate drip chart Epinephrine drip chart Glascow Coma Scale Adult Trauma Transport Criteria Wong-Baker FACES pain rating scale

12. Airway / Oxygenation/ Ventilation Enhanced providers may still use laryngoscope and Magill forceps to relieve airway obstruction Indications for plural decompression (serious signs/symptoms of tension pneumothorax) –Respiratory distress with cyanosis –Loss of radial pulse (hypotension) –Decreased level of conciousness

13. Airway / Oxygenation/ Ventilation In the 2010 edition of the protocols, EMT- Intermediate will have standing orders for: –Plueral decompression –Nasal intubation –Post-intubation sedation

14. Adult Cardiac Protocols No major Changes Consistent with ACLS Information added about cardiac arrest in dialysis patients –More detailed information in Dialysis/Renal Failure protocol

15. Adult Cardiac Protocols 1.Adult Emergency Cardiac Care 2.Adult Asytole and Pulseless Electrical Activity 3.Adult Bradycardia 4.Adult Tachycardia – Narrow Complex 5.Adult Tachycardia – Wide Complex

16. Adult Cardiac Protocols 6.Adult Ventricular Fibrillation and Pulseless Ventricular Tachycardia 7.ROSC (Return of Spontaneous Circulation) –Name changed from post resuscitation –Moving to the adult cardiac section 8.Termination of Resuscitation

17. Termination of Resuscitation Reworded to clarify –Allows EMS providers to stop resuscitation in cases where CPR started inappropriately Once any ALS procedure is initiated, provider must contact medical control for an order to cease resuscitation efforts

18. Allergic/Anaphylactic Reaction In the 2010 edition, EMT-Intermediate may administer Solu-medrol on standing orders if patient is hemodynamically unstable or in respiratory distress Epinephrine will be given IM instead of SQ with maximum dose of 0.5mg Physician may order IV 1:10,000 epinephrine in severe cases

19. Altered Mental Status Need to assess patient to determine cause of altered mental status No more “coma cocktail”

20. Behavioral Emergencies No Major Changes

21. Bites and Stings No major changes

22. Breathing Difficulty Added Nitroglycerin Paste ONLY when using CPAP –Providers will apply one inch of paste to patient’s chest and cover with occlusive dressing –WEAR GLOVES when handling paste –Paste onset: at least 30 minutes so SL NTG should be given every 3-5 minutes

23. Burns Morphine dose changed to 2 mg –Waiting 5 minutes between doses removed Allows EMT-Intermediate and EMT- Paramedic to give up to 10 mg morphine on standing orders Can call medical control for more if needed

24. Cerebral Vascular Accident Minor changes to implement the hyper/hypoglycemia protocol if the blood sugar is 500 mg/dL

25. Chemical Exposure New name for the poisoning protocol Simplified from 6 pages into 1 page Focuses on chemical exposures that can be treated by EMS providers If it cannot be treated by EMS providers, decontaminate and transport while providing supportive care

26. Chest Pain/AMI Nitroglycerin paste added –Only if pain persists after 3 SL NTG and morphine

27. Combative Patient Added Ativan –Should be given with Haldol In the 2010 edition EMT-Paramedics have standing orders for Haldol and Ativan In the 2010 edition EMT-Intermediates and EMT-Paramedics may administer Benadryl on standing orders for dystonic reactions

28. Dialysis/Renal Failure New protocol EMT-Intermediates and EMT-Paramedics have standing orders for calcium chloride and sodium bicarbonate for dialysis patients in cardiac arrest –Physician order if not in arrest –ALWAYS FLUSH thoroughly (40ml) between calcium and sodium to prevent precipitation

29. Dialysis/Renal Failure Also includes instructions for bleeding shunt/fistula –Firm fingertip pressure (may have to hold for 20+ minutes) –Pressure bandages do not work –Tourniquet above fistula site if life threatening bleed

30. Commercially Available Tourniquets

31. Drowning/Near Drowning ALL patients involved in a submersion incident should be encouraged to accept transport- they are at high risk for secondary drowning (development of life- threatening pulmonary edema) NG/OG tubes are not appropriate for non- intubated patients

32. Electrical/Lightning Injuries Not all lightning strike victims need to be transported to a Trauma Center

33. Extraordinary Measures Not just for trauma anymore! No other major changes

34. Hyper/Hypoglycemia New protocol Emphasizes patient must be conscious and able to swallow to receive oral glucose Thiamine ONLY if patient is known alcoholic or malnourished 250 ml NS bolus for hyperglycemic patients- may repeat up to 1000 ml total

35. Hypothermia No major changes

36. Nausea/Vomiting New protocol Zofran replacing Phenergan in the drug box –Dose is 4 mg slow IV push –EMT-Intermediates and EMT-Paramedics have standing orders –Should not be given with Amiodorone or Haldol

