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2014 Protocol Roll-Out

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2014 Protocol Roll-Out

2014 Protocol Roll-Out

Protocol Manual Lay-OutForeword Terms and ConventionsAdult Treatment ProtocolsPediatric Treatment ProtocolsOperations ProtocolsProcedures ProtocolsFormularyAppendices

The layout of the protocol manual has changed little in the new algorithmic iteration. It consists of the forward, a table of the terms and conventions used in the manual, the adult treatment protocols and pearls, pediatric treatment protocols and pearls, operations protocols, procedure protocols, the formulary and the finally the Appendices. 2ForewordGoal is to standardize care delivered in Clark CountyScope is limited to licensed personnelAlgorithm defines sequence but allows for critical thoughtProtocol deviations are allowed under defined circumstances

The forward has changed a bit. Language was added to limit the use of the protocols to licensed attendants. The protocols allow for the attendant to critically think through the process. The protocol deviation procedure remains unchanged. 3ForewordProtocol Key

The protocol key defines icons used throughout the document. The level indicators E, A and P show the minimum level that is authorized to perform a specific task. The manual shows the new level of certification and they will be used throughout this presentation. The levels in the protocols mean that a paramedic may perform the tasks of a paramedic, AEMT and an EMT. An AEMT may perform the tasks of an AEMT an EMT and an EMT may perform those tasks indicated. 4ForewordPatient definitionPediatric patient considerationsMiscellaneous

The definition of a patient as shown in the foreword is any individual that meets one of the following: 1) A person who has a complaint or mechanism suggestive of potential illness or injury; 2) a person who has obvious evidence of illness or injury; or 3) a person identified by an informed 2nd or 3rd party caller as requiring evaluation for potential illness or injury.

Pediatric considerations include transport of patients less than 18 years to a pediatric receiving facility, and that pediatric protocols are to be used, unless otherwise defined in the particular protocol, in children who have not yet experienced puberty as defined in the AHA guidelines.

The rest of the foreword includes lists of medical directors, SNHD staff and hospital addresses and phone numbers.5Terms and ConventionsShows common abbreviations used in the documentExample below

The terms and conventions pages list common abbreviations used throughout the document.6Treatment ProtocolsFormatAlgorithmPearls

As you will soon see the treatment protocol have been separated into adult and pediatric. This is probably the most significant difference in the new protocol format. Adult protocols and pearls are listed first and pediatric protocols and pearls second. The protocols are presented in an algorithmic format with decision guides to assist with flow. After each algorithm a second page lists important pearls in the assessment and management of the patient. The algorithm and the pearls compliment each other and you should be familiar with both.7Adult Treatment ProtocolsGeneral Adult Assessment

The general adult assessment directs the provider to the most appropriate treatment protocol based on the primary assessment. The example above shows the first portion of the protocol and the decision guides. The decision guides are not comprehensive as you can see in the level of consciousness assessment. The protocol asks if the patient is unresponsive and then if the patient has a pulse. This method is followed through the remainder of the assessment. This protocol was previously an 8 page section that included multiple aspects of patient care such as documentation, communication, disposition, TFTC criteria, etc. These items have now been moved to dedicated sections within the Operations portion of the protocols. 8Adult Treatment ProtocolsGeneral Adult Assessment Pearls

Half of the pearls page is listed here. Valuable information includes the FAO-Hospital link number, transport guidelines and waiting room triage guidelines (not shown)9Adult Treatment ProtocolsGeneral Adult Trauma Assessment

We added the general adult trauma assessment to the protocol manual to help guide with the assessment of trauma patients. It doesnt take the place of the Trauma Field Triage Criteria (TFTC) in determining who is a trauma system patient. The decision guides are based on input from our trauma system physicians. The secondary survey does not include all injuries but includes a few of the possible injuries that should be considered. 10Adult Treatment ProtocolsAbdominal/Flank Pain, Nausea & Vomiting

