EMS PROTOCOL ROLL-OUT 2014 Cleveland Clinic Regional Hospitals EMS
Don Spaner, MD CCF East Region Medical Director
Scott Wildenheim, Paramedic, EMSI
OVERVIEW
New Safety FeaturesMedication ConsolidationStandardized TerminologyScope of Practice UpdatesFirst Patient Contact to 12 Lead Parameters AddedCapnography Stressed / Added
SAFETY - CAUTIONS / STOPS
Cautions Allows us to put warnings
immediately adjacent to medication or procedure to assure key points are remembered
Stops On page reminder to keep
certain actions from occurring without lengthy explanation in key points that will likely be forgotten, missed, or misunderstood.
GROUPED INTERVENTIONS
Actions / interventions grouped in protocol, reflecting the way it would actually be done in field, rather than individual boxes
CONTACT MED CONTROL
Current Old CONTACT MEDICAL
CONTROL red box confusing, makes it seem like every patient contact required call to Medical Control
Revised Box
Spells out events as they are actually performed
WHO TO CONTACT?
YOUR MEDICAL CONTROL IS HILLCREST HOSPITAL.
THE PATIENT WANTS TO BE TRANSPORTED TO CCF MAIN AS THEY HAVE A FEVER AND THE LVADPLACED 2 MONTHS AGO, HAS AN INFLAMED TENDER SURGICAL SITE.
YOUR FOLLOW YOUR PROTOCOL, START AN IV AND TRANSPORT.
WHO DO YOU CALL TO GIVE A REPORT?
HILLCREST OR CCF MAIN?
FIRST PATIENT CONTACT TO 12 LEAD
First patient contact to 12 lead acquisition and transmission interval added where ACS may be causative factor
Affected Protocols ACS CHF Abdominal Pain Respiratory Distress Altered LOC
Stroke
SCOPE OF PRACTICE CHANGES Effective date 10.16.2013 Mainly affect EMT and AEMT
VERBIAGE CHANGES
All protocol pages updated to be consistent with Ohio EMS Scope of Practice / OAC
Titles changed throughout protocol to new standards
EMT(Formerly EMT-B)
AEMT(Formerly Intermediate)
Paramedic (Formerly EMT-P)
EMT SCOPE CHANGES
Intubation for EMT removed Jan 1, 2013
Still only permitted to use advanced supraglottic (King / LMA) airways on pulseless and apneic patients
EMT SCOPE CHANGES (CONT)
Direct laryngoscopy removed for EMT of FBAO
EMT SCOPE CHANGES (CONT) NTG, Aerosols still “patient assisted” which
includes online Med Control order
Epi Pen added for protocol use
EMT SCOPE CHANGES (CONT)
Intranasal Naloxone (Narcan) permitted for all first responders and EMT’s
AEMT / Paramedic allowed to use IM / IV as well
Used to reverse the respiratory effects of narcotics
NALOXONE (NARCAN) PHARMACOLOGY
Class and Mechanism of Action
Narcotic antagonist Competes for and binds to
narcotic receptors in the brain Reverses respiratory
depression associated with narcotic overdose
Works on narcotics only
Heroin Morphine Fentanyl Dilaudid Codeine Methadone Percocet Demerol Not a complete list
NALOXONE (NARCAN) PHARMACOLOGY
Contraindications None if patient not breathing
or breathing insufficiently
Precautions May cause withdrawal effects
in opiate dependent patients (Hypertension, tachycardia, N&V, etc)
Indications Altered mental status AND; Patient breathing
insufficiently (Low resp rate high Co2)
Patient not breathing at all (Resp rate 0, no Co2 or waveform)
NALOXONE (NARCAN) ADMINISTRATION
Push hard push fast to atomize
1ml / per nostril limit Carried 2mg in 2ml Half of the syringe in each
nostril
CASE: 18 Y/O FEMALE UNRESPONSIVE AT A PARTY
GLUCOSE 80 RESPIRATIONS 6,
SNORING RESPIRATIONS B/P= 90/70 P=120 POX=80 TREATMENT?
CASE:20 Y/0 MALE SLEEPING IN FRONT OF GOODWILL STORE
EASILY AROUSED POX=96% R=14,P=90,B/P 120/80 INTACT AIRWAY KNOWN HEROIN ABUSER TREATMENT?
