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2006 Protocol Update Central Shenandoah EMS Council 1 Summary of Major AHA Changes 2006 Protocol Update 2 Advanced Life Support - Adults • Recommended use of endotracheal (ET) intubation is limited to providers with adequate training and opportunities to practice or perform intubations. • Confirmation of ET tube placement requires both clinical assessment and use of a device (e.g. exhaled CO2 detector, esophageal detector device). Use of a device is part of primary confirmation of tube placement and is no longer characterized as secondary confirmation. 3 Advanced Life Support - Adults • Intravenous or intraosseous (IO) drug administration is preferred to endotracheal administration. • Implementation of the EZ-IO – More on this later… 4 Advanced Life Support - Adults • General concepts of treating pulseless arrest – BLS skills, including effective chest compressions with minimal interruptions, are the priority skills and interventions for cardiac arrest. – Insertion of an advanced airway may not be a high priority. – Organize care to minimize interruptions in chest compressions for rhythm check, shock delivery, advanced airway insertion or vascular access. 5 Advanced Life Support - Adults • Treatment of VF or pulseless VT – One shock followed immediately by CPR (beginning with chest compressions). – Manufacturer’s recommendations for energy settings. – Do not attempt to palpate a pulse or check the rhythm after shock delivery. – After about two minutes of CPR if an organized rhythm is apparent during rhythm check, the provider checks a pulse. 6 Advanced Life Support - Adults • Treatment of VF or pulseless VT – Deliver drugs during CPR. – Prepare drug doses before they are needed. – If rhythm check shows VF/VT, the vasopressor or antiarrhythmic should be administered as soon as possible after the rhythm check. • It can be administered during the CPR that precedes or follows the shock delivery. 7 Advanced Life Support - Adults • Treatment of VF or pulseless VT – The timing of drug delivery is less important than is the need to minimize interruptions in chest compressions. 8 Advanced Life Support - Adults • Treatment of VF or pulseless VT – Vasopressin is administered when an IV/IO line is in place, if VF or pulseless VT persists after the first shock. – Vasopressin replaces the first and second doses of epinephrine. – Amiodarone is administered after the dose of vasopressin. – Amiodarone has replaced lidocaine. 9 Advanced Life Support - Adults • Treatment of asystole/PEA: – Vasopressin replaces the first and second doses of epinephrine. • Treatment of symptomatic bradycardia: – The atropine dose is now 0.5 mg IV, which may be repeated to a total of 3 mg. 10 Advanced Life Support - Adults • Therapy for acute coronary syndrome (ACS): – Emphasis on 12-lead ECG acquisition by EMT-Bs and all ALS providers. 11 Advanced Life Support - Pediatric • Apply health-care provider “child” CPR guidelines to victims from one year of age to the onset of puberty. • No endotracheal intubation <8 years of age. • IO placement is an acceptable alternative for vascular access in children of all ages. • Timing of one shock, CPR and drug administration during pulseless arrest has changed and now is identical to that for ACLS. 12 Advanced Life Support - Pediatric • No vasopressin for pediatric cardiac arrest. • Amiodarone is considered the drug of choice for shock-refractory VF/pulseless VT. 13 Learn More… • www.americanheart.org • Click on… – CPR & ECC AHA Guidelines for CPR & ECC 14 2006 ALS Protocol Review CSEMS Council 15 Adult Dysrhythmia Management 2006 Protocol Update 16 Asystole/PEA 15 More… 17 15 Asystole/ PEA 18 VF and Pulseless VT 15 More… 19 17 VF and Pulseless VT 20 19 Bradycardia 21 Bradycardia 20 • Key Points – Severely symptomatic patients should receive immediate pacing. – Atropine may be used for nausea in a severely symptomatic patient. Titrate atropine to a maximum of 3 mg over 15 minutes. – Toxicological etiology follow the appropriate toxicology protocol. – Sedation with midazolam. • 2.5 mg slow IVP titrated to effect. May repeat dose every 5 minutes if needed. • Sedation should not delay pacing in the severely symptomatic patient. 