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2013 OEMS Prehospital
Protocol Update
Amy Gutman MD
EMS Medical Director
[email protected] / www.teaems.com
Objectives
• Inform Massachusetts prehospital
providers of updates to the OEMS
Prehospital Treatment protocols
effective as of March 1st, 2013
• Review evidence-based literature
rationale behind the changes
www.mass.gov/dph/oems
Medication Changes
•
Majority of changes are routerelated or provide alternatives
during medication shortages
•
Updated wording reflects
national standards, for example
removing “trailing zeros” from
medication dosing in all
protocols, appendixes & drug
references
www.jointcommission.org
Rationale: Joint Commission safety recommendation, consistent with
national patient care practices
General Principles for Specific Skills
• EMS crews should not begin or administer interventions
requiring medical assessment if patient brought to environment
where intervention will not be provided / monitored
– i.e. Giving IV narcotics to patient not being transported to a medical facility
• Principle does not apply to giving medications if patient being
brought to a facility where personnel available to assess
patient, such as a physician’s office or a skilled nursing facility
Rationale: Clarification of role of EMS as medical providers
General Principles for Specific Skills
•
Recent advances in resuscitation science have increased potential for
survival in out-of-hospital cardiac arrest (OOHCA)
•
Some MA EMS systems monitor their OOHCA survival rates with
excellent results comparable to national norms. Ideally every EMS
system should monitor & strive to improve their OOHCA survival rates
•
For services not currently monitoring & taking steps to improve their
OOHCA outcomes the following is recommended:
– EMD instructions to provide hands-only CPR if patient unconscious & not
breathing normally
– Emphasis on continuous compressions to maintain 80% compression fraction
– Delay intubation to after 1st 8 mins CPR in primary cardiac arrest to avoid
interrupting compressions
– Field followed by hospital hypothermia for ROSC
– Rapid 12-lead EKG after ROSC to determine if STEMI POE should be used
Rationale: Monitoring out-of-hospital cardiac arrest care
Ewy GA, Sanders AB. Alternative approach to improving
survival of patients with out-of-hospital primary cardiac
arrest (OOHCA). J Am Coll Cardiol. 2013. Jan 15;61(2):113-8
•
Cardiocerebral resuscitation (CCR) significantly improved survival of
OOHCA patients in 2 Wisconsin counties from 15% to 39%, and in 60
Arizona EMS departments to 38% over one year. Using CCR, over a
five year period, survival from primary cardiac arrest in Arizona
increased from 18% to 33%
•
Conclusions: Advocating bystander compression only CPR for
patients with primary OOHCA, and encouraging EMS CCR vs prior
CPR guidelines which included emphasis on ventilations and early
airway management
Ewy GA, Kern KB. Recent advances in cardiopulmonary
resuscitation: cardiocerebral resuscitation. J Am Coll
Cardiol. 2009 Jan 13;53(2):149-57
•
CCR advocates continuous compressions without mouth-to-mouth
ventilations for witnessed cardiac arrest
•
For bystanders with AED access & EMS arriving in electrical (1st 4-5
mins) phase of VF, prompt defibrillation recommended
•
For EMS arriving in circulatory phase of VF arrest (>5 mins) when
fibrillating myocardium has used up energy stores, compressions
mandatory prior to & immediately after defibrillation
•
Recommendations: delayed endotracheal intubation, avoid excessive
ventilations, & utilize early epinephrine
Clemmensen P, et al. Diversion of STEMI patients for primary
angioplasty (pPCI) based on wireless prehospital 12-lead ECG
transmission directly to cardiologist's handheld computer: a
progress report. J Electrocardiol. 2005 Oct;38:194-8
•
Time to reperfusion critical in STEMI patients. Transfer from receiving
hospital to a catheterization center can cause unacceptable delays
•
Prehospital ECGs transmitted for 408 CP patients (success 93%).