AEMT SCOPE CHANGES
Advanced EMT now allowed to INTUBATE APNEIC as well as PULSELESS andAPNEIC patients
Advanced EMT now allowed to use supraglottic airway (King / LMA) on APNEIC as well as PULSELESS andAPNEIC patients
VAD PROTOCOL Not specific to LVAD (most
common) Encompasses all types,
LVAD, RVAD, BiVAD Emphasis on correct
transport destination (Implantation Center)
Emphasis on keeping power to unit
Emphasis on Contacting specialized VAD team following patient
New Protocol !
TRACH PATIENT MANAGEMENT
Verbiage added in Adult Airway and Adult Respiratory Distress in key points regarding managing Trachpatients
Emphasis on suctioning and maintaining open airway
Emphasis on replacing uncuffed Trach tubes with ET tube if ventilation required
LUCAS CPR DEVICE
Added at request of departments that utilize the device – not required by protocol
Automated CPR device Use in medical arrest
situation only Patients > 12 years old Contraindications – Trauma
Arrest / Patient will not fit device
Manual CPR must continue while device is being prepared and placed
NEW!
NEW POLICY
New Department Supplied Equipment
Allows individual departments to purchase devices not specifically outlined in protocol and have their respective Medical Directors authorize its use
Departments required to have written policy on its use
Updated Restocking Policy
CCF updated EMS Medication and Equipment Policy will be added
MEDICATION CONSOLIDATIONLORAZEPAM (ATIVAN) Lorazepam (Ativan) replaces 1 - Midazolam (Versed) 2 / 22 - Midazolam (Versed) 5 / 13 - Diazepam (10 / 2) as the Benzodiazepine of choice all protocols
Lorazpam (Ativan) storage 90 days unrefrigerated Till expiration date
refrigerated
Affected Protocols
Adult Airway ACS Adult Bradycardia Adult Narrow Complex Tachycardia Adult Wide Complex Tachycardia Adult Extremity Trauma Adult Seizure Peds Bradycardia Peds Narrow Complex Tachycardia Peds Seizure
OB Emergencies
MEDICATION CONSOLIDATIONLORAZEPAM (ATIVAN)
Comparison 1 mg Lorazepam (Ativan) =
approx 10 mg Diazepam (Valium)
Half Life 10 Hours
RoutesIntravascular (IV)Intraosseous (IO)Intramuscular (IM)
Intranasal (IN)
Supplied2 mg / 1 ml Carpuject
CASE: SOLDIER STARTS SEIZING AT COMPUTER TRAINING CENTER
AFTER INITIAL SEIZURE HE IS POSTICTAL.
BS=130 VS:140/90, P=120,R=20 COMPLEX GENERALIZED
SEIZURE REOCCURS. TREATMENT?
DIALYSIS PATIENT SYMPTOMATIC HYPERTENSION Added to Dialysis / Renal
Patient protocol to remind Paramedics agents are available for specific situations where prehospitalintervention of hypertension may be indicated
Routine management of hypertension is not recommended – for specific situations
Medical Control contact required
Follows similar BP measures found in Stroke / CVA protocol ( SBP 220 or DBP 120 )
Patient is symptomatic pre/post dialysis HTN PT ( dizzy, HA, Diaphoresis, blurred vision)
Labetalol 10 mg IV with Med Control Consult
Labetalol 20 mg IV with Med Control Consult
WHAT IS HTN EMERGENCY?
SIGNS OF END ORGAN DAMAGE DUE TO SEVERE ELEVATED B/P.
NEUROLOGIC SYMPTOMS CARDIAC SYMPTOMS RENAL SYMPTOMS ANY PRE HOSPITAL
TREATMENT REQUIRES MEDICAL CONTROL ORDER SOLDIER!
MEDICATION CONSOLIDATIONDEXTROSE D50 – Adult Only D25 – Peds Only D10 – Neonate, Peds, and
Adults Need to carry for neonates
anyway, can be used in any population
Simplifies administration if department chooses D10
Safer
Affected Protocols
Altered LOC Diabetic Emergencies Peds Altered LOC Peds Asystole / PEA Peds Diabetic Emergencies Peds Head Trauma Peds Seizure Peds Shock Neonatal Resuscitation
DEXTROSE 10% PHARMACOLOGY Required use in Neonate Can be used in all patient
populations (Adult, Peds, Neo)
Not required use in Peds / Adult – Department Choice
1 Bag 250 ml D10 = 25 Grams Dextrose (Same as 1 AMP D50)
Not as thick, piggyback on already established IV –Hands free – Can Hand Push from syringe
5-2-1 RULE FOR DEXTROSE
D10 MUST BE USED FOR INFANTS UNDER 12 MONTHS OF AGE.
