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2016 EMS PROTOCOL INSTRUCTOR UPDATE How We Got Here • Year long project • Team approach • Frequent Team meetings 2 times a month since January 4 to 5 hours per meeting • Emailed every section to the Medical Director and Specialists for comment and approval Protocol Team • Dominic Silvestro, Paramedic, EMSI • Todd Kulina, Paramedic, EMSI • Bill Bernhard, Paramedic, EMSI • Scott Wildenheim, Paramedic, EMSI 341 Pages 74808 Words 11251 Editing Mins 4.5 MB File New Protocol Goals • • • • • • • • • Fresh new look, unique to UH Improve ease of use Add safety features Format Pediatric section same as adult Streamline treatment pathways Match prehospital care with care provided in the ED Group interventions as they would be actually undertaken in field Review / Update clinical care to meet current research and studies Assure inexperienced providers have clear, understandable, treatment pathways with little room for misunderstanding • Allow experienced providers the room to practice good prehospital medicine Creation and Approval Process New Order of Protocol Sections Unique New Look Sections Color Coded Blue – Adult Pink – Peds Purple – OB Gray- Reference Edge Tabs for Easy of Use as Printed Document Blue tab is current section Gray tabs are other sections in document Safety Features Added to Protocol Tree New Bold Colors & Rounded Boxes Transport - “CONTACT MECDICAL CONTROL” box reworded to actual order of events Legend moved to bottom of page Hyperlinked Protocol • Single file adobe .pdf • Downloadable • Multi-platform (Anything that supports adobe .pdf) • Hyperlinks within the .pdf (Over 3500 Hyperlinks) • Internet connection not required for hyperlinks • Hyperlinks will be explained later in this PowerPoint. Built In Safety Features Stops / Cautions • Stops – Brings critical contraindications to the treatment tree • Cautions – Reminds provider of pertinent decision making issues during treatment Grouped Interventions • This new layout “Blocks” interventions in groups as they are actually performed • However most will usually be done concurrently by multiple providers PROCEDURE CHANGES, ADDITIONS, AND UPDATES EMT Scope of Practice Change “Patient Assisted” Meds • In the State EMT Scope of Practice there are Two Meanings for Patient Assist as it relates to Medication administration – Can assist with patient’s Prescription upon patient request and with written protocol - OR – Can Provide supplied medications with verbal medical direction • This Protocol will adopt this definition for EMT’s • Off line Meds – EPI PEN, ASA, Narcan Working Cardiac Arrest on Scene • Survival odds decrease when patients are transported This is a Suggestion only, each situation should be judged individually every situation is unique. Use common sense. • The best option for patients who do not have special resuscitation circumstances (hypothermia, electrocution, etc.) is to attempt to gain ROSC on scene. • ALS only • Adult only • Transport once ROSC is achieved Sedation in Airway • Pre Intervention if patient responds to pain • Post Intervention if patient awakens • Use Midazolam or Lorazepam as available • STOP for head injured patients • THIS IS NOT RSI Sedation in Airway • Expectations with Ativan and Versed – These Drugs are NOT Paralytics – Your patient will not fall motionless on your cot – These meds provide amnestic effects as well as sedation (they won’t remember) • Apnic Oxygenation – Assures the patients pulse ox stays up during intubation attempts Respiratory Distress - Stridor • Added column for Severe Distress with STRIDOR adults • Nebulized epinephrine for treatment of upper airway constriction • Differentiated from lower airway with hashed background • Lower airway issues are treated per the left column (not pictured here) and the middle column “Moderate / Servere Distress” as shown on this slide Half Amp Dextrose • Change recommended by UH endocrine specialists • BGL < 40 – Full Amp (25 Grams) of D50 • BGL > 40 up to 70 Treat with Half Amp (12.5 grams) of D50 (With signs and symptoms as stated in the Key Point of this protocol) • Repeat as necessary • Recent research reveals that treating acute CVS’s with D50 should only be done if the glucose level is below 60 as hyperglycemia may injure the punumbra. • • Large Glucose molecules draw fluid. High and low swings in glucose levels streese the body systems Alcohol Related Emergencies • New Protocol • Addresses Mild Symptoms, Severely Combative, Obtunded, and Alcohol Withdrawal Patients • This is a protocol that takes several existing treatments and puts them in one protocol / location • When using Oral Zofran remember that this is a soft tablet that dissolves rapidly DO NOT try to push it through the package as it may crumble • In this case the Benzo’s (Ativan / Versed) are for sedation and only given by Medics CPR Device • There have been documented cases across the country of cardiac arrest patients waking up during CPR device chest compressions ie: LUCUS CPR ever though they are still in a non-life sustaining rhythm. • If CPR device yields Consciousness, pain management with fentanyl (sublimaze) is indicated. Bleeding / Hemorrhage Control Procedure • One general procedure covers – – – – Tourniquet iT Clamp Hemostatic Gauze BLS – Gauze Bandage, Direct Pressure, Pressure Points, Etc. • Remember to either keep product packaging or refer to the protocol for removal procedures as some receiving facilities may not be familiar with some of these products (iT Clamp) Active Shooter / Direct Threat • Outlines basic scene care for “warm zone” casualties of violent events • Standard EMS care to resume after patient extricated from scene Double Sequential Defibrillation • For VFIB / VTACH refractory to 360 J and medications • 720 J – Requires 2 Defibrillators – This is a LAST RESORT for refractory VFIB / VTACH patients – Do not waste time acquiring a second device if device not already on site • • • • Medical control contact required for DSD consideration (Red Box) 1 set of Pads Anterior / Posterior 1 Set of Pads Apex / Sternum Charge both monitors to 360 J and press Shock at the same time Induced Hypothermia • Passive cooling only • AHA No longer recommends Chilled Saline for induced hypothermia • Use Cooling Collar • Cold Packs • No target temp, EMS Induced Hypothermia is designed to start the cooling process as soon as possible Peds Dosing Charts • • • • Pre-Calculated Follows Broslow Colors Error Reduction Includes all protocol medications • Hyperlinked from med pages (shown in upcoming slide) • We are currently working to standardize the drug boxes across the system. Until then, double check the concentration to make sure it matches these charts. (Early 2016) Dialysis / Renal Patient • EKG examples provided for hyperkalemia • Addresses multiple topics pertinent to dialysis patients • Covers Respiratory issues, Cardiac changes, Hypertension, Hypotension, Chest Pain, and Bleeding catheters • Albuterol and Calcium for Peaked T waves • Calcium and Bicarbonate for Sine Wave (see next slide) Dialysis / Renal Patient • Peaked T waves should be narrow and higher than the QRS in this setting • Albuterol is easy and fast and should be done rapidly • Calcium is safe and should be given SLOWLY over 2-3 minutes in a good IV /IO line • Once you see Sine Wave there is only minutes until cardiac arrest and you must treat aggressively with Calcium and Sodium Bicarbonate • Flush IV before CALCIUM and before SODIUM BICARBOANTE Narcan • Everyone seems to have a different thought process on how much to give • Need to standardize for teaching / simplicity reasons • We took a middle of the road approach • Give at least 1 mg IV / IO • 2 mg IN • Now found in the Toxic Ingestion Protocol • Also Per AHA Narcan can be given in Cardiac Arrest when you suspect Opiate overdose as the cause. Severe Pain Management • The Severe Pain Management has been reworked as well • Some dosages have been changed to meet current standards as well as an update of indications and contraindication based on current research and current accepted ED treatment • Added Hydromorphone (Dilaudid) to your pain management options Severe Pain Management Hydromorphone (Dilaudid) • • • • 8-10 x Potency Morphine, Longer lasting Preferred for unremitting / intractable pain Supplied 1 mg / ml, 1 ml Carpuject Dose 0.5mg – 1.0mg IV/IO/IM May repeat to a Max 2.0mg (Half Dose >65 yrs old, Liver or Renal disease) Fentanyl (Sublimaze) • Preferred for hemodynamic instability, trauma, procedural pain management, Can be given IN, Shorter acting • New Dose 25 – 100mcg IV/IO/IM/IN 100mcg MAX • Small chance of chest wall ridgity (only happens if pushed to fast remember to push slowly Morphine • Still available, mostly for peds / ACS • New Dose 2.5 – 5.0mg IV/IO/IM – MAX 10mg Toradol • Dosage change due to recent literature