37. OB/GYN Pregnancy/Vaginal Bleeding Renamed since not all vaginal bleeding is related to pregnancy Added transport guidelines for high-risk maternity patients –Not new- has been a part of appendix H for multiple years –May not apply to the rural agencies

38. OB/GYN Pregnancy/(Pre-) Eclampsia Eclampsia may occur post delivery The order in which medications are given has changed –Ativan given first to stop current seizure –Magnesium Sulfate given to prevent further seizures

39. Pain Management / Non-Cardiac Morphine dose changed to 2 mg –Removed the 5 minute wait time between doses May implement Nausea/Vomiting protocol as needed

40. RSI This is an agency specific protocol

41. Rehabilitation Clarification of mixing sports drinks –Single serve taken at normal strength –Powdered dry mixes are mixed at half- strength, due to ice displacing the water Changes made in an effort to be consistent with current NFPA guidelines Hyperthermia protocol may be needed

42. Seizures Ativan is the first drug of choice for seizures –Dose is 2 MG IV/IM Works best when given IV Do not give Ativan rectally- use Valium instead –Not harmful just ineffective when given IO is the ABSOLUTE last resort to give medications for seizures

43. Shock/Non-Traumatic New Protocol Pressors for vasogenic or cardiogenic shock- Physician Order Only –Dopamine contraindicated for hypovolemic patients Tourniquets are coming back –Not the same as IV tourniquets –Commercially available tourniquets (examples on next slide)

44. Commercially Available Tourniquets

45. Spinal Immobilization No longer in “Trauma” section Medical patients may need spinal immobilization as well Protocol as listed needed clarification in some areas –Age extreme patients –Unknown If unable to explain how patient ended up on the floor, then IMMOBILIZE!

46. Spinal Immobilization ( Reliable Patient) Calm Cooperative Not impaired by drugs, medications, alcohol or existing medical conditions Awake, alert and oriented to person, place, time and event Without any distracting injuries

47. Spinal Immobilization Criteria Signs and Symptoms of possible Spinal Cord Injury –Extreme pain or pressure in head, neck or back –Tingling or loss of sensation in hand, fingers, feet or toes –Partial or complete loss of control over any part of the body –Urinary or bowel urgency, incontinence or retention –Difficulty with balance and walking

48. Spinal Immobilization Criteria Signs and Symptoms of possible Spinal Cord Injury continued –Abnormal band like sensations in the thorax- pain, pressure –Impaired breathing after injury –Unusual lumps on the head or spine

49. Spinal Immobilization Criteria The EMS provider may conclude that a spinal cord injury is unlikely if they do not exhibit any S and S listed and meet the following criteria –Unaltered mental status –No neurological deficits –No intoxication from alcohol, drugs or medications –No other painful distracting injuries

50. Spinal Immobilization Criteria Distracting injuries Reliable patient Special needs patients Age extremes –Pediatrics –Geriatrics Kyphosis

51. Toxicological Emergencies New name for overdose Focuses on toxicological emergencies that EMS can treat Does not cover every possible drug/medication Narcan is used to treat respiratory depression –Not given just because pt is unconscious

52. Trauma: Crush Syndrome No major changes Remember this protocol exists and review it

53. Trauma Simplified Removed morphine May implement Pain Management: Non- Cardiac protocol as needed Includes trauma transport criteria

54. Vascular Access Now includes adult IOs Includes lidocaine dose/information for IOs –Standing order 20-40 mg for adults –Standing order for 0.5 mg/kg for pediatric 14 gauge needle is for needle decompression only Technician discretion for IV or Saline lock –IV is required for administration of D50

55. Pediatric Reference Charts for normal vital signs by age Charts for average weight, ETT size APGAR Chart Burn Chart Wong Baker FACES pain rating scale Pediatric Trauma Transport Criteria

56. No major changes Remember CHKD is not a trauma center When in doubt, contact either CHKD or SNGH for transport decision

57. Asystole/PEA No atropine “A BLS airway is an adequate airway. A brief attempt at an advanced airway by an experienced provider is appropriate.”

58. Bradycardia Compressions if HR <60 with poor perfusion despite oxygenation and ventilation Epinephrine is the drug of choice for pediatric bradycardia Pacing –No guidelines in PALS or PEPP –OMDs agree rate of 100 is reasonable

59. Pediatric Tachycardia- Narrow Complex Assessment is key –Distinguish ST vs SVT Stable SVT –Adenosine by physician order only –Try vagal maneuvers first Ice to face Blow on thumb Arm on abdomen No ocular pressure or carotid massage

60. Pediatric Tachycardia- Narrow Complex Unstable SVT –Cardiovert ASAP –Vagal Maneuvers are appropriate prior to the administration of adenosine –Adenosine is a physician order

61. Pediatric Tachycardia- Wide Complex No major changes

62. V-Fib/Pulseless V-Tach AEDs –Pediatric AEDs preferred for children 1-8 –No recommendation for/against using AEDs on infants –Pads should not touch- use pediatric pads or front-back placement Pediatric pads may or may not attenuate- check with manufacturer

