Clinical Advisory Subcommittee of the Emergency Medical Care Committee

Meeting Agenda 10:15 A.M., Tuesday January 10, 2017

Health Agency 2180 Johnson Avenue, 2nd floor Large Conference Room San Luis Obispo

Members Chair: Dr. Mark Eckert, County Medical Society TBD, RN, MICNs Rob Jenkins, Fire Service Paramedics Nate Otter, Ambulance Paramedics Paul Quinlan, Fire Service EMTs Dr. Jana Reed, Non-Base Station ED Physicians Dr. Joe Robinson, Base Station ED Physicians Dr. Stefan Teitge, County Medical Society

Staff STAFF LIAISON: Kathy Collins, RN, SCS Coordinator Vince Pierucci, EMS Division Director Dr. Tom Ronay, Medical Director Vicci Stone, Administrative Services Officer II Megan Herrington, Administrative Assistant

Marigrace Waage, Ambulance EMTs Chris Anderson, Lead Field Training Officer

AGENDA ITEM LEAD

Call to Order Introductions Dr. Eckert

Public Comment

Discussion Policies – DRAFT summary of final updates going to EMCC(attached) to see any of the polices in their full format pleasecontact Kathy at the EMS office kcollins@co.slo.ca.us

EMS Policy 601A -Universal Definitions – attached

Pediatric Arrest – discussion summary attached

Pediatric Intubation - discussion summary attached

D50 vs D10 – discussion summary attached

Dr. Ronay & staff

Adjourn Declaration of Future Agenda Items

Dr. Eckert

Meeting Dates for 2017 March 14 May 9 July 11 September 12 November 14

1015 hours - 2nd

floor Conference Room, Health Agency

San Luis Obispo County Public Health Department Policy # 601-A

Division: Emergency Medical Services Agency Effective Date: XX/XX/XX

UNIVERSAL ALGORITHM ADENDUM ADULT PEDIATRIC (≤34 KG)

HEMODYNAMIC DEFINITIONS

Medical Hemodynamic Instability SBP < 100 mmHg

Evidence of poor perfusion - capillary refill,color, temp, etc.

ALOC or GCS ≤ 13

Shortness of breath

Pulmonary edema

Trauma Hemodynamic Instability

SBP < 90 mmHg Evidence of poor perfusion - capillary refill,

color, temp, etc.

GCS ≤ 13

Respiratory rate < 10 or > 30/minute

Pulse > 120 BPM

Medical Hemodynamic Instability Evidence of poor perfusion - capillary refill,

color, temp, etc.

ALOC or GCS ≤ 13

Shortness of breath

Pulmonary edema

Trauma Hemodynamic Instability GCS ≤ 13

Evidence of poor perfusion - capillary refill,color, temp, etc.

Respiratory rate:o > 60/min or apneao < 20/min in infants < 1 yr

Heart Rateo ≤ 5 yrs. (< 22Kg) - < 80/min or >

180/mino ≥ 6 yrs. (23-34 Kg) - < 60/min or >

160/min.

Blood Pressureo Newborn (< 1 mo.) SBP < 70 mmHgo Infant (1 mo-1 yr.) SBP < 70 mmHgo Child (1 yr-10 yrs.) SBP <70mmHg

+ (2X age in yrs.)o Child (11-14 yrs.) SBP <90 mmHg

OTHER DEFINITIONS FOR BOTH ADULT AND PEDIATIRC

Patient status:

Stable – A&O X 4 with vital signs within normal range and the expectation to remain consistent

Unstable – Vital sign are not normal or there is the potential to change, and the possibility of adecline in the patient’s condition

Extremis – At the point of death, unable to ventilate or establish venous accessAbsent Signs of Life - Results of the physical exam:

o Signs of obvious death Decapitation Evisceration of heart or brain Incineration Rigor mortis Decomposition

o Lack of pulseso Apneico Lack of heart and lung sounds,o Fixed and dilated pupils,o Presence of skin lividityo Confirmation of ECG tracing and capnography readings if available

