Download Policy Update Presentation 2016 - Marin Emergency Medical Services

THIS PRESENTATION IS NOT A SUBSTITUTE FOR
READING THE MARIN COUNTY POLICY AND PROTOCOL
MANUAL IN ITS ENTIRETY. IT IS AN INTRODUCTION
TO THE POLICY AND PROTOCOL UPDATES TAKING
EFFECT ON JULY 1, 2016.
EMS SYSTEM EVENT REPORTING FORM
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Replaces EMS Notification Form
Includes instruction for completion
No “levels” of events
Initiators may be anonymous
Initiators must reference pertinent P&P
Includes opportunity for sharing an interesting
case for education purposes
PARAMEDIC INTERNSHIP *NEW*
• Provides guidance and establishes minimum standards
for paramedic internships.
• Preceptor Requirements:
• 2 years experience as California EMT-P
• Current and active (non-probationary) California EMT-P license and local accreditation in
Marin County for one year.
• Completed training as outlined/required by the Provider Agency and/or Paramedic
Training Program.
• Formal preceptor designation by the Provider Agency.
PARAMEDIC INTERNSHIP *NEW*
• Paramedic Interns
• Work only in basic scope of practice, unless approved for optional scope
procedures.
• Work only under direct supervision of their assigned preceptor(s).
• In the absence of their preceptor(s), student works in basic EMT
scope.
UNIFIED RESPONSE TO VIOLENT INCIDENTS *NEW*
• To provide triage, medical care and extrication to
patients in an incident involving an active
shooter/violent incident or other hazardous
incident being primarily managed by law
enforcement agencies/departments
UNIFIED RESPONSE TO VIOLENT INCIDENTS *NEW*
• Education, training and joint exercises with Law
Enforcement, Fire and EMS must be conducted before Fire
and EMS providers are allowed to enter an active scene
UNIFIED RESPONSE TO VIOLENT INCIDENTS *NEW*
• All law enforcement, fire and/or EMS provider shall have
department policies regarding entry of responders into
warm zones or secure areas as described in this policy
UNIFIED RESPONSE TO VIOLENT INCIDENTS *NEW*
• The EMS response to violent encounter/active shooter
incidents should be coordinated utilizing ICS, SEMS, NIMS
and Unified Command with on scene Law Enforcement/
Fire / EMS/ Facility Cooperator
UNIFIED RESPONSE TO VIOLENT INCIDENTS *NEW*
• Law Enforcement will be responsible for patient
extrication if other first responders are not able to enter
the scene. Patient extrication will be initiated at the
earliest possible opportunity after the scene is relatively
secured and/or the threat is neutralized
UNIFIED RESPONSE TO VIOLENT INCIDENTS *NEW*
• The on scene Incident Commander/ Unified Command, in
addition to departmental policies, will determine PPE
requirements for entry into any warm zones
TACTICAL PARAMEDIC *NEW*
• Tactical Paramedic– A paramedic
who meets all established prerequisites and is authorized to
provide medical support services
for law enforcement operations.
TACTICAL PARAMEDIC *NEW*
• Must be an accredited Marin County paramedic with
successful completion of a Tactical Medicine Course that is
certified by the Peace Officers Training and Standards
(POST) and approved by the California EMS Authority.
TACTICAL PARAMEDIC *NEW*
• Tactical paramedics must be sworn peace officers in order to carry a firearm
PREHOSPITAL/HOSPITAL CONTACT
• Policy Section and Physician
Consultation sections were
reorganized and cleaned up.
• Patient identification
information added for STEMI
and STROKE patients during
early notification process.
PREHOSPITAL/HOSPITAL CONTACT
Patient Identifying Information
• Kaiser STROKE/STEMI Patients – Give Kaiser # (Give
Name and DOB if unknown Kaiser #)
• MGH STROKE/STEMI Patients – Give Name and DOB
• NCH STROKE Patients – Give Name and DOB
PREHOSPITAL/HOSPITAL CONTACT
• Do not delay care or dedicate excessive time to
phonetically spelling out a complicated name.
• e.g. Zachary Galifianakis
FIELD TRANSFER FORM
• New fields added
• Focus is to provide the hospitals the necessary
information when a PCR is not able to be completed at the
hospital.
• Requires initiator to provide a phone number for
significant other/care provider.
• Must be legible and signed!
FIELD TRANSFER FORM
• Updated
FIELD TRANSFER FORM
• Updated
FIELD TRANSFER FORM
• Updated
ALL TREATMENT POLICIES
• Changed from “Body Substance Isolation” to
“Always Use Standard Precautions”
PROCEDURE FOR INTRANASAL MEDICATIONS
MIDAZOLAM (VERSED) & NARCAN
• INDICATION – Removed RR < 8
12-LEAD ECG PROCEDURE
• CONTRAINDICATION section removed.
DETERMINATION OF DEATH – ALS
• Indication definition changed.
• Medical indications revised with addition of potentially
reversible cause of death added.
• Under medical indications revised to replace “nonperfusing wide ventricular complex” with PEA.