The Abdominal /Flank pain, Nausea & Vomiting protocol has changed only in format from the previous version. The pearls page includes guides for history, signs & symptoms and possible differential diagnosis. The pearls also include a recommended exam process and other information.11Adult Treatment ProtocolsAcute Coronary Syndrome (Suspected)

This protocol looks a bit busy at first, but the key is in understanding what side of the protocol to follow from the initial decision point. Once the determination is made as to the presence or absence of a STEMI it is simply a matter of following the indicated side. Previously, ACS protocols were drafted with respect to levels of training (BLS vs ALS). Because provider levels are now built into the treatment algorithm, protocols such as this one can seem similar or repetitive, with only 1-2 key differences in management depending on a single factor (such as the EKG in this protocol). As with other protocols the pearls page is a compliment to the protocol. 12Adult Treatment ProtocolsAllergic Reaction

This is another protocol that is not measurably different than the current one. Because the provider levels are now color-coded into the treatment algorithm, this protocol now based on clinical severity (airway compromise, hypotension, etc) rather than the certification level of the responding providers. The pearls page lists the severity scale, special considerations and QI metrics that will be used by your QA coordinators to ensure that quality patient care is being delivered.13Adult Treatment ProtocolsAltered Mental Status/ Syncope

This protocol includes a middle section that shunts the provider to other treatment protocols based on assessment findings. Previously, the AMS protocol was a 3-page protocol that was fairly dense. It included seizure, hypoglycemia, and hemodynamic instability as causes of altered mental status, which were felt to warrant their own individual protocols to ensure consistent management. The treatment side of this protocol still includes hypoglycemia and opiate overdose. The pearls here are similar to others throughout the document in that they recommend assessment priorities and remind the provider to consider other causes for altered mental status.14Adult Treatment ProtocolsBehavioral Emergency

Behavioral emergency starts as the current protocol does with a new decision branch point added asking if the patient has threatened or acted in a way that suggests threat to self or others. This question is intended to gauge the possible risk to the providers and patient and guide the provider in deciding whether or not to use physical and/or chemical restraints. If chemical restraints are used a cardiac monitor must be attached. Additionally, end tidal CO2 monitoring may be useful in alerting the crew to potential complications. The pearls page includes information on excited delirium, dystonic reaction and defines the SAFER method. The approved formulary medications included in this protocol have been expanded to include droperidol and ketamine, if approved by the agencys medical director. 15Adult Treatment ProtocolsBradycardia

Bradycardia follows AHA guidelines and allows for the decision points post 12 lead acquisition if a STEMI is identified. This should alleviate previous confusion in regard to the use of Atropine versus pacing in the presence of suspected MI or chest pain. If the patient is bradycardic but not symptomatic the treatment is also indicated above. Pearls include QI metrics such as identification of high degree blocks, pacer pad placement if atropine is administered and appropriate pacing performed. 16Adult Treatment ProtocolsBurns

The Burns protocol branches at the determination of what caused the burn, be it thermal or chemical/electrical. Differences in management for Chemical and electrical burns were not previously accounted for in the previous protocol manual . Thermal management includes stopping the burning process and removing any smoldering clothing and jewelry. Its important not to try and remove clothing that is stuck to the patient. Thermal injury treatment includes saline infusion based on BSA burned and may be repeated. Pain management should be addressed as soon as practical. On the chemical/electrical side cardiac monitoring should be initiated quickly with the same consideration to pain management. The pearls include a graphic of the rule of nines. 17Adult Treatment ProtocolsCardiac Arrest (Non-Traumatic)

This protocol combines the old CCC protocol with some of the cardiac dysrhythmia protocols. The result is a more clinically relevent and organized protocol. A major change has been made in regard to providing early ventilations where hypoxia is suspected as the cause of the arrest. The pearls page include the Hs and Ts along with assessment guides. 18Adult Treatment ProtocolsChest Pain