Cardiologists receiving ECG recommended 113 patients (28%)
diverted for pPCI
•
Results: EMS scene time increased by 7 mins when ECG transmitted
to cardiologist compared to control. Time from ECG to ED arrival 25
mins. Hospital treatment time significantly reduced for diverted
patients - ED arrival to pPCI 40 mins vs 94 mins in control group
Wenzel V, et al. Comments on the 2010 guidelines on
cardiopulmonary resuscitation of the European
Resuscitation Council. Anaesthesist. 2010 Dec;59(12):1105-23
•
Chest compressions minimum 100/min, 5 cm depth at ratio of 30:2
with ventilation. Avoid interruptions in compressions to ventilate
•
After every defibrillation attempt (initially biphasic 120-200J,
monophasic 360J, subsequently with respective highest energy),
compressions immediately reinitiated for 2 min independent of rhythm
•
ETI performed only by experienced providers during ongoing
compressions with a maximum interruption of 10 sec to pass ETT
through vocal cords. Supraglottic airways are alternatives to ETI
•
Active compression-decompression & inspiratory threshold valve are
not superior to good standard CPR
Wenzel V, et al. Comments on the 2010 guidelines on
cardiopulmonary resuscitation of the European
Resuscitation Council. Anaesthesist. 2010 Dec;59(12):1105-23
•
Pediatric BLS:
– Initially 5 rescue breaths, followed by compressions (100-120/min
depth 1/3chest diameter), compression-ventilation ratio 15:2
– Foreign body airway obstruction with insufficient cough: alternate
back blows & compressions (infants), or abdominal compressions
(>1 yo)
•
Pediatric ALS:
– Epinephrine 10 ug/kg IV or IO every 3-5 min. Defibrillation (4 J/kg)
followed by 2 min CPR, then ECG & pulse check
1.5 ACS, 1.6 ROSC, 3.11 Acute Stroke
• Added: Avoid hyperoxygenation, administer O2 using
appropriate delivery device as clinically indicated
• If pulse oximetry available, give supplemental oxygen only if
oxygen saturation level <94% on room air
Rationale: Hyperoxygenation causes coronary & systemic
vasoconstriction, resulting in decreased coronary blood flow, increased
coronary vascular resistance & free radical formation
Ranchord AM, et al. High-concentration versus titrated
oxygen therapy in STEMI: a pilot randomized controlled
trial. Am Heart J. 2012 Feb;163(2):168-75
•
Methods: 136 STEMI patients uncomplicated by cardiogenic shock or
hypoxia randomized to receive high-concentration (>6 L/min) or titrated
O2 (to achieve O2 saturation 93%-96%) for 6 hrs. Outcomes were 30-day
mortality & infarct size assessed by troponin level at 72 hrs. Secondary
outcomes: meta-analysis of mortality data from previous trials, &
infarct size assessed by MRI at 4 - 6 weeks
•
Conclusions: No benefit or harm from high-concentration O2 compared
with titrated O2 in uncomplicated STEMI. Because meta-analysis data
had a large confidence interval (meaning, data uncertainty) larger
randomized studies required to resolve any clinical uncertainty
Shi J, et al. A new idea about reducing reperfusion injury
in ischemic stroke: Gradual reperfusion. Med Hypotheses.
2013 Feb;80(2):134-6
•
Occlusion of intracranial arteries leads to direct cell death with cell
functional impairment surrounding dead core (ischemic penumbra).
Opening the occluded artery to limit ischemic penumbra size is aim of
thrombolysis therapy, but reperfusion induced injury counteracts
potential benefits of thrombolysis
•
Conclusions: Gradual reperfusion reduces reperfusion injury by
reducing free radical production; free radicals come from reperfusion
penumbra & respiration cycle which is upregulated during ischemia.
Once reperfusion occurs, respiratory chain enzymes need only normal
amount of O2 & glucose to avoid producing free radical intermediates.
Gradual reperfusion reduces free radical production by limiting O2 &
glucose provided to the respiratory chain
3.4 Bronchospasm/ Respiratory Distress
•
Added to ALS-P Standing Orders: in patient
with known asthma or COPD, without history
or findings concerning for CHF give
hydrocortisone 100 mg IV, IM, IO or
methylprednisolone 125 mg IV, IM or IO
•
In patients <40 yo epinephrine 0.15-0.3 mg IM*
by autoinjector only as 1 time dose, contact
medical control for additional dosing
•
Added to MCO: “BY AUTOINJECTOR ONLY”
www.hubpages.com
Rationale: Therapy for severe distress by reducing inflammation
associated with bronchospasm; Effective treatment to patients <40 yo
in treatment of bronchospasm/respiratory distress due to asthma;
safety reminder regarding dosing device
4.2 Burns / Inhalation Injuries
•
Added to ALS-P Standing Orders: In
patient with hypotension, AMS, or
indications of cyanide toxicity who may
have experienced smoke inhalation,
consider hydroxocobalamin 5gm IV
over 15 mins (adult), or 70 mg/kg (to
max 5 gm) IV over 15 mins (pediatric)
sanatate.bzi.ro
Rationale: Effective treatment for acute cyanide poisoning
O’Brien DJ, et al. Empiric management of cyanide toxicity
associated with smoke inhalation. Prehosp Disaster Med.
