2015

Southwest Ohio

pre hospital Protocol

UpdateAcademy of Medicine of Cincinnati

Protocol Subcommittee

Hamilton Lempert, MD FACEP CEDC

Chairman

Protocol Committee

Mary Ahlers, RN, CP, NRP

Mark Baird, EMT-P

Justin Benoit, MD

Larry Bennett, Esq

Mike Bilkasley, EMT-P, L.O., L.Ped

Mike Bohanske, MD

Troy Bonfield

Todd Burwinkel EMT-P

Dustin J. Calhoun, MD

Steve Coley, NREMT-P

Kenneth Crank, NREMT-P

Roseann Cyriac, MD

Dave Derbyshire, NREMT-P

Tom Dietz, NREMT-P

Pamela Erpenbeck RN, NREMT-P

Hamilton Lempert, MD FACEP Chairman

Greg Faris, MD

Kirk Fisher, RN, NRP

Paul Gallo, EMT-P

Ryan Gerecht, MD

Marilyn Goin EMT-P

Constance Gong, MD

Bob Herrlinger RN, EMT-P

Randall Johann, FP-C, EMT-P

Andy Kalb, EMT-P

Dave Kemper EMT-P

Ashley Larrimore, MD

Andrew Latimer, MD

Dustin LeBlanc, MD

Donald Locasto, MD

Walt Lubbers, MD

Daniel Mack, NREMT-P

Jason McMullan, MD

Will Mueller, EMT-P

Mike Moyer, PhD, MS, EMT-P

Bob Murray, EMT-P

Mel Otten, MD

Todd Owens, EMT-P

Joel Pranikoff, MD

Andrew Rice, MS, NREMT-P

Hamilton Schwartz, MD

Joe Stoffolano, NREMT-P

Mike Steuerwald, MD

Ferenc Tirkala, EMT-P

Jonathan Van Zile, MD

Paria Wilson, MD

Introduction

• Many new protocols

• Administrative

• Symptom Based

• Medical

• Surgical

• Pediatric

• Procedures

• Medication list

• Drug License

Administrative

• A108 – Use of EMS units as Transport Units

• New Protocol

• Some departments do this

• Must have written orders for treatment outside of

protocols

• Can not operate out of scope of practice

• May need additional personnel

Administrative

• A109 Advanced EMT

• New Protocol

• Allows EMT – A to function at their level within their

scope of practice

• Lays out a state mandated list of procedures and

medications that EMT – A’s can use

Symptom Based

• SB205 Hypotension/Shock

• Brand new Protocol

• Covers many different types of shock

• Hypovolemia

• Cardiogenic

• Obstructive

• Distributive

• Sepsis

• Push Dose EPI

Push Dose EPI

• 1 ml of 1:10,000 epi – cardiac epi

• Mix with 9 ml of Normal Saline

• Administer 1 ml every 1-2 minutes as needed

• Takes the place of Dopamine

Cardiac

• C302 Bradycardia

• Moved Versed