The chest pain protocol has been arranged to provide for three general differentials each with specific treatment plans and one with a shunt to the ACS protocol. Note as with other protocols the method for providing oxygen is geared towards maintaining O2 saturation at or above 94%. The pearls section includes information regarding key history questions, differentials and notes on appropriate administration of nitroglycerine. 19Adult Treatment ProtocolsChildbirth/Labor

The previous Obstetrical and Gynecologic Emergencies protocol was quite broad, and included multiple specific entities (such as childbirth) that had their own unique management aspects. For this reason, the protocol was divided into a Childbirth/Labor protocol as well as a Obstetrical Emergencies protocol. The childbirth/labor protocol divides early into possible presentations of impending delivery and associated treatment paths for each. 20Adult Treatment ProtocolsChildbirth/Labor Pearls

The pearls section of the Childbirth/labor protocol includes information on APGAR scoring and what a normal APGAR score is so that this information can be accurately reported to the receiving hospital. This is a new addition to the protocol manual. 21Adult Treatment ProtocolsDrowning

The new Drowning protocol was developed with the assistance of Dr. Justin Sempsrott of Lifeguards Without Borders. This protocol was added to address a gap in the current manual as identified through providers and physicians. The initial decision branch point hinges on adequate ventilation and patent airway. Adequate ventilation should take precedence in these patients. Do not hesitate to ventilate the patient by BVM even if there is foam in the airway. These patients typically die from hypoxia, not from foam in the upper airway. The prevalence of C spine injuries associated with drowning incidents is less than 1%. Cervical spine immobilization should be considered but should not delay resuscitation. 22Adult Treatment ProtocolsDrowning Pearls

Pearls include history of submersion in water regardless of depth, duration of submersion and if the water has been contaminated. The caveats as presented above reiterate the use of good ventilation techniques in treating this patient population. 23Adult Treatment ProtocolsHyperkalemia (Suspected)

This protocol has been limited for use in patients with chronic kidney disease with suspected hyperkalemia. Continued therapy past albuterol is dependent on ECG findings. Patients with bradycardia, peaked t waves widened QRS or cardiac arrest are treated with Calcium Chloride and Sodium Bicarbonate. The pearls include assumed levels of potassium based on ECG findings. 24Adult Treatment ProtocolsHyperthermia

Two new protocols are geared towards environmental illnesses. The first one pictured here is the treatment algorithm for hyperthermia. Initial assessment should determine the severity of the heat illness. Under heat exhaustion one of the treatments include active cooling measures. These include application of ice packs, fanning or the use of air conditioning. Pearls include signs and symptoms of heat cramps, heat exhaustion and heat stroke. Heat cramps are relatively benign muscle cramps caused by dehydration that is not associated with an elevated body temperature. Heat exhaustion consists of dehydration, salt depletion, dizziness, altered mental status etc. Heat exhaustion includes tachycardia, hypotension and elevated temperature. Heat stroke also consists of dehydration, tachycardia, altered mental status hypotension and very high body temperature > 104f.25Adult Treatment ProtocolsHypothermia

The second environmental illness protocol if for the treatment of hypothermia. The degree of exposure and level of consciousness drive the treatment plan from the localized cold injury to systemic hypothermia with unresponsiveness. Active warming measures include the use of hot packs and heaters to re-warm the patient. Pearls include definitions of mild, moderate and severe hypothermia based on body temperature. Mild is 90 to 95 f Moderate 82-90 f and severe 94 or >90 for home o2 patients or those with chronic conditions such as COPD. Initial basic airway maneuvers or if the patient requires a tracheostomy tube replacement are listed first.39Adult Treatment ProtocolsVentilatory Management (cont)

If basic interventions are not effective the protocol guides the provider to move it an extraglottic airway or endotracheal intubation.40Adult Treatment ProtocolsVentilation Management (cont)

As you continue down the algorithm from basic to advanced management if it has been determined that attempts to intubate or ventilate are ineffective the provider is directed to perform a needle cricothyroidotomy. The pearls section provides for the appropriate measurement of End Tidal CO2 and mnemonics to assist with recognizing and documenting difficult airways. 41Pediatric Treatment Protocols

