1. Revision Review Region X SOP’s March 1, 2007 Condell Medical Center EMS System May, 2007 Site Code #10-7200E-1207 Prepared by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives To familiarize the EMS provider with the changes to the March 1, 2007 Region X SOP’s in preparation for examination Assess patients to be stable or unstable to determine if a conservative intervention is appropriate (ie: medications) or more aggressive intervention is needed Clarify interpretation of the SOP’s Review Lead II rhythm strips

3. Region X March 1, 2007 SOP’s Some pages have been reformatted –reading left to right –moving from less critical to more critical conditions/situations reading left to right –attempted consistency of language through out the document (ie: low acceptable B/P 100) Most changes in the SOP’s were made to reflect the updates in the 2005 AHA guideline revisions SOP’s must be followed by the EMS provider; Medical Control can choose to deviate

4. Table of Contents Reorganized into sections Introduction Cardiac Respiratory Medical Trauma Obstetrics Pediatric Pediatric Considerations Appendices Alphabetized within each section

5. Introduction to Use of SOP’s - pg 1 Added statement to allow judgement in decision making –“An alternate order of listed interventions may be appropriate based upon patient assessment” If EMS is unable to establish communication with Medical Control, follow interventions approved in the SOP’s Clarification of pediatric age –under the age of 16 –this means 15 and under

6. Routine Medical Care - pg 2 Combined with “General Patient Care” Pain scale is part of vital signs If following the Acute Coronary Syndrome protocol, a 12-lead EKG is indicated If a 12-lead is obtained, it needs to be transmitted Not every patient that needs to be monitored needs to have a 12-lead obtained

7. Adult IV Conscious Sedation for Intubation - pg 7 Age contraindication raised to 16 (consistency) Initial Versed dosage raised to 5 mg IVP If not sedated within 60 seconds (1 min) give Versed 2 mg IVP every minute until sedated Following sedation, if needed for agitation, can give Versed 1 mg every 5 minutes Total dose of Versed is 15 mg IVP

8. Adult IV Conscious Sedation for Intubation cont’d Morphine is given following the start of the Versed dose Versed & Morphine together potentate effects of the drugs enhancing results greater than either drug alone Versed relaxes and sedates the patient; Versed does not affect the level of pain

9. “Secure Airway” Term used on all protocol pages when responding to the arrested patient Term used to indicate to secure the airway in whatever way possible and whatever means available at the time You are to accomplish this with minimal interruption to CPR Initially using a BVM with or without an oropharyngeal or nasopharyngeal airway would accomplish the task of securing an airway with minimal interruption

10. Asystole/PEA - pg 8 2 algorithms combined into one A 6 th “H” added to possible causes - hypoglycemia Intubation to be accomplished when time is appropriate, not necessarily immediately, and with minimal interruption to CPR Atropine administered for asystole and when the PEA rate is <60 No transcutaneous pacing for Asystole

11. Withdrawing Resuscitation Efforts - pg 9 Language changed for consistency “confirmation of intubation” replaced with “advanced airway secured”

12. Bradycardia and AV Blocks - pg 11 Repeat dosage of Atropine is 0.5 mg “when they’re alive, give them 0.5” Wide complex bradycardias (Type II second degree heart block and third degree AV block) –begin with TCP first –consider sedation (Valium)

13. Acute Coronary Syndrome - pg 12 Note added regarding prior Aspirin intake “Aspirin may be withheld if patient reliable and states has taken within 24 hours” Document what time and what dosage was taken by the patient If pain persists after a 2nd dose of Nitroglycerin, proceed to Morphine Once you have moved onto Morphine, continue Nitroglycerin after consultation with Medical Control

14. Transition of Care From AED Trained Personnel To ALS - pg 14 AED users need to follow whatever prompts are given by the particular AED unit Older AED’s will prompt for 3 shocks and 1 minute of CPR Newly reprogrammed AED’s will prompt for 1 shock followed immediately by 2 minutes of CPR before reanalysis

15. Supraventricular Tachycardia (Narrow Complex Tachycardia) - pg 15 Diltiazem moved to this page to follow Adenosine failures When the stock of Diltiazem is exhausted, to be replaced with Verapamil Verapamil to be given 5 mg IVP slowly (over 2 minutes) If no response in 15 minutes, repeat Verapamil 5 mg slow IVP

16. Rapid Atrial Flutter/Fibrillation (Narrow Complex Tachycardia) - pg 16 Added note to use Verapamil when Diltiazem is no longer available Verapamil can cause hypotension –give slowly (over 2 minutes plus) –treat hypotension with IV fluid challenge of 200 ml Normal Saline