DETERMINATION OF DEATH – ALS
• Removal of “three rounds of medication appropriate for
presenting rhythm have been administered.”
• Additional language: “If determination of death can still not be
made for medical arrests, continue resuscitation for ten additional
minutes (30 minutes total) at which point resuscitation may be
discontinued and determination of death made if ROSC has not
occurred.
• IF patient in recurring or refractory VF, continue resuscitation and
transport the patient.
DETERMINATION OF DEATH – ALS
• Physician consult box reworded.
• Notification of Law Enforcement and filing out DOD form
moved to below Physician consult box.
ADULT MEDICATIONS
AUTHORIZED/STANDARDIZED DOSE
• Removal of D50
• Addition of D10
• 125 ml bolus IV/IO over 10 minutes; recheck BG and
repeat as needed
• Narcan concentration corrected to 2mg/2ml
PATIENT TRANSFER AND TRANSPORTATION
• Additions on hemorrhage control
• Control significant external bleeding using direct pressure. If
bleeding remains uncontrolled, apply gauze or hemostatic
dressing and/or tourniquet.
• Limb with the tourniquet must remain exposed
• Hemostatic dressing must be approved by California EMS Authority
• https://www.youtube.com/watch?v=-NgfgofN6-M&feature=youtu.be
VENTRICULAR FIBRILLATION/
PULSELESS VENTRICULAR TACHYCARDIA
• Revisions made to follow AHA 2015 changes.
• Addition to refer to Cardiac Arrest Policy.
• Statement that manual CPR is preferred over mechanical.
VENTRICULAR FIBRILLATION/
PULSELESS VENTRICULAR TACHYCARDIA
• BLS airway management is preferred in the first 5
minutes of CPR.
• If NO ventilation occurring with basic maneuvers,
proceed to advanced airway.
PULSELESS ELECTRICAL ACTIVITY AND ASYSTOLE
• Reference to Cardiac Arrest Policy added.
WIDE COMPLEX TACHYCARDIA
• Biphasic language removed
ST ELEVATION MYOCARDIAL INFARCTION (STEMI)
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Provide Early STEMI Notification with identifying
patient information.
COLD INDUCED INJURY
• If there are no signs of life and asystole remains
after 60 seconds, ventilate for three minutes;
auscultate for heart rate and assess for electrical
activity for 60 seconds.
COLD INDUCED INJURY
• If still asystolic and no pulse, begin CPR; if VF/VT
defibrillate once @ 200J or 360J (depending on
manufacturer) and if no change, begin CPR.
COLD INDUCED INJURY
• If PEA (even very slow); withhold CPR; continue
warming measures; begin transport, continue IV
fluid boluses (as above); handle gently and
manage airway.
• Withhold ACLS medications until core
temperature reaches 86F/30C.
COLD INDUCED INJURY
• Hypothermia from submersion: Based on reliable
report or witness, if submersion is<60 minutes,
attempt resuscitation/active rewarming.
• If submersion is known to be >60 minutes,
resuscitation should not be initiated (see
Determination of Death Policy, ATG6).
COLD INDUCED INJURY
• Overhauled
COLD INDUCED INJURY
• Subtler presentations exist in the elderly,
newborns, chronically ill, patients taking
medications and alcohol.
• Handle the patient gently for all procedures;
physical manipulations have been reported to
precipitate ventricular fibrillation.
COLD INDUCED INJURY
• Continue re-warming in patients with temperature
< 35C (95°F) with known or suspected
hypothermia (hypothermia from submersion <60
minutes) as the primary cause or significant
contributor of death, unless obvious death or valid
DNR are present
ADULT CARDIAC ARREST
• Removed “Guideline” from title of policy.
• Incorporates AHA 2015 changes
• Clarifies when transport of a patient in cardiac
arrest is warranted.
ADULT CARDIAC ARREST
• Regardless of achieving ROSC on scene,
transportation is warranted in the following
situations:
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Refractory VF
Unsafe Scene Conditions
Unstable Airway
Hypothermia as a primary cause of arrest (<95F/35C)
Any patient pulled from a fire in cardiac arrest
ADULT CARDIAC ARREST
• Manual CPR is not optimal in the back of a moving
ambulance. If transporting a patient needing CPR,
consider using mechanical CPR if available.
SPINAL MOTION RESTRICTION (SMR)
• Includes info on athletic equipment removal.
• Athletic Equipment (football helmet and shoulder
pads; lacrosse helmet and shoulder pads;
baseball/softball catcher’s helmet)
SPINAL MOTION RESTRICTION (SMR)
• In event of suspected spine injury during participation in
equipment-intensive sport, removal of equipment is recommended
prior to application of SMR.
• Equipment should be removed by the rescuers most familiar with
the equipment (i.e. Athletic Trainers when present).
• Removal of helmet and/or shoulder pads provides early access to
the patient’s airway/chest.