42Pediatric Treatment ProtocolsPediatric General Assessment

43Pediatric Treatment ProtocolsPediatric Trauma Assessment

Refer to Pain Management Protocol for pain control. Maintain SP02 equal to or >94%. ETCO2 monitoring for TBI. Arrows direct you to appropriate treatment for assessment findings.44Pediatric Treatment ProtocolsPediatric Abdominal Pain Nausea & Vomiting

Morphine is not recommended for use in children with abdominal pain. Otherwise no changes to this protocol.45Pediatric Treatment ProtocolsPediatric Allergic Reaction

No changes to this protocol.46Pediatric Treatment ProtocolsPediatric Altered Mental Status

Beginning of the assessment emphasizes blood glucose testing. Consider a 12Lead EKG. Consider possible causes of AMS such as postictal state, hypoperfusion, and trauma or head injury. Just like with the adult protocols, there is now a separate protocol for Seizures.47Pediatric Treatment ProtocolsPediatric Behavioral Emergencies

Implement the SAFER model ( Stabilization, Acknowledgement, Facilitation of Understanding, Encourage Effective Coping, and Recovery or Referral.) Appropriate Benzodiazepine for children is Valium.48Pediatric Treatment ProtocolsPediatric Burns

Key points are stop the burning process, beware of potential airway compromise and protect the patient from hypothermia. Pain management is no longer included specifically in the burn protocol, but is included instead by reference to the Pain Management protocol. 49Pediatric Treatment ProtocolsPediatric Drowning

Drowning now has its own protocol. Adequate ventilation is the key to resuscitation. Do not suction foam from the airway initially, as this will provide an unnecessary delay in correction of hypoxia with assisted ventilation. Deaths from drowning are primarily hypoxic events, rather than aspiration events. The algorithm-based protocol is designed to highlight this fact. 50Pediatric Treatment ProtocolsPediatric Hyperthermia

No changes to this protocol.51Pediatric Treatment ProtocolsPediatric Hypothermia

No changes to this protocol.52Pediatric Treatment ProtocolsNeonatal Resuscitation

No deep suctioning. CPR ratio 3:1 Check a blood glucose level. Most newborns that require resuscitation will respond well to BVM, compressions and Epi. Be aware of the possibility of a pneumothorax due to under developed lungs. 53Pediatric Treatment ProtocolsPediatric Overdose

As with the adult protocol, this protocol now accounts for a variety of specific ingestions and overdoses, with appropriate treatment listed. 54Pediatric Treatment ProtocolsPediatric Pain Management

This is a new separate protocol. Round the Ondansetron pill up to the nearest pill. Fentanyl is the alternate for Morphine with the drug shortage. Physician order required for additional doses of analgesics. Once an narcotic analgesic has been administered, do not switch to a different narcotic with subsequent doses, unless specifically ordered by a physician.55Pediatric Treatment ProtocolsPediatric Respiratory Distress

Addition of Ipratropium (Atrovent) to the protocol via single dose or via DuoNeb once via SVN.56Pediatric Treatment PrtocolsPediatric Seizures

New separate protocol for Seizures. No history of seizure be suspicious of blood glucose level, assessment for possible traumatic event. 57Pediatric Treatment ProtocolsPediatric Shock

In patient with known adrenal insufficiency, administer patients own Solu-Cortef as prescribed. For non-traumatic shock perform glucose testing.58Pediatric Treatment ProtocolsPediatric Smoke Inhalation

No changes to this protocol.59Pediatric Treatment ProtocolsPediatric Tachycardia/Stable

Physician order needed for Adenosine, Amiodarone, Mag Sulfate and synchronized Cardioversion in the stable tachycardia pediatric patient. 60Pediatric Treatment ProtocolsPediatric Tachycardia/Unstable