22 Narrow QRS Tachycardia 21 More… 23 Narrow QRS Tachycardia 21 24 Narrow QRS Tachycardia 22 • Give adenosine rapidly over 1 to 3 seconds through a large (e.g., antecubital) vein • followed by a 10 mL saline flush and elevation of the arm. • Sedation with midazolam. • Synchronized cardioversion – Use the device-specific doses for synchronized cardioversion, as recommended by the monitor manufacturer, if different from protocol-recommended energies. • Unable to synchronize? – Use high-energy unsynchronized shocks. • If the 360 J shock does not convert a dysrhythmia, contact [Medical Control] for direction. 25 Wide QRS Tachycardia 22 More… 26 Wide QRS Tachycardia 22 27 Wide QRS Tachycardia 22 • If cardioversion and amiodarone do not terminate wide complex tachycardia, contact [Medical Control]. 28 Pediatric Dysrhythmia Management 2006 Protocol Update 29 Asystole/PEA 27 30 VF and Pulseless VT 29 More… 31 VF and Pulseless VT 29 32 31 Bradycardia More… 33 Bradycardia 31 34 33 Narrow QRS Tachycardia 35 35 Wide QRS Tachycardia 36 Medical & Trauma Protocols 2006 Protocol Update 37 Anaphylaxis 38 • Essentially unchanged. • Note that methylprednisolone is not included as a STT/E level drug according to the state drug schedule. – Regional medical director will be addressing the regional inclusion with the state medical direction committee. 38 Chest Pain (Non-traumatic) 43 • Nitroglycerin to a total of 3 doses. • Emphasis on 12-lead acquisition. – Notification of hospital. – Patient disposition. 39 Environmental (Hyperthermia) 45 • Essentially unchanged. 40 Environmental (Hypothermia) 47 • If the patient does not respond to 1 shock, further defibrillation attempts should be deferred. • Give initial cardiovascular drugs based on presenting rhythm. If the patient fails to respond to the initial drug therapy, defer additional boluses of medication. 41 Hyperglycemia 50 • New protocol. • IV of normal saline for glucose 300 mg/dL. • Fluid for signs and symptoms of shock. 42 Hypoglycemia 51 • “New protocol.” • D50 and D25 only. – 1 g/kg up to 25 g of dextrose. 43 Obstetrics – Newborn Resuscitation 56 • Meconium suctioning permitted. – Vigorous newborn = standard suctioning. – If the newborn is NOT vigorous (poor or absent respiratory effort, flaccid, lethargic), consider immediate meconium aspiration via endotracheal suctioning. 44 Obstetrics – Newborn Resuscitation 56 • Review… • Respirations adequate, HR >100, centrally cyanotic: – Blow-by oxygen. – No response in 30 seconds BVM 40 to 60 breaths per minute. • Respirations inadequate or HR <100: – Ventilation with a BVM. – Continue until HR >100. • HR <60 after 30 seconds of BVM: – Chest compressions at a rate of 120/min. – Compression to ventilation ratio of 3:1. – Continue until HR >60. 45 Obstetrics – Newborn Resuscitation 57 • HR <60 despite BVM chest compressions for 30 seconds: – – – – – Establish IV/IO access. Give epinephrine 1:10,000 0.01 mg/kg IV/IO. Repeat every 3 to 5 minutes if HR remains <60. Dextrose 12.5% 1 g/kg (8 mL/kg). 10 mL/kg normal saline. Administer fluid bolus using a syringe and a three-way stopcock. 46 Obstetrics – Newborn Resuscitation 57 • When administering a fluid bolus of normal saline, consider the volume of fluid given with Dextrose 12.5% and adjust accordingly. • If a diaphragmatic hernia is suspected, place an orogastric tube and apply low, intermittent suction. 47 Respiratory – Airway Obstruction 61 • In addition to BLS maneuvers previously discussed… – Direct visualization of the airway via laryngoscopy. – Cricothyrotomy. 