COMA/ALTERED LEVEL OF CONSCIOUSNESS
• Removed D50, added D10
• If BS < 60 or immeasurable: Dextrose 10%
25GM/250ml: 125 ml bolus IV/IO over 10
minutes; recheck BG and repeat as needed
SEIZURES
• Removed reference to D50
• Added language to treat hypoglycemia according
to N1 COMA/ALOC policy
SYNCOPY
• Removed reference to D50
• Added language to treat hypoglycemia according
to N1 COMA/ALOC policy
CEREBROVASCULAR ACCIDENT (STROKE)
• Rewritten to provide clarity on when to activate as
an Early Stroke Notification.
• Provide patient identifying information during
notification.
• Extends LKW to 4.5 hours.
• Includes more anticoagulant examples.
CEREBROVASCULAR ACCIDENT (STROKE)
• Provide Early Stroke Notification if all of the
following are true:
• Abnormal Cincinnati Prehospital Stroke Scale (CPSS) Score
• Last known well < 4.5 hours
• Symptoms are most likely due to stroke and not a stroke mimic
(see special considerations)
• Blood glucose level >70
CEREBROVASCULAR ACCIDENT (STROKE)
• Obtain name and contact information for patient
family member/decision maker and/or those who
had last seen the patient normal (e.g., skilled
nursing personnel).
ALL PEDIATRIC POLICIES
• Measure with color-coded resuscitation tape and
treat according to the Pediatric Dosing Guide
(P18A). Apply Corresponding wrist band.
NEWBORN RESUSCITATION
• Added language to now clearly state, “3:1 ratio”
above bullet point for “90 compressions / 30
ventilations per minute”
• If HR remains < 60/MIN perform BVM with chest
compressions at 3:1 ratio
PEDIATRIC RESPIRATORY DISTRESS
• Clarified Epinephrine dosage for Lower Airway
Obstruction/Wheezing:
• 2015: “If response inadequate, Epinephrine 1:1,000 (0.1 mg/kg)
IM, max. single dose 0.3 mg; maximum dose = 0.6 mg.”
• 2016: “If response inadequate, Epinephrine 1:1,000 (0.01 mg/kg)
IM, maximum single dose 0.3 mg; MR x 1.”
PEDIATRIC TACHYCARDIA POOR PERFUSION
• Under Critical Information, removed “Monophasic
and biphasic doses are the same”
PEDIATRIC SHOCK, SEIZURE, ALOC, ALTE
• Removed D25/D50 and replaced with D10.
• Treat Blood Glucose if < 60 mg/dl (<40 mg/dl neonate):
• Neonate: D10W 2ml/kg IV/IO over 10 minutes
• > Neonate: D10W 5 ml/kg IV/IO over 10 minutes
PEDIATRIC PAIN MANAGEMENT
• Added Zofran
• If nausea/vomiting, consider Ondansetron (Zofran)
• Ages 2-3: 2mg ODT or slow IV/IO over 30 seconds; MR x1 in 10 minutes
• Ages ≥4: 4mg ODT or slow IV/IO over 30 seconds; MR x 1 in 10 minutes
PEDIATRIC MEDICATIONS
AUTHORIZED/STANDARD INITIAL DOSE
• Dextrose 10% replaced D25 and D50.
• Epinephrine 1:1,000 – As stated in P3.
PEDIATRIC PATIENTS
NOTE
• Remember to use pediatric colored bands.
PEDIATRIC INTRAOSSEOUS INFUSION PROCEDURE
• Added Lidocaine if patient is awake or responds to
pain.
• For patients >3kg: If awake and/or responsive to pain,
infuse 2% Lidocaine 0.5mg/kg slowly (max dose =
40mg; treat according to the Pediatric Dosing Guide
P18A). Allow the Lidocaine to work 30-60 seconds
prior to administering fluids.
2015-2016 MARIN COUNTY
PHYSICIANS ADVISORY COMMITTEE
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Dustin Ballard, MD – Marin County EMS Agency
Jonathan Vlahos, MD – San Rafael Fire
Zita Konik, MD – Novato Fire
Vicki Martinez, MD – Corte Madera Fire
Mark Bason-Mitchell – Marin County Fire/RVPA/SMEMPS
2015-2016 MARIN COUNTY
P&P COMMITTEE
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Karrie Groves - Marin County EMS Agency
Randy Saxe – Marin County EMS Agency
Bridget Peterson – Marin County Fire/RVPA/SMEMPS
Heather Price-Fair – Marin County Fire/RVPA/SMEMPS
Brett McTigue – Marin County Fire/RVPA/SMEMPS
Mike Gianini – Marin County Fire/RVPA/SMEMPS
Liz Froneberger – Corte Madera Fire/Kaiser San Rafael
Dan Reese – Corte Madera Fire
2015-2016 MARIN COUNTY
P&P COMMITTEE
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Fred Maru – San Rafael Fire
Shawn Gordon – San Rafael Fire
Aaron Hakenen – Novato Fire
Kim Lesik – Novato Fire
Maureen Stull – Marin General Hosptial
Jeff Cress – Reach Air
Chris LeBaudour – Falck/Veri-Health
Steven Coleman – NORCAL Ambulance
THE END…