San Luis Obispo County Public Health Department Policy # 601-A

Division: Emergency Medical Services Agency Effective Date: XX/XX/XX

Notes

Treatable/Reversible Causes for Critical Patients

Hypoxia

Tachycardia/Bradycardia

Hyper/Hypotension

Hyper/Hypovolemia

Altered Mental Status

Fractures/Bleeding/Tension Pneumothorax

Anaphylaxis

Chest Pain

Overdos

2180 Johnson Avenue, 2nd floor San Luis Obispo, California 93401

(805) 788-2511 FAX (805) 788-2517 www.sloemsa.org

Jeff Hamm Penny Borenstein, M.D., M.P.H.

Health Agency Director Health Officer

COUNTY OF SAN LUIS OBISPO HEALTH AGENCY

Pu b l i c H e a l t h D ep a r t m en t

Emergency Medical Services Agency

PLEASE POST

SLO County Emergency Medical Services Agency Bulletin 2015-03 January 20, 2017 Policies and Procedure Updates The entire Policy and Procedure Manual for San Luis Obispo County EMS has been

reviewed, reformatted and revised. The attached matrix provides an overview of the

changes.

A Power Point review presentation and post review questionnaire has been developed

for your use. Each agency shall be responsible for ensuring their staff have reviewed

the changes and shall have documentation that their staff has completed the policy

review exam.

Highlights

New Format – all policies were reformatted to meet County policy format

BLS and ALS treatment polices were merged and include both adult and pediatric

treatments.

Renumbering of treatment protocols and procedures occurred with merging

The content of most polices remained unchanged. Policies and protocols with

significant changes are included in the attached matrix

See the EMS website for the full text of all the policies - www.sloemsa.org

Please feel free to contact the EMS Agency, with any additional questions.

Kathy Collins, R.N. Interim EMS Division Director Specialty Care Systems Coordinator 805-788-2514 kcollins@co.slo.ca.us

DRAFT !!!!!!

2

Attachments: Matrix of changes

Policy # Policy Name Change

Administration

100 Quality Improvement The State EMS Authority approved EMS QI

Plan has been added and procedure

updated

Communication and Documenting

120 (old #) Procedure to Secure MedCom

Radio System

DELETED - obsolete

121 Paramedic Base Station

Report – NEW

NEW format

Requires each radio base contact to be

preceded by the call type i.e. Alert,

Consult, Medication Request,

Notification etc.

Language added to clarify what

information should be transmitted with

each call type

NEW Trial study with Marian Medical Center

Paramedic may communicate

directly with Marian Medical Center

(MMC) for south county patients

going to MMC that do NOT require

base orders or consultation

o Notifications o STEMI Alerts o Trauma Alerts (Step 1&2) o Stroke Alerts o ROSC – no additional orders needed

121 - A Attachment – Base Hospital

Notification Matrix -NEW

NEW - A matrix to identify which Base

Hospital should be contacted in each of the

notification situations

124 -A Documentation of Prehospital

Care

Updated list of accepted abbreviations

125 Determination of Death/DNR -

NEW

NEW –Determination of Death and the DNR

policies were combined into one policy –

Language added to clarify criteria for

determining death and if/when a Base

contact is required

BLS may determine death when:

The criteria of Obvious Death are

present. Or

The patient is absent sign of life (vital

3

signs) and confirmed the patient is

the person with the DNR order.

ON Duty EMT, Paramedic or Flight Nurse

may determine death (NO BASE CONTACT

REQUIRED) when:

Reliable history of cardiac arrest with

no CPR for more than 20 minutes

Blunt traumatic arrest - absent signs

of life (pulseless/apneic) upon EMS

arrival

Penetrating traumatic arrest - absent

signs of life upon EMS arrival and

the transport to a Trauma Center or

a receiving hospital is greater than

20 min

Severe or multiple injuries clearly

incompatible with life.