Physician order for Adenosine and synchronized cardioversion in narrow complex/unstable tachycardia. Physician order for Mag Sulfate in unstable torsades, and for synchronized cardioversion in unstable monomorphic VT.61Pediatric Treatment ProtocolsPediatric Ventilation Management

This is a new separate protocol. Use supplemental oxygen to maintain O2 saturation of equal to or over 94%, and >90% for patients on home O2 for chronic conditions. Ketamine or Propofal as alternates to Midazolam. 62Operations Manual

The operations portion of the protocol manual now includes some aspects of the protocols that were previously included in the General Patient Care. It was felt that these protocols would be more appropriate in the Operations Manual. 63OperationsCommunications

General description of transports requiring a telemetry call. 64OperationsChronic Public Inebriate

No changes. 65OperationsDo Not Resuscitate (DNR/POLST)

The DNR and/or POLST paperwork should be kept with the patient and/or family members at all times, so that it can be presented to healthcare providers at the receiving facility. The validity of a DNR or POLST form is verified by confirming the patients name, age and condition of identification. If more than one version of a DNR/POLST form is presented, the most recent one should be honored. A DNR may be revoked at any time and in any manner by the patient. 1.A Physician Order for Life-Sustaining Treatment form may be revoked at any time and in any manner by: (a)The patient who executed it, if competent, without regard to his or her age or physical condition; (b)If the patient is incompetent, the representative [legally, the representative may ONLY be the durable power of attorney as declared in the patient's advance directive or their legal guardian]of the patient; or (c)If the patient is less than 18 years of age, a parent or legal guardian of the patient. 2.The revocation of a POLST form is effective upon the communication to a provider of health care, by the patient or a witness to the revocation, of the desire to revoke the form. The provider of health care to whom the revocation is communicated shall: (a)Make the revocation a part of the medical record of the patient; or (b)Cause the revocation to be made a part of the medical record of the patient.If a DNR/POLST form is presented or discovered AFTER resuscitative efforts have already been initiated, medical control should be contacted before terminating resuscitation. 66OperationsDo Not Resuscitate (DNR/POLST)

Supportive care that is appropriate when a DNR/POLST is present.67OperationsDo Not Resuscitate (DNR/POLST)

Specific listing of life-resuscitating treatment that is to be withheld with a valid DNR/POLST. Review #7. 68OperationsDocumentation

Minimum information required on a PCR. Review and understand #1- definition of a patient. A PCR needs to be completed on any contact listed under #1 A., B., and C.69OperationsDocumentation

TFTC status is extremely important information for the caregiver as well as Trauma center staff. The information in item M. 70OperationsInter-Facility Transfer of Patient By Ambulance

1. A- attendants are authorized to administer all medications listed on the drug inventory as appropriate for their level of licensure and as per protocol. Do not transport patients with medications not listed on the drug inventory or not within your scope of practice unless qualified personnel accompany the patient.71OperationsInter-Facility Transfer of Patients By Ambulance

Transferring facility is required to provide the above noted information to the crew transporting the patient.72OperationsPre-Hospital Death Determination

No changes to this protocol.73Operations Quality Improvement Review

Review each step so crews are aware of this process.74OperationsTermination of Resuscitation

No changes to the protocol.75OperationsTransport Destination

No changes. For new providers be sure to become familiar with the destinations.76OperationsTrauma Field Triage Criteria

Signs or symptoms that require transport to a Level I or II Trauma Center.77OperationsTrauma Field Triage Criteria

Be aware of potential risk/death for patients over 55. Even relatively minor mechanisms of injury (such as ground level falls) can cause significant trauma in elderly patients. Providers should also maintain a high index of suspicion for patients on anticoagulants and history of bleeding disorders. Burns with trauma mechanism to be transported to UMC Trauma/Burn Center.78OperationsWaiting Room Criteria

Verbal report must be made during transition of patient care to hospital staff. Transfer of care is required by law to occur within 30 minutes of arrival to an approved receiving facility. 79ProceduresCervical Stabilization