D25 AGE 1-15 D50 ADULT
D10= 5CC/KG D25=2CC/KG D50=1CC/KG
STANDARDIZED BP TERMINOLOGY
NEW STANDARD TERMINOLGY
IV NORMAL SALINE BOLUSTo Maintain SBP 90 or Radial Pulses
Changed from specifying bolus amount to what is done in practice
CAPNOGRAPHY Added wherever there may be
potential for gross abnormalities in ventilation, perfusion, or metabolism
Already required by AHA for intubation
Added where sedation or multiple doses of respiratory depressants medications are used
Lorazepam (Ativan) for procedural sedation and seziures
Second doses of Morphine or Hydromorphone
Affected Protocols
Adult Medical Adult Trauma Peds Medical Peds Trauma OB Emergencies
HOSPITAL CAPABILITIES
Updated and enhanced with additional services
AIRWAY Direct laryngoscopy
removed for EMT Lorazepam replaces
midazolam Apnic oxygenation for
intubation Stops for head injury,
medications down supraglottic airway
Advanced airway use rules as cautions for EMT / AEMT
ACS First Patient Contact to
EKG timeframe added Stops added for NTG Pathway added for;
Clean 12 lead with suspicion of MI, perform right sided 12 lead
Lorazepam (Ativan) replaces Midazolam / Diazepam for cocaine induced STEMI
CHF First Patient Contact to
EKG timeframe added Stops for NTG, CPAP,
and ResQGARD added Captopril blue boxed,
assuming no stops prevent administration
Lasix remains red boxed per best practices
Cardiogenic shock highlighted (gray box) to remind providers its not “hypotensive CHF”
ANAPHYLACTIC SHOCK
Stops added for 1:1000 vs: 1:10000 IV, Solu-Medrol, and Albuterol for EMT use
EPI – PEN added in protocol for EMT use
Anaphylactic shock highlighted (gray box) to remind provider that the patient needs IV medications rather than IM
CASE:ANAPHYLAXIS AFTER EATING TRAIL MIX BAR
PATIENT COLLAPSE POX=70% B/P 60/40 P=120 R=30 TREATMENT?
RESPIRATORY DISTRESS
Albuterol / Atroventyellow boxed with STOP for EMT use without direct Medical Control
First Patient Contact to EKG timeframe added
Stops added in CPAP and Solu-Medrol
CPAP REMINDERS CPAP DOES NOT
VENTILATE. CPAP IS USED FOR
OXYGENATION AND TO OPEN UP AVEOLI.
COPD AND ASTHMA PATIENTS HAVE DISTENDED AVEOLI AND CPAP MAY CAUSE BAROTRAUMA TO THESE PATIENTS. LAST DITCH USE FOR EXTREME HYPOXIA.
WE DO USE BIPAP FOR THESE PATIENTS
MAJOR USE IN PRE HOSPITAL IS CHF.
CAN’T USE IN HYPOTENSION.
CAN’T USE WITH FACIAL TRAUMA.
CAN’T USE WITH VOMITING OR AIRWAY ISSUES, INCLUDING ALTERED MENTAL STATUS.
CAN’T USE WITH PNTX TILL TREATED.
STROKE Improved Cincinnati
stroke scale to help catch posterior circulation problems
CincinnatiPlus Added Visual Fields,
Following, and Acuity Labetalol blue boxed
with cautions and stops
First Patient Contact to EKG timeframe added
ADD FINGER NOSE FINGER FOR CEREBELLAR TESTING.
ADD FIELD OF VISION TESTING AND EXTRA OCCULAR MOVEMENTS TO TEST OCCIPITAL AREA AND BRAINSTEM.
PSYCH EMERGENCIES
Lorazepam (Ativan) added as sedative in addition to Haloperidol / Diphenhydramine
PEDS HEAD TRAUMA
Capnography targets added to mirror adult head trauma