2011. Oct;26(5):374-82
•
Closed-space smoke inhalation 5th most common cause of US
unintentional injury deaths. Cyanide is a toxin in many cases of smoke
inhalation but it’s presence cannot be rapidly confirmed
•
Findings suggesting cyanide toxicity include: closed-space fire with
likely smoke inhalation; oropharyngeal soot or carbonaceous
expectorations; altered LOC, otherwise inexplicable hypotension
•
Prehospital studies demonstrate feasibility & safety of empiric
treatment with FDA-approved hydroxocobalamin for patients with
suspected smoke inhalation cyanide toxicity. Based on literature
review & on-site observation of the Paris Fire Brigade, prehospital
protocols to guide empiric & early hydroxocobalamin administration in
smoke inhalation victims with high-risk presentations recommended
4.3 Head Trauma &
4.7 Spinal Column / Cord Injuries
4.3 Head Trauma
•
Removed: “Hyperventilation may
help brain injury by reducing
intracranial pressure. Hyperventilate
patient in suspected cases of
herniation syndrome (e.g. decorticate
posturing, decerebrate posturing,
fixed, dilated pupils, etc.)”
•
Removed: “Consider hyperventilation
if clinically appropriate with a
significant closed head injury & signs
of herniation syndrome”
4.7 Spinal Column / Cord Injuries
•
Removed: “Consider hyperventilation
with 100% oxygen with BVM if
associated with a significant closed
head injury & signs of herniation
syndrome”
Rationale: Hyperventilation causes increased ICP & decreased
peripheral blood flow, worsening patient outcomes
Dumont TM, et al. Inappropriate prehospital ventilation in
severe traumatic brain injury increases in-hospital
mortality. J Neurotrauma. 2010. Jul;27(7):123-41
•
In traumatic brain injury (TBI), hyperventilation to reduce ICP may be lifesaving. However, undue use of hyperventilation may increase incidence of
secondary brain injury through direct reduction of cerebral blood flow
•
Methods: TBI patients with GCS <8 (n = 65) sorted into hypocarbic (Pco2
<35 mmHg), normocarbic (Pco2 35-45 mmHg), & hypercarbic (Pco2 >45
mmHg). Survival related to admission Pco2 in TBI patients requiring ETI.
Patients with normocarbia had in-hospital mortality of 15%, significantly
improved over patients presenting with hypocarbia (77% mortality) or
hypercarbia (61% mortality).
•
Conclusions: Abnormal Pco2 on presentation after TBI correlated with
increased in-hospital mortality and advocate prehospital normoventilation
4.6 Soft Tissue / Crush Injury
• Removed: under Basic Procedures words “direct pressure”,
“pressure points”
• Added: “If suspect severe crushing injury / compartment
syndrome, if injury permits”
Rationale: To avoid contradicting new changes for hemorrhage control
(direct pressure followed by tourniquet). Allows use of tourniquet if no
other way to stop hemorrhage
4.7 Spinal Column / Cord Injuries
•
Non-penetrating trauma added when considering immobilization
•
“Evidence of significant non-penetrating trauma above the clavicles”
Rationale: Immobilized patients with penetrating trauma have worse
outcomes than non-immobilized patients
Paiva WS, et al. Spinal cord injury and its association with
blunt head trauma. Int J Gen Med. 2011;4:613-5
•
What are risk factors for spine trauma plus traumatic brain injury (TBI)?
•
Results: 180 pts with moderate or severe TBI had cervical spine x-ray
and CT. Most common causes of TBI were pedestrians struck by
vehicles (31%), MVC (28%) & falls (25%). Systemic injuries found in 80
(44%) patients. 53% had severe , & 47% had moderate head trauma. 14
patients (8%) had a spinal cord injury (12 cervical, 1 lumbar, 1 thoracic).