Treatment was initiated and

information became available, that

would have prevented the initiation

of resuscitation were the information

available before resuscitation was

initiated, (i.e. Physician Orders for

Life Sustaining Treatment

(POLST) or advanced directive).

CONSULTATION with STEMI Base

(French) for:

For termination of resuscitative

measures for medical cardiac arrest

> 34 kg unresponsive to ALS

procedures after 20 min of

resuscitation (may include a

sustained capnography reading of

< 10 mmHg).

Left Ventricular Assist Device (LVAD)

or other similar mechanical

ventricular device is present

125-A Attachment – Algorithm for

determination of death - NEW

NEW

Flow chart for Policy 125

Destination and Transport

150 Physician Request for Transfer

of Patient By Ambulance

ADDED Advanced Practice Provider” (Physician Assistant or Nurse Practitioner) in addition to a physician may request “ambulance only

4

response” for certain situations

152 STEMI Triage and Destination UPDATED to include:

ROSC shall be transported to a STEMI receiving center regardless of 12 lead

Clarity: Refractory V-Fib/V-Tach - consult with STEMI Base for destination

154 Diversion ADDED

A hospital shall notify MedCom and the transporting agencies of a scheduled maintenance that would place a hospital on partial diversion i.e. CT scanner 24 hours in advance when possible

When a hospital is on diversion they shall continue to remain the intended base/specialty Care center for medical control and destination

155 EMS Helicopter Operations UPDATED

Verbiage was modified to simplify the requesting criteria for dispatch and first responders.

The requirement of poling prior to dispatching into the expedited launch areas was eliminated. The county is divided into two primary response areas.

Med Com shall remain the sole dispatcher for EMS aircraft.

An updated map is available and has been supplied to Med Com.

Trauma patients meeting Step 3 or 4 utilizing EMS aircraft shall continue consult with the Trauma Center for EMS aircraft destination.

Trauma patients meeting Step 1 or 2 shall continue to be transported to the closest trauma center (which could be out of the county)

155 A-F EMS Aircraft Operations

attachments A through F

Attachments updated to reflect policy

changes

Opportunity for Improvement form to be

completed for calls that fall outside of

policy

Expedited Launch Zones - narrative

Maps with expedited zones and county

division lines

Flight Times and Landing Zone Safety

and Selection information

EMS Aircraft Request and Destination

information

5

Operations

208 Out of County Paramedic in

SLO County During

Emergency Operations -

UPDATED

UPDATED to comply with Fire Scope

language:

The ordering point, dispatch center,

Logistics Section Chief or Medical Unit

Leader shall notify the EMS Agency Medical

Director or other designated EMS Agency

staff member in a timely manner when out-

of-county paramedics are assigned to

function as a paramedic in strike teams or

other mutual aid response entities assigned

and present in the County of SLO.

209 A Use of SLO Paramedic

Outside of SLO County -

UPDATED

UPDATED:

Controlled substance inventory updated:

MS – quantity 2

Midazolam – quantity 2

210 MCI Plan - REVISED NEW -See separate training memo

LEVEL l – 3-10 patients

Level ll – greater than 10 patients

210 -A MCI Matrix - NEW NEW:

Matrix reviewing the roles during a MCI

Education and Training

350-351 MICN Authorization/Re-

authorization

For clarity these are now two separate

polices

BLS /ALS

Changes to all treatment protocols and procedures include:

Reformatting

Merged BLS and ALS

Merged Adult and Pediatric

Pediatric treatment protocols based on weight ≤ 34Kg

New policy numbering

o General Treatments (601 - 603)

o Medical (610 - 621)

o Environmental (630 - 632)

o Cardiac (640 - 644)

o OB/GYN (650 - 651)

o Trauma (660)

o EMS Procedures (701 - 712)