17. Ventricular Fibrillation or Pulseless Ventricular Tachycardia - pg 17 All defibrillation attempts are singular All defibrillation immediately followed by 2 minutes of CPR prior to rhythm check Antidysrhythmic drugs (choose one) –Amiodarone 1 st dose 300 mg IVP (diluted) –Repeat dosage in 5 minutes Amiodarone 150 mg IVP (diluted) –Lidocaine 1 st dose 1.5 mg / kg IVP –Repeat dosage in 5 min Lidocaine 0.75 mg/kg

18. AHA Guideline Revision If arrest is witnessed, begin and perform CPR until defibrillator is charged and ready –If arrest time < 4-5 minutes, perform CPR just until defibrillator ready If arrest unwitnessed (or time >4-5 minutes since arrest), perform 2 minutes of CPR before stopping to defibrillate Immediately after each defibrillation attempt resume 2 minutes of CPR After 2 minutes of CPR stop for <10 seconds for rhythm check

19. Ventricular Tachycardia or Wide Complex Tachycardia (Patient with a Pulse) - pg 18 Amiodarone added as a choice of antidysrhythmic –if chosen, dosage of Amiodarone is 150 mg diluted in 100 ml D5W IVPB over 10 minutes Mix IV bag, gently rotate bag to mix medication, spike IV bag with mini-drip tubing and prime tubing, plug in IV tubing to primary line, run drip so you can see drops

20. Acute Pulmonary Edema - pg 19 CPAP procedure steps moved to Appendix If the patient is unstable, CPAP provided only on orders of Medical Control Remember: –All interventions (Nitroglycerin, Lasix, Morphine, and CPAP) can cause hypotension

21. Transcutaneous Pacing Protocol - pg 20 TCP suggested for symptomatic bradycardia –back-up to Atropine failure for narrow complex –primary intervention if QRS is wide Second degree type II - Classical Third degree heart block - Complete Valium used for patient comfort

22. Acute Abdominal Pain/Flank Pain - pg 21 Added flank pain to title On this SOP, Medical Control must be contacted for any pain medication order Pain management orders often based on your radio report –be an effective patient liaison –if you feel pain management is appropriate and you don’t receive the order, you need to ask for one

23. Airway Obstruction - Adult - pg 22 Follows AHA standards –If the obstruction is unrelieved, perform CPR –An extra step is taken each time you open the airway look in the mouth to visualize for an obstruction if one is noted, attempt removal if no obstruction is noted, continue with 2 breaths and move onto 30 compressions

24. Adult Allergic Reaction Anaphylactic Shock - pg 23 Defined stable and unstable patients –Stable: hives, itching, rash, GI distress, alert, warm & dry, B/P >100 –Stable with airway involvement: alert, warm & dry, B/P >100 –Unstable: altered mental status; B/P < 100 Defined slow IVP for Benadryl dose - over 2 minutes To anaphylaxis added Benadryl 50 mg slow IVP and if wheezing, albuterol nebulizer

25. Allergic Reactions & Anaphylaxis For simple reactions without airway involvement, Benadryl used (stops release of histamines) For allergic reactions with airway involvement or anaphylaxis, start with Epinephrine followed by Benadryl –Epinephrine is life saving –Effects are immediate to vasoconstrict blood vessels to support circulation –Benadryl slowly stops progression of the allergic response - stops release of histamines

26. Altered Mental Status - pg 24 Title condensed Added to consider etiology as you are caring for the patient –may help lead the decision making for treatment & interventions

27. Asthma/COPD with Wheezing - pg 25 Added –“Contact Medical Control to consider use of CPAP in a patient has symptoms of COPD”

28. Stroke / Brain Attack - pg 26 Added –“Determine time of onset of symptoms” Opportunity to definitively treat a patient with an occlusive stroke is a very narrow window of time - 3 hours from time of onset To expedite patient intervention, notify Medical Control as soon as general impression of a stroke is made

29. Seizures & Status Epilepticus - pg 30 Changed the order of medications –Valium attempted first –Dextrose listed 2 nd This is a good example of the statement in the Introductory to allow for the EMS provider, after patient assessment, to use judgement to follow an alternate order of listed interventions

30. Severe Respiratory Febrile Illness - pg 31 New SOP Promoting the use of PPE and limiting contamination are the goals of this SOP If a patient must wear a mask, they are to be given a surgical mask The N95 mask is reserved for use by the medical team and never to be given to the patient N95 mask

31. Region X Field Triage Criteria for Assessing Trauma Patients - pg 33 Gives guidelines for transporting patient based on: hemodynamic values (ie: serial B/P) stability of vital signs anatomy of injuries mechanism of injury existence of co-morbid factors special circumstances: traumatic arrest; burns >20%; inability to open airway