In the elderly, presence of systemic injuries & GCS <9 were significant
risk factors for spine injury
•
Conclusions: Spinal cord injury related to moderate & severe brain
trauma usually affects the cervical spine
4.7 Spinal Column / Cord Injuries
•
Deleted: “including adult fall from standing” from the high risk factors
for determining possible spinal injury
•
Age <8 years or >65 years still considered “high risk mechanisms”
Rationale: Fall from standing only a risk in patients >65 years of age
Lomoschitz FM, et al. Cervical spine injuries in patients 65
years old & older: epidemiologic analysis regarding the effects
of age & injury mechanism on distribution, type, & stability of
injuries. Am J Roentgenol. 2002 Mar;178(3):573-7
•
Methods & Results: 225 cervical spine injuries in 149 patients >65 yo
retrospectively assessed. Mechanism (falls from standing or seated
height vs higher energy mechanisms) & initial neurologic status
recorded. 95 (64%) patients had upper cervical injuries. 59 (40%)
patients had multilevel injuries. Main causes for cervical injuries were
MVCs in "young elderly" (65-75 yo; 61%) & falls from standing or
seated height in "old elderly" (>75yo; 40%). Patients >75 yo
(independent of mechanism), & patients falling from standing height
(independent of age), more likely to injure the upper cervical spine
•
Conclusions: Elderly patients in general including those falling from
standing height are more prone to injuries of the cervical spine
4.10 Traumatic Amputations
•
Language Added to Basic
Procedures:
– Control/stop any life
threatening hemorrhage
– If other methods cannot
control bleeding apply
appropriate tourniquet
– Document exact time of
tourniquet application
www.thefreedictionary.com
Rationale: ITLS recommends use of tourniquets to control life
threatening bleeding; pressure points & elevation have been removed
Kragh JF, et al. Survey of the indications for use of
emergency tourniquets. J Spec Oper Med. 2011
Winter;11(1):30-8
•
Optimal tourniquet use in trauma appears to depend on device,
doctrine, training, speedy evacuation, & performance improvement.
Challenges remain in estimation of blood loss & injury lethality
•
Methods: Data on emergency tourniquet use analyzed from a clinical
study of 728 casualties with 953 tourniqueted limbs. Authors compared
known prior datasets to this clinical study
•
Recommendations: Current indication for emergency tourniquet use is
any compressible limb wound that provider assesses as having
possibly lethal hemorrhage. This indication has shown good outcomes
only when devices, training, doctrine, evacuation & research optimized
Appendix D Emergent Airway
• Appendix renamed “Difficult Airway Protocol”
Rationale: More representative of when process should be utilized
Appendix T Nerve Agent Dosing &
Reference Table
•
Added: Duodote to Appendix T
•
Mark I kits & Duodote not approved for
routine pediatric use, however should be
used as initial therapy for children with
life-threatening nerve agent toxicity (in
extremis) when IV therapy not available
•
“Assumes” 0.8 inch needle insertion
depth
www.myfirefighternation.com
Rationale: Accepted treatment for children with severe life-threatening
nerve agent toxicity
1.1 Asystole
•
Added to ALS-P Standing Orders: if
epinephrine 1:10,000 unavailable due to
drug shortage, vasopressin 40 units
may be substituted & given every 20
minutes IV or IO
www.drugline.org
Rationale: Handle epinephrine shortages
Wenzel V, et al. A comparison of vasopressin & epinephrine
for out-of-hospital cardiopulmonary resuscitation. NEJM.
2004 Jan 8;350(2):105-13
•
Background: Vasopressin is an alternative to epinephrine for
vasopressor therapy during CPR
•
Study Methods: Adults with OOHCA received 2 injections of either 40
IU of vasopressin or 1 mg of epinephrine, followed by additional
treatment with epinephrine if needed. Primary end point was survival
to admission; secondary end point was survival to discharge
•
Study Conclusions: Effects of vasopressin similar to those of
epinephrine in management of VF and PEA, but vasopressin superior
to epinephrine in patients with asystole. Vasopressin followed by
epinephrine may be more effective than epinephrine alone in
refractory cardiac arrest
Protocols / References Involving Morphine and
Fentanyl
(1.2, 1.3, 1.4, 1.5, 1.9, 1.11, 3.7, 3.14, 4.2, 5.13)
• Standing Orders:
– Deleted “This is a one time dose option”; Replaced with “Medication
dose may be given in divided doses up to the maximum”
– This includes titrating to pain control for ACS (Protocol 1.5)
• Added:
– Fentanyl linked to drug reference page
– IM route added for fentanyl
Rationale: Allow pain control titration of under standing orders,
technical fix to text, added administration route
Protocols & References Involving
Epinephrine (1.4,1.6, 3.2, 5.1, 5.2, 5.3, 5.5)
• Infusion:
– Administer 1 mcg to 10 mcg / min IV or IO
– For example: mix 1 mg of 1:1000
Epinephrine in 250 ml NS
– 15 micro drops/min = 1 mcg / min
commons.wikimedia.org
Rationale: Standardized language, administration routes clarified by
adding IV & IO routes
1.5 ACS
• NTG 0.3mg removed from MCO
section
www.webmed.com
Rationale: Standardized language
Protocols Involving Amiodarone (1.6 & 1.11)
•
Added: “for example” to drip information
– Amiodarone 1 mg/min IV drip for
example: 100mg/100ml - 1mg/min
www.rxprescriptionguide.org
Rationale: Standardize dosing option in ALS-P & MCO
Allergic Reaction/Anaphylaxis
3.2 Adult
5.2 Pediatric
•
Added:
– IO route to diphenhydramine
•
Added:
– IO route to diphenhydramine
•
Added to ALS-P Standing Orders:
– Hydrocortisone 100 mg IV, IM, IO
or
– Methylprednisolone 125 mg IV, IM
or IO
•
Added to ALS-P Standing Orders:
– Hydrocortisone 2 mg/k. to
maximum 100 mg IV, IM, IO or
– Methylprednisolone 2 mg/kg to
maximum125 mg IV, IM or IO
•
Added to MCO Section:
– Epinephrine “by autoinjector
only” 1:1,000: 0.15-0.3mg IM
Rationale: Appropriate administration & therapy route to rapidly reduce
inflammation; safety reminder
3.13 Toxicology / Poisoning / SA / OD
•
Deleted:
– EMT-B procedures naloxone 0.4mg
– Protocol now reads “Administer
naloxone 2.0mg nasal via atomizer”
store.airwaycam.com
Rationale: Correct dosing as under special project waivers
Merlin MA, et al. Intranasal naloxone delivery is an
alternative to intravenous naloxone for opioid overdoses.