Treatment Protocols

General

601 Universal Referenced in all policies

Replaces “IV Therapy/Hypotension”

protocol which was commonly used for

6

routine patient care

602 Airway management CHANGE - emphasis on applying O2 to

only those in need

O2 administration is not required with O2

Sat > 94%

When applying O2 use the simplest

method to maintain O2 Sat > 94%

Do not withhold O2 if a patient is in

respiratory distress

603 Pain Management ADDITION:

Added to standing orders for Morphine

administration - “dislocations and burns

without associated multi-trauma”

Ondansetron maybe given for “severe”

nausea and vomiting associated with

MS administration

Burns associated with trauma should

transported to TC

Burns not associated with trauma -

transport to the nearest hospital for

evaluation and stabilization

Medical

610 Abdominal Pain - NEW No changes

611 Allergic Reaction CHANGE:

Benadryl dose for adults changed to 50 mg

IV/IM (no longer weight based)

612 Altered Level Of

Consciousness

CHANGES/ADDITIONS

Narcan administration for respiratory

depression move to Respiratory

Distress (Opiate Overdose) Policy #618

613 Behavioral CHANGES/ADDITIONS:

Added IN route for pediatric Midazolam

Pediatric IN volume - up to 0.3 ml per

nostril

Added a reference for the use of

restraints Procedure # 711

Added language regarding the removal

of tasers by law enforcement

614 Ingestion/Poisoning - NEW MOVED - Activated Charcoal now a ALS

standing order

CHANGE – Adult and Pediatric dose of

Activated Charcoal – Adult 50 Gm and

Pediatric 25 Gm ( no longer weight

7

based)

615 Nausea and Vomiting No changes

Respiratory Distress Respiratory distress is now 3 separate

policies

o Bronchospasm

o CHF

o Respiratory depression - Opiate

OD

616 Respiratory Distress –

Bronchospasm - NEW

ADDED to bronchospasm – treatment for

Croup

617 Respiratory Distress

Pulmonary Edema - NEW

NEW - separate policy

No new treatment changes

618 Respiratory Distress - Opiate

Overdose - NEW

NEW – A separate policy to capture other

respiratory depression from opiate OD

CHANGE: Narcan titration changed to:

“Administer up to 1 mg IV/IM –assess

for adequate respirations, repeat as

needed”

CHANGE: SL dose of Narcan changed

to 0.5 mg from 0.4mg

ADDED – use of O2 Sat < 94 % to

assess respiratory status to determine

the need and response to Narcan

619 Shock - Medical No changes

620 Seizure (Active) No changes

621 Suspected TIA/Stroke Includes BEFAST – stroke evaluations

Environmental

630 Bite/Sting/Envenomation -

NEW

NEW Policy

References Allergic Reaction Policy

#611

Added marine envenomation treatment

631 Hyper and Hypothermia - NEW NEW policy

632 Hazardous exposure Moved to a Policy XXX

Cardiac

640 Chest Pain No Changes

641 Adult/Pediatric Pulseless

Arrest - UPDATED

UPDATED

High Performance CPR (HPCPR)

Procedure # 712 was separated from

Pulseless Arrest Policy #641

HPCPR now considered for all non-

traumatic arrests

No medication changes

ROSC is transported to a STEMI hospital

8

regardless of 12 Lead in adults

French Hospital is the Base Hospital for

cardiac arrest and terminations

French Hospital is the base for treatment

and destination of refractory V-fib/V-

tach

Non-cardiac arrests i.e. OD and drownings,

contact the closest base hospital

NEW for Pediatric Pulseless Arrest

o Added: stay on scene to establish

vascular access, provide for

airway mamagement, and first

dose of epinephrine (if

appropriate) followed by 2 min of

CPR.