32. Transporting The Trauma Patient Unstable trauma patient (adult B/P <90 x2 or peds B/P <80 x2 or Category I trauma patient (based on unstable vital signs &/or mechanism or injury) –transport to highest level Trauma Center within 25 minutes you need to be aware of this especially if responding mutual aid where this applies –CMC departments will go to a Level II trauma hospital as no Level I exists within a guaranteed response time 24/7 of 25 minutes

33. Trauma Transports Traumatic arrest – Closest Trauma Hospital Unable to secure an airway – Closest Emergency Department regardless of Trauma status

34. Amputated and Avulsed Parts - pg 35 Care of stump added –covered with damp sterile dressing and elastic wrap with uniform pressure

35. Chest Injuries - pg 38 New SOP - long standing interventions Authorizes EMS responder to perform bilateral chest decompression for a patient with traumatic arrest –the mechanism of injury should indicate potential or actual traumatic injury to the chest

36. Heat Emergencies, Adult Defined heat stroke as hot and dry or hot and moist skin –classic heat stroke is hot and dry –exertional heat stroke is hot and moist

37. Routine Pediatric Care - pg 52 New SOP - generic care for all peds patients Reminder that pediatric age is <16 Pediatric assessment triangle (PAT) –used to quickly establish level of severity & identify key physiologic problems –assesses appearance, work of breathing, circulation to skin –obtain this information as you cross the room and are approaching the patient

38. Pediatric Care Guidelines Note: Any pediatric drug calculation should never exceed the adult drug maximum

39. Pediatric Respiratory Failure - pg 53 Expanded signs & symptoms of respiratory distress & failure Distress –  work of breathing,  respiratory rate, use of accessory muscles, nasal flaring, effectively compensating Failure - needs to be bagged!!! –exhausted energy reserves, cannot maintain adequate oxygenation & ventilation, low resp rate,  effort, bradycardia, agitation, lethargy, cyanosis

40. Pediatric Altered Level of Consciousness - pg 54 Added reference to fluid challenge –“Administer IV fluid challenge 20 ml/kg”

41. Pediatric Acute Asthma - pg 55 Phased approach of care added –mild to moderate distress (increased work of breathing) –severe distress (inadequate oxygenation, ventilation, or both) The patient in severe distress (and especially the pediatric patient with bradycardia & respiratory failure) may need to be ventilated via a BVM with 100% O 2

42. Pediatric Airway Obstruction - pg 56 AHA guideline changes –“back blow” terminology changed to “back slaps” –5 back slaps and 5 chest thrusts repeated in sequence for patients < 1 year old Unrelieved obstructions handled alike for all patients –Perform steps of CPR –Pause before the 2 ventilations to look directly into airway & attempt removal if object noted

43. Pediatric Ventricular Fibrillation or Pulseless Ventricular Tachycardia - pg 57 Title change Follows 2005 AHA guidelines CPR- compression rate 100/minute –30:2 for 1 person CPR all victims –15:2 CPR for child and infant if 2 person CPR Airway –Once intubated, ventilation rate one breath every 6-8 seconds asynchronous with compressions

44. Pediatric VF/Pulseless VT cont’d Amiodarone is alternative antidysrhythmic to Lidocaine –5 mg/kg IVP/IO –Repeat dosage thru Medical Control order –needs to be diluted due to irritation to vein ETT route discouraged (absorption unreliable) but not eliminated –IV and IO are preferred routes

45. Pediatric Asystole, PEA, Pulselsss Idoventricular Rhythms - pg 58 Follows AHA guidelines –6 th “H” to possible causes- hypoglycemia –Revised CPR guidelines CPR 30:2 for 1 and 2 person CPR CPR 15:2 for 2 person CPR for children and infants Once intubated, patient is ventilated once every 6-8 seconds ETT drug route de-emphasized

46. Pediatric Bradyarrhythmias - pg 59 Expanded signs and symptoms of compromise Epinephrine 1:10,000 - 0.01 mg/kg IVP/IO repeated every 3-5 minutes for the duration For persistent bradycardia, contact Medical Control for possible order for Atropine Medical Control needs to be contacted for order for external pacing

47. Pediatric Tachycardia with Poor Perfusion - pg 61 Under probable ventricular tachycardia column, contact Medical Control for possible antidysrhythmic order (Amiodarone or Lidocaine)

48. Pediatric Tachycardia with Adequate Perfusion - pg 62 Under probable ventricular tachycardia column, if Amiodarone is chosen, must be diluted and administered over 20 minutes –Dilute dosage in 100 ml D5W –Prime mini-drip tubing –Plug piggyback into primary line –Run Amiodarone drip to count 30 minidrips / 10 seconds

49. Croup/Epiglottitis - pg 64 Position of comfort encouraged but transportation must be done safely and following current traffic laws Transport in parent/caregiver arms no longer allowable