Am J EM. 2010. Mar;28(3):296-303
•
Proposal that EMS intranasal (IN) naloxone administration preferable
to intravenous (IV) naloxone without risk of needle exposure
•
Methods: retrospective chart review of ALS patients performed on
confirmed opioid overdose patients. Initial and final unassisted
respiratory rates & GCS used as indicators of naloxone effectiveness
•
Conclusion: IN naloxone statistically as effective as IV naloxone in
reversing effects of opioid overdose with similar average increases in
RR and GCS. IN naloxone is a viable alternative to IV naloxone while
posing less risk of needle stick injury
3.14 Adult Pain & Nausea Management
5.13 Pediatric Pain & Nausea Management
•
Added: PO and ODT odansetron
routes as a standing order &
treatment option
www.finlandpharmacyonline.com
Rationale: Reasonable treatment route & formulation without threat of
needlestick injury
Seizures
3.9 Adult
•
Added To ALS-P Standing Orders:
– Midazolam 2.5-5mg slow IV
push or IM
5.7 Pediatric
•
Added To ALS-P Standing Orders:
– Midazolam 0.05 mg/kg IV, IO,
IM to max single dose of 4 mg
Rationale: An option for benzodiazepine therapy shown to work faster
in some studies; addresses medication shortages
5.4 Pediatric Bronchospasm / Respiratory
Distress
•
Added to ALS-P Standing Orders :
– For >2 yo with known diagnosis of asthma hydrocortisone 2 mg/kg
to maximum 100 mg IV, IM, IO or
– Methylprednisolone 2 mg/kg to maximum 125 mg IV, IM, IO
Rationale: Therapy reduces inflammation associated with bronchospasm
Knapp B, Wood C. The prehospital administration of IV
methylprednisolone lowers hospital admission rates for
moderate to severe asthma. PEC. 2003 Oct-Dec;7(4):423-6
•
Compare hospital admission rates for patients with moderate to severe
asthma who receive prehospital vs ED methylprednisolone
•
Results: 31 moderate to severe asthmatics received prehospital
methylprednisolone. 33 asthmatics transported by EMS & later received
IV methylprednisolone in the ED. Only 13% (4) of patients receiving
prehospital solumedrol were admitted to the hospital vs 33% (11)
receiving solumedrol in the ED
•
Conclusions: Patients with moderate to severe asthma receiving
prehospital methylprednisolone have 3 times fewer hospital admissions
Summary of Medication Changes
•
•
•
•
•
•
•
•
•
•
Vasopressin 40 units every 20 mins IV or IO if epinephrine 1:10,000 shortage
Morphine & fentanyl may be given in divided doses to the maximum
IM route added for fentanyl
NTG 0.3mg removed from MCO
IO route added for diphenhydramine
Added hydrocortisone 100 mg IV, IM, or IO or methylprednisolone 125 mg IV, IM
or IO
“By autoinjector only” added to MCO for epinephrine 1:1,000, 0.15-0.3mg IM
Midazolam 2.5-5mg slow IVP or IM
Midazolam 0.05 mg/kg IV, IO or IM to max single dose of 4 mg (pediatrics)
PO / ODT as odansetron route as a standing order & a treatment option
Summary
[email protected]
• This review serves as notification of the changes to the MA
Prehospital Treatment Protocols effective March 1st, 2013
• Provide evidence-based information regarding why changes
occurred
• Please review the protocol changes yourselves and contact
your EMS Education Officer or Medical Director for specific
questions or concerns