48 Respiratory – Asthma 62 • Essentially unchanged. – Capnography • More on this later… 49 Respiratory – Pulmonary Edema 67 • SBP 100 – SBP >180: Give nitroglycerin, 2 tablets, 0.4 mg SL and 2 inches of nitropaste 2%. If respiratory distress persists and SPB >180 and HR 60 bpm, repeat nitroglycerin, 2 tablets SL every 3 minutes. – SBP 100 – 180: Give nitroglycerin, 1 tablet, 0.4 mg SL and 1 inch of nitropaste 2%. If respiratory distress persists and SPB 100 and HR 60 bpm, repeat nitroglycerin, 1 tablet SL every 5 minutes. – Administer CPAP with 10 cmH20 PEEP. 50 Seizures 69 • Essentially unchanged. • Initial… – Diazepam IV/PR or midazolam IM. • Refractory to diazepam… – Midazolam. 51 Shock – Non-hypovolemia 73 • Cardiogenic shock • Essentially unchanged. 52 Toxicology 79-80 • 4.25.2 – ALCOHOL INTOXICATION/WITHDRAWAL – Essentially unchanged. • 4.25.3 – NARCOTICS / OPIATES – “New” protocol. No longer in coma/altered LOC. • 4.25.4 – ORAL HYPOGLYCEMIC AGENTS – Essentially unchanged. 53 Toxicology 81 • 4.25.5 – TRICYCLIC ANTIDEPRESSANTS – Sodium bicarbonate 50 mEq IV over 2 minutes. Repeat in 15 minutes if no improvement. – Consider magnesium sulfate 2 g over 5 minutes. • Reserved for VT unresponsive to alkalization. • 4.25.6 – CHOLINERGICS – Essentially unchanged. 54 Toxicology 82 • 4.25.7 – CALCIUM CHANNEL BLOCKERS – Essentially unchanged. • 4.25.8 – COCAINE / METHAMPHETAMINE – Follow seizure protocol. 55 Procedures 2006 Protocol Update 56 CPAP 90 • CPAP guidelines for agencies electing to use device. • Generic procedure. • Agency-based device-specific training. 57 Cricothyrotomy, Melker 91 • Expanded procedure descriptions including illustrations. 58 Cricothyrotomy, Surgical 93 • Expanded procedure description. • Includes option for using gum elastic bougie. 59 Capnography 95 • Indications – Confirmation, monitoring and documentation of endotracheal and Combitube intubation. – Assessment, monitoring and documentation of the respiratory status of the non-intubated patient experiencing respiratory distress including but not limited to asthma and COPD. • Agency-based device-specific training. • CSEMS will incorporate capnography into CE program. 60 Capnography 95 • Quick overview – Normal ETCO2 values: 35 – 45 mmHg 61 Colormetric ETCO2 Detection 97 • Expanded procedure. 62 Esophageal Detector Device 100 • New procedure. • Use as needed in addition to a colormetric endtidal CO2 detector. 63 Gastric Decompression 101 • Indication expanded to include un-intubated patients undergoing positive-pressure ventilation. – Especially pediatrics 64 Intraosseous 103-110 • OMDs will require use of Vidacare’s EZ-IO intraosseous system. • Procedures for Jamshidi/Cook style devices and the F.A.S.T.1 device remain in the procedures. – Transitional period. 65 Intraosseous 103-110 • CSEMS Council will… – Provide train-the-trainer programs for agencies. – Seek and 100% RSAF grant to defer costs. – Dollar-for-dollar credit for F.A.S.T.1 devices has been negotiated. 66 Intubation, Nasotracheal 111 • Expanded procedure description. 67 Intubation, Orotracheal 112 • Expanded procedure description. • Maximum of 2 attempts. – Place Combitube. • Continue with procedure restricted to patients aged 8 years and older. – OMDs will reconsider pediatric intubation after one year of experience with capnography in adult intubations. 68 Intubation, Orotracheal 112 • Ventilation – During CPR: • Deliver 8 to 10 breaths per minute. Deliver each breath over about 1 second while chest compressions are delivered at a rate of 100 per minute, and do not attempt to synchronize the compressions with the ventilations. – Patients with a perfusing rhythm: • Deliver approximately 10 to 12 breaths per minute (1 breath every 6 to 7 seconds). Deliver these breaths over 1 second. 69 PVAD Access 115 • Pre-existing vascular access device. • Expanded procedure description. 70 Suctioning, Meconium 118 • New procedure. • Cardiac, Intermediate, and Paramedic levels. 