that finds more than 15mg IV /IO does nothing more for pain and increases risk of bleeding. • Dose - 15 mg IV / IO, 30 mg IM – 1 DOSE LIMIT • Has many Contraindications (list below) Peds Severe Pain Management Morphine • For IV / IO / IM administration Fentanyl (Sublimaze) • IN use ONLY ACS Pain Management • You now have two options for pain management in the Acute Coronary Syndrome Patient • Morphine Sulfate or Fentanyl (Sublimaze) – Fentanyl will not drop BP and gives you an IN option – Note Dose Changes Narrow Complex – Rate Control • Metoprolol (Lopressor) now red boxed • Concerned about incorrect use, many contraindications • If Capnography is in normal range there is no need to change the rate • Not for physiological tachycardias, cocaine use • Cocaine is a sympathetic alpha and beta stimulant. A beta blocker only will leave unopposed alpha and the blood pressure may actually rise Behavioral / Psych Emergencies • New Columns – Agitation – Non Combative – Combative – Physical Restraint – Combative – Chemical Restraint • While Benzo’s and Benadryl are Advanced EMT Drugs (Green Box) in this protocol it is a Medic only (Blue box) because they are being used for sedation with Haldol and to treat EPS (Benadryl) caused by the administration of the Haldol and should only be given by a Paramedic in this instance. Hypertensive Emergencies • New Protocol • Primarily a direction finding protocol – Use Critical Thinking. It is important to find an underlying cause if present. – This protocol is used to remind you of the possible causes and direct you to the specific protocol. (Hyperlinked in the electronic version) Stroke / MEND • Addition of MEND to stroke protocol • MEND is not done on scene. Conduct the MEND while enroute to the receiving facility. • May be able to detect strokes NOT evident from The Cincinnati Stroke Scale Neonatal Resuscitation • Ventilate with ROOM AIR in the first 30 seconds at 40 – 60 BPM • Low Pulse Ox is a normal finding as it may take up to 10 minutes for the neonate to be in the 90% range Med Pages • Pregnancy Class – A – No Risk in controlled human studies – B – No risk in other studies – C – Risk not ruled out – D Positive evidence of risk – X – Contraindicated in pregnancy • • • • Adult Dose Peds Dose Color coded for level of care Peds dosing weights hyperlinked to dose charts in .pdf version shown earlier in this Lecture. Special Operations • • • • • • Procedures Nitrous Oxide Administration Tasered Patient Active Shooter / Direct Threat Protocol Patient Decontamination Nerve Agent Exposure Kit Blood Collection for Evidence • • • • • • • • • • Medications Ciprofloxicin (Cipro) Clopidrogril (Plavix) Vobramycin (Doxycycline) Duo-Dote Etomidate (Amidate) Hydroxocobalmin (Cyanokit) Ketamine Nitrous Oxide Succinylcholine (Anectine) Tenecteplase (TNKase) Altered Level of Consciousness • There are many causes for Altered Level of Consciousness • Identifying the cause will ensure rapid care • This is a Direction finding protocol each possible cause will be hyperlinked to the appropriate protocols listed in the .pdf version Croup • New Peds Protocol • Upper airway is separate protocol from lower • Stridor at rest – Aerosolize Epinephrine 1:1000 • Nebulized saline otherwise Peds Aerosols • Lower airway • Rainbow added Duoneb this year in Severe Column • Albuterol first, then transition to Duoneb for Mild / Moderate Peds Toxic Ingestion / Exposure / OD • Rainbow approved dosing for Calcium Chlorine in Calcium Channel Blocker OD • 10 mg / kg IV/IO MAX 1 gram • Narcotic OD moved here same as adult protocol What's Hyperlinked? Section Tabs What's Hyperlinked? Table of Contents What's Hyperlinked? Procedures What's Hyperlinked? Medications What's Hyperlinked? Medication Indication Click on the indication and you will be taken to that protocol What's Hyperlinked? Pediatric Dosing Rollout • System wide Protocol Rollout Education throughout the month of December • Hard Copy Protocols will be given to each department for each Ambulance in their fleet. • Electronic .pdf complete with all hyperlinks will go live on our website on January 1, 2016 • You will be able to download this .pdf to any computer, tablet, smart phone, etc. that supports Adobe .pdf. • We encourage you to put this on every computer in your station and fleet. Protocol Email • Established email for protocol suggestions / corrections • [email protected] • Seen by all team members Questions ?