50. SIDS - pg 66 Expanded external appearance of SIDS victim cold skin frothy blood tinged fluids around mouth & nostrils vomit may be present lividity or dark reddish blue mottling on dependent side of the body unusual position due to muscle spasms at time of death

51. Burns, Pediatric - pg 67 New SOP Formatted following adult Burn SOP Contact Medical Control for pain management orders Rule of Nines moved to Appendix

52. Pediatric Toxic Exposures - pg 68 Title change For toxic exposures, follow Hazardous Materials SOP

53. Pediatric Heat Emergencies - pg 69 New SOP Follows format of adult heat emergencies During cooling process, if pediatric patient begins to shiver, administer Valium to stop the shivering (shivering generates energy and heat - counterproductive to efforts to lower body temperature) Heat stroke can present hot and dry or hot and moist (classic or exertional)

54. Pediatric Allergic Reaction/Anaphylaxis - pg 70 Columns headed like adult SOP –Allergic Reaction Stable –Allergic Reaction Stable with Airway Involvement –Anaphylactic Shock Benadryl added to 3 columns –Benadryl 1 mg/kg –Max at the adult dosage stable - 25 mg maximum stable with airway involvement & anaphylaxis - 50 mg maximum

55. Glasgow Coma Scale/Revised Trauma Score - pg 76 Moved to back of SOP’s GCS to be obtained on every EMS call

56. Calculating Body Surface Burn Percentages - pg 77 Includes schematic for adult, child, and infant Includes breakdown of body areas –superior and inferior (ie: chest & abdomen) –anterior versus posterior Note: Different resources may vary the percentage slightly; not all award any percentage to perineum

57. CPR for Infants and Children - pg 78 Follows revised 2005 AHA guidelines 1 person CPR –30:2 for all persons 2 person CPR for adults –30:2 2 person CPR for infants and children –15:2 Compression rate 100/minute

58. Pediatric Resuscitation Medication - Cardiac and Medical - pgs 80, 81 Expansion of pediatric weights Provides information of ml (helpful for bedside care) and mg (helpful for documentation) Epinephrine 1:1000 –On Cardiac page, ETT dosage is shown for arrested and critical level patient –On Medical page, SQ route is shown for non- arrest and stable patients

59. IV Fluid Challenge Formula for all persons –20 ml / kg All persons need reassessment –every 200 ml of fluid administration while the fluid challenge is being administered

60. Region X Approved Drug Information List - pgs 82-84 Information on individual medications revised Preferred routes in arrest: IV/IO; ETT unpredictable (last resort) Adenosine –do not use in setting of WPW history Amiodarone –Adult - initial dose in arrest 300 mg; repeat dosage 150 mg in 5 minutes –Adult & pediatric dose in patients with pulse - must be diluted in 100 ml D5W and run slowly

61. Region X Approved Drugs cont’d Benzocaine –limit spray to < 2 seconds Lidocaine –Added to indications for suppression of cough reflex when used for patient with head injury (medical or trauma) requiring conscious sedation intubation Nitroglycerin –Added to avoid use if Viagra or Viagra-type drug taken within past 24 hours

62. Region X Approved Drug Verapamil –New addition –Calcium channel blocker to slow the ventricular response of stable SVT or rapid Atrial Fibrillation or Atrial Flutter –To be used when stock of Diltiazem/Cardizem is no longer available –Avoid in any wide complex rhythm, in the setting of heart block, in severe CHF, in the presence of hypotension

63. Region X Approved Drug Versed –Noted increase dosing of Versed used during Conscious Sedation 5 mg to start continued at 2 mg every minute til sedated 1 mg every 5 minutes to continue sedation after intubated

64. Appendix - Needle Decompression, Chest - pg 89 Insertion site is 2 nd intercostal space, midclavicu- lar line

65. Combitube, Dual Lumen Airway Device - pg 91 Available alternative to secure an airway for the individual department that places it into service Once trained, the EMS provider (Basic and Paramedic) may use the Combitube

66. What’s This Rhythm?

70. What’s This Rhythm (rate 80)?

71. What’s This Rhythm?

75. NO PULSE

76. What’s This Rhythm?

77. 2 different simultaneous leads

78. Rhythm Answer Key #1 - Ventricular fibrillation #2 - Ventricular tachycardia #3 - Atrial fibrillation #4 - Second degree Type II - Classical #5 - Sinus Rhythm #6 - Sinus Bradycardia #7 - Atrial fibrillation

79. Rhythm Answer Key cont’d #8 - Paced rhythm #9 - Second degree Type I - Wenckebach #10 - PEA #11 - SVT #12 - Third degree heart block - complete