71 Transcutaneous Pacing 124 • Expanded procedure description. • Adult… rate = 80 bpm • Pediatric… rate = 100 bpm 72 Vein Cannulation, Peripheral 126 • New procedure. • EMTs transporting patients with INTs addressed in this section. 73 Pharmacology 2006 Protocol Update 74 General Pharmacology 128 • Lidocaine removed… Amiodarone added. • All drug listings have been revised. – Some have revised action descriptions. – Added chemical class, pharmacokinetics, etc. • We will review significant modifications or changes. 75 Drugs Essentially Unchanged • • • • • • • Adenosine Albuterol Calcium Chloride 10% Diphenhydramine Dopamine Epinephrine 1:1,000 Epinephrine 1:10,000 • • • • • • Furosemide Glucagon Ipratropium Methylprednisolone Naloxone Promethazine 76 Amiodarone 130 77 Amiodarone 130 78 Amiodarone 130 79 Amiodarone 130 • Pharmacies will begin stocking amiodarone on July 1, 2006. • Check the “date packed” so that you know what is in your drug box. • Will have a period of time where either lidocaine or amiodarone is used. – Follow appropriate guidelines. 80 Atropine 132 • Adult: – Bradycardia: 0.5 mg, repeat every 5 minutes to a total dose of 3 mg. – Asystole/PEA: 1 mg, repeat every 3 to 5 min (up to 3 doses). – Cholinergic Toxicity: 2 mg IV, repeat every 5 minutes. – ET route de-emphasized. • Pediatric: – Bradycardia: 0.02 mg/kg, repeat once in 3 to 5 minutes. – Not indicated for asystole. 81 Dextrose 134 • Adult: – Give dextrose 50% 1 g/kg up to 25 g IV. Repeat once in 2 minutes if GCS remains 12. • Pediatric: – Give dextrose 25% 1 g/kg up to 25 g IV. Repeat once in 2 minutes if GCS remains 12. • Neonate: – Give dextrose 12.5% 1 g/kg (8 mL/kg).. 82 Diazepam 135 • Adult: – Give 0.25 mg/kg up to 5 mg slow IV push, titrated to effect. Repeat dose in 5 minutes if seizure persists. • Pediatric: – IV: Give 0.25 mg/kg up to 5 mg slow IV push, titrated to effect. Repeat dose in 5 minutes if seizure persists. – PR: Give 0.25 mg/kg up to 5 mg PR. • Medical Control not required for repeat dose. 83 Magnesium Sulfate 144 • 20% solution. – 2 g dose, mix 2 g (4 mL) with 6 mL of normal saline. • Pulseless: – 2 g (20% solution) IV over 1 to 2 minutes. • With Pulse: – 2 g (20% solution) IV over 5 minutes. Repeat dose if needed. • Pediatric – Pulseless: Give 25 mg/kg up to 2 g IV/IO, for torsades de pointes. 84 Metoprolol 147 • Indications – Irregular narrow-complex tachycardia. – Regular narrow-complex tachycardia that does not covert following administration of adenosine. – Stable wide-complex tachycardia [Medical Control]. – Acute myocardial infarction [Medical Control]. • Administration – Give 5 mg IV over 2 minutes. Repeat every 5 minutes if needed to a total dose of 15 mg. 85 Midazolam 148 • Administration - Adult – 2.5 mg slow IV titrated to effect. May repeat dose every 5 minutes if needed. – 5 mg IM if unable to readily establish IV access. • Administration - Pediatric – 0.1 mg/kg slow IV, titrated to effect. May repeat every 5 minutes as needed [Medical Control]. – 0.1 mg/kg IM if unable to readily establish IV access [Medical Control]. 86 Morphine 149 • New indication – Acute abdominal pain [Medical Control]. 87 Nitroglycerin 152 • Sublingual – Chest Pain: Give 0.4 mg SL. Repeat every 5 minutes, if needed, up to 3 doses. – Pulmonary Edema (SBP >180): Give 2 tablets, 0.4 mg SL. Repeat 2 tablets every 3 minutes if needed. – Pulmonary Edema (SBP 100–180): Give 1 tablet, 0.4 mg SL. Repeat 1 tablet every 5 minutes if needed. 88 Sodium Bicarbonate 156 • Cardiac arrest unchanged. • TCA overdose – No longer administer drip infusion. – 50 mEq IV over 2 minutes. Repeat in 15 minutes if needed. 89 Vasopressin 157 • First-line vasopressor for all cardiac arrest. • One dose of vasopressin is substituted for the first and second doses of epinephrine 1:10,000. 90 Drug by Weight Chart 166 91 IV Infusion Chart 168 92 Questions 93