o Minimize interruptions to < 5

seconds

o Do not hyperventilate – small

volume over 1 second at 15:2

o Pediatric arrest are transported to

the closest hospital

641 - A Adult Pulseless Arrest

algorithm

HPCPR

Compression to ventilations ratio of 10:1

ROSC, termination, or consultation with

French Hospital STEMI Base

641 - B Pediatric Pulseless Arrest

algorithm

HPCPR

Compression to ventilation ratio of 15:2 and

transport to closest hospital

642 Supraventricular Tach No treatment changes

643 V- Tach with Pulses No treatment changes

Definition for Atrial Fib with RVR added

644 Bradycardia CHANGE

Atropine for unstable pediatric cases now a

base order. Epinephrine drug of first choice

in pediatrics

OB/GYN

650 Childbirth ADDED

Seizure treatment with eclampsia

651 Newborn No treatment changes

Resuscitation pyramid added

Reference to not intubate or suction low

vigor meconium stained newborns per AHA

9

guidelines

Trauma

A NEW series of trauma treatment policies - added

660 General Trauma - NEW NEW

BLS

Hemorrhage control – see Tourniquet

and Hemostatic Agents Procedure #

706 for approved list

Spinal motion restriction (SMR)

Procedure # 702

Re-emphasizes TC notification of ANY

episode of hypotension

ALS

Treatment for traumatic hypotension

emphasizes the use of less volume –

use up to 500 cc boluses

Add Saline Lock to IV tubing in the

unstable patient

Pelvic binder for pelvic iinjury with

hypotension

660 - A General Trauma Addendum for

BLS trauma care ADDED -

List BLS treatment for

Facial injuries

Impale objects

Chest injuries

Abdominal injuries

Pregnancy

Extremity injuries

665 Burns – NEW NEW - Fluid administration, dry dressings

after stopping the burning process, and pain

control updated per current burn guidelines

NEW - transport burns associated with

trauma to TC all others to closest hospital

Procedures

701 ETCO2 No changes

702 Spinal Motion Restriction

(SMR) – NEW for BLS and

ALS

NEW –

This is a BLS skill

Goal is to use backboard for only those

that meet criteria , extrication and

transfer purposes

Based on Canadian Nexus criteria

702-A Attachment A – matrix for

applying SMR

NEW - Algorithm SMR clearance and/or

application

10

703 CPAP RESTATED indications to include:

Acute pulmonary edema

COPD

Asthma

Drowning

Pneumonia

Somnolent/ALOC i.e. OD

704 Needle Cricothyrotomy No changes

705 Needle Thoracotomy -NEW NEW added a procedure – had not existed

in the past

706 Tourniquet/Hemostatic Agents ADDED-

Sequential use of pressure dressings and

tourniquets prior to using hemostatic agents

706-A Attachment A -

Tourniquet/Hemostatic Agents

ADDED

The approved hemostatic agents

707 12 Lead EKG No change

708 AED No Change

709 Intranasal medications ADDED

Pediatric ideal volume of 0.25 to 0.3ml

710 Vascular Access CHANGES/UPDATES

BLS may monitor IV fluids that do not

contain medications or electrolytes

Emphasizes vascular access as

preferred route

REMAINED: Two peripheral attempts

prior to IO

REMOVED -90 sec prior to IO attempt

ADDED: “Continue to attempt peripheral

IV access after IO established”

REMOVED – monitoring IV with

Potassium added- Potassium is no

longer an EMS approved drug for

paramedics

711 Patient Restraints MOVED from Operations – no changes

712 High Performance CPR

(HPCPR) - NEW

NEW Procedure – HPCPR procedure

separated from cardiac arrest treatment for

both adult and pediatric

ADDED - Pediatric HPCP procedures

Drug Formulary Changes

Activated Charcoal CHANGE: (no longer weight based)

Adult 50 Gm PO

Pediatric 25 Gm PO

11

Atropine CHANGE;

Pediatric Symptomatic Bradycardia – Atropine is now a Base Order

Diphenhydramine CHANGE: (no longer weight based for allergic reaction)

Adult dose to 50 mg

Naloxone CHANGE Adult

Titrate up to 1 mg IV/IM – repeat to maintain adequate respirations (IV preferred route)

Extremis: 0.5 mg SL - repeat to maintain adequate respirations

Pediatric

Titrate 0.1 mg/kg IV/IM-to a maximum dose of 1 mg – may repeat to maintain adequate respirations