63. Pediatric Airway/Oxygenation/Ventilation –New protocol –Includes parts of pediatric airway obstruction –No nasal intubations –Enhanced are still allowed to use laryngoscope and Magill forceps for obstruction –BLS airway

64. Pediatric Allergic/Anaphylactic Reaction New Protocol Similar to the adult protocol Administer epinephrine IM (preferred method), not SQ –Physician may order epinephrine IV in severe anaphylaxis –IV epinephrine should be 1:10,000 not 1:1,000 Solumedrol is not routinely indicated for pediatrics- online medical control may order

65. Pediatric Altered Mental Status Focus is on assessment to determine a likely cause of the altered mental status CVA (stroke) is possible in children with sickle cell disease

66. Pediatric Breathing Difficulty New name for Pediatric Respiratory Distress Includes treatment for croup, epiglottitis (from the old Pediatric Airway Obstruction protocol)

67. Pediatric Breathing Difficulty Epiglottitis –If patient has stridor, drooling and forward posture, let him/her maintain position of comfort and maintain own airway Croup –Nebulized epinephrine –Not a new treatment but providers forget it is there

68. Pediatric Burns New Protocol Mirrors the Adult Burns Protocol Key Point: CHKD can handle burn patients as long as there is no airway involvement If you need guidance for destination contact SNGH or CHKD

69. Care of the Newly Born Umbilical vein cannulation should not be routinely used Check blood sugar if premature, distressed or mom is a diabetic Do not give Narcan to newborns, even if mom is a narcotics user –Can precipitate withdrawal seizures –Respiratory depression is easier to handle than the seizures

70. Care of the Newly Born Keep them warm –Mottling, acrocyanosis (blue hands/feet) are both signs of hypothermia in newborns

71. Pediatric Hyper/Hypoglycemia New protocol Includes instructions on how to mix D10 and D25 Hypoglycemia is life-threatening in children and must be corrected ASAP –Dextrose can be administered rectally with a physician order

72. Pediatric Hyper/Hypoglycemia Hyperglycemia –Bolus only if assessment reveals signs of dehydration Dry mucous membranes Tachycardia

73. Pediatric Nausea/Vomiting New protocol Zofran –Pediatric dose: 0.15 mg/kg IV –May be repeated once after 20 minutes (standing order) –Maximum dose is 8 mg Higher than the adult dose because children have a faster metabolism

74. Pediatric Pain Management Should be considered for patients with: –Fractures –Sickle cell crisis –Burns –Cancer Can be used for other painful conditions with a physician order –Not usually appropriate for abdominal pain

75. Pediatric Pain Management Use Wong-Baker FACES pain rating scale with younger children Morphine –Dose 0.1 mg/kg –Standing order only for isolated extremity injuries –Implement Pediatric Nausea/Vomiting protocol as needed

76. Pediatric Seizures Rectal Valium (diazepam) –O.4 mg/kg (rectal dose) Ativan (lorazepam) –Pediatric dose: 0.1 mg/kg maximum 2 mg –SLOW IV administration- risk of apnea if pushed too quickly –DO NOT administer rectally- not harmful but is ineffective

77. Pediatric Seizures Patients must be on cardiac, SpO2 monitors when benzodiazepines are administered Order of treatment –Rectal Valium first for younger children and/or difficult IV –Ativan IV for older children and/or easier IV –Ativan also may be given IM –Do not start an IO just to give an anti-epileptic

78. Appendices The Appendix section contains the following: –A. Related Policies and Procedures –B. Regional Drug and IV Box Policy –C. Special Resources –D. Patient Restraint –E. DDNR –F. Policy for Ambulance Restocking –G. Tidewater Regional Ambulance Diversion Policy

79. Appendices –F. Policy for Ambulance Restocking –G. Tidewater Regional Ambulance Diversion Policy –H. Ambulance Patient Destination Policy –I. Tidewater Regional Trauma Plan –J. Specialty Protocols –K. Medications

80. CBRNE 1.CBRNE- Biological 2.CBRNE- Blistering Agents 3.CBRNE- Cyanide 4.CBRNE- Choking Agent 5.CBRNE- Nerve Agents a.Adult b.Pediatric

81. 6.CBRNE- Nuclear 7.CBRNE- Riot Control Agents 8.CBRNE- RDD

82. New Medications Ativan (Lorazepam) –A potent benzodiazepine anticonvulsant for seizures and seizures proximal to chemical exposure –Seizures, Chemical Exposure, Combative Patient

83. New Medications Nitroglycerin TD paste –A potent vasodilator for decreased oxygen demand in chest pain, and fluid shifting in CHF –Chest Pain, AMI, ACS, Breathing Difficulty (CHF)

84. New Medications Zofran (Ondansetron) –A seratonin antagonist antiemetic for nausea and vomiting –Nausea/Vomiting