In an effort to reduce unnecessary use of backboards, the Spinal Immobilization protocol has been replaced with the Cervical Stabilization protocol. This protocol can be used by any level of licensed provider. A. If (A-E) above are ALL NEGATIVE, cervical stabilization is not required.B. If required, cervical stabilization is the placement of an approved, properly sizedcervical collar before the patient is moved.C. Backboards are only indicated for extrication and patient movement. Patientsare not to be transported on backboards (unless movement off the backboardwould delay immediate transport of patients with life-threatening injuriesor acute spinal injuries).D. Tape, head straps, wedges, and head and/or neck support devices are notrecommended.H. In special situations, alternate stabilization devices (e.g. vacuum mattress,KED, etc. may be used as indicated).I. Pediatric patients may be stabilized in an approved car seat or with acommercial pediatric stabilization device.80ProceduresCPAP

CPAP is still a paramedic only procedure. This procedure is for patients 18 years old or older in CHF, Respiratory Distress with bronchospasm or pneumonia with retractions or accessory muscle use, RR over 25 and SPo2 less than or equal to 94%. The device must be used per manufacturer instructions. Key considerations include assessing VS spo2 and etco2 prior to use. Reassessment every 5 minutes and document status. If the patient develops any contraindication or requires airway control discontinue the device and treat accordingly.81ProceduresElectrical Therapy/Defibrillation

No changes to this procedure.82ProceduresElectrical Therapy/ Synchronized Cardioversion

Cardioversion in the pediatric patient requires physician order. 83ProceduresElectrical Therapy/Transcutaneous Pacing

??? Standby mode? Having pacer pads in place should they be required later?84ProceduresElectrical Therapy/Transcutaneous Pacing

Pediatric pacing should be done by physician order only. Fentanyl or Hydromorphone as alternates to morphine due to drug shortage.85ProceduresEndotracheal Intubation

End-Tidal CO2 detection device/capnography must be recorded monitored at all times in an intubated patient. 86ProceduresExtraglottic Airway Device

No changes to this procedure87ProceduresExtraglottic Airway Device

Verify placement with capnography or colorimentric device.88ProceduresHemorrhage Control Tourniquet

This a new procedure. Key points are to record the time of the application of the tourniquet. A second tourniquet placed proximal to the first one is acceptable if bleeding is not controlled.89ProceduresHemorrhage Control Tourniquet

Tourniquet placement sites. 90ProceduresMedication Administration

Confirm the right drug, right patient, right dose, right time, right route, and right documentation.91ProceduresNeedle Cricothyroidotomy

Pediatric needle cricothyroidotomy requires a physician order. 92ProceduresNeedle Thoracentesis

Monitor the patient for deterioration as a second needle thoracentesis may be required if the original becomes clogged. 93ProceduresTracheostomy Tube Replacement

No changes to this procedure.94ProceduresTraction Splint

Be sure to assess motor, sensory and circulatory function prior to and after placement of the splint. 95ProceduresVagal Maneuvers

Do not implement diving reflex in patients with history of ischemic heart disease or the carotid massage in patients over 40 years of age. 96ProceduresVascular Access

Do not delay transport in critical patients awaiting vascular access. Access can be obtained enroute to the hospital.97FormularyIpratropium Bromide (Atrovent)

The formulary section was changed to the above simplified format including dosing. We have added Atrovent to the formulary for use in respiratory distress. It is used like albuterol and may resemble albuterol in the drug bag. We have also added DuoNeb which is Atrovent and Albuterol together for use in respiratory distress. Both atrovent and duoneb are paramedic only medications at this time.98AppendixSample Release of Medical AssistanceScope of PracticeMedicationsSkills/ProceduresReceiving Hospital Directory

The appendix includes the sample of release of medical assistance form with algorithm, the scope of practice for medications and skill/procedures and a table showing current hospital addresses phone numbers and pertinent capabilities. Its important to remember that the table is accurate at the time of publication and should be used as a guide only.99QUESTIONS???????