Extremis 0.5 mg SL - repeat to maintain adequate respirations

Oxygen Change in indications:

Patients who have oxygen saturations ≥ 94% without signs or symptoms of hypoxia or impending respiratory compromise/distress should not receive O2

When applying O2 use the simplest method to maintain O2 Sat ≥ 94%

Do not withhold O2 if patient is in respiratory distress Potassium REMOVED from Drug Formulary

Discussion Item History Recommendation

Pediatric Intubation

Pediatric intubation is considered an optional skill for Paramedics by the State EMS Authority. To continue to keep it in SLO County the EMS agency needs to submit information to continue the skill as a trial study. Historical data: 2016 – 3 patients

5 mo. Successful 3 yr. – successful NB – unsuccessful

2015 – 4 patients 8 yr. – unsuccessful – facial trauma 8 mo. Successful 4 yr. – unsuccessful NB – successful – meconium stain (No longer AHA recommendation)

Number of EMS agencies with optional pediatric intubation skill - 26

Discussion to continue to monitor and apply for extension of the optional skill or discontinue

Pediatric Pulses Arrest

High Performance CPR has seen some very good results in the adult population. A review of literature for the pediatric arrest suggested the following:

Pediatric patients ≤ 34 kg

o Stay on scene to establish vascular

access, provide for airway

mamagement, and administer the

first dose of epinephrine (if

appropriate) followed by 2 min of

CPR.

Articles: Pediatric Pit Crew CPR, EMS 12 Lead, June 2014, Tom Bouthillet Resuscitation. 2015 Sep;94:1-7. doi: 10.1016/j.resuscitation.2015.06.012. Epub 2015 Jun 19. Time on the scene and interventions are associated with improved survival in pediatric out-of-hospital cardiac arrest./Tijssen JA1, Prince DK2, Morrison LJ3, Atkins DL4, Austin MA5, Berg R6, Brown SP2, Christenson J7, Egan D8, Fedor PJ9, Fink EL10, Meckler GD11, Osmond MH12,

Recommendation: Add to pediatric pulseless arrest policy

Sims KA2, Hutchison JS13; Resuscitation Outcomes Consortium.

D50 vs D10 Several studies recommend the use of D10 over D50 for a number of factors, including:

Feasibility

Availability (single medication)

Safety (no dilution required)

Efficiency Findings:

Study suggested – higher concentration of dextrose did not expedite reversal of hypoglycemia

Lower concentrations more likely to achieve normal glycemic values

18% repeated dose

Effective

No adverse effects

An amp of D50 provides five times the amount of glucose in a normal adult’s blood. The PALS-recommended pediatric dose of 0.5-1g/kg of glucose (diluted to D25, D12.5 or D10) provides 6-11 times the amount of glucose in the blood of a normal child. The recommended pediatric dose administered over a minute or two provides 50-100 times the amount of glucose that the body can use during that time

Articles: Dextrose 10% in the treatment of out-of-hospital hypoglycemia./Kiefer MV1, Gene Hern H1, Alter HJ1, Barger JB D50 vs D10 for Severe Hypoglycemia in the Emergency Department December 31st, 2014 | Endocrine-Metabolic, Expert Peer Reviewed (Clinical), Pre Publication Critique (Clinical) |11 Comments /By: Adam Spaulding, PharmD BCPS Emergency Physician Monthly, D10 May Be Better Than D50 For Acute Hypoglycemia/ By Paul Rostykus, MD, MPH ON August 27, 2015

Recommendation: Change EMS administration from D50 to D10 Dosing: (from Alameda EMS) Adult: 100 ml of D10 (10 g) Pediatric: NB : 2ml/kg of D10 (0.2g/kg) Pediatric: all other 5ml/kg (0.5g/kg) to a max of 10 ml or 10g Recheck BG in 5-10 min. Repeat 50 ml (5g) to total of 150ml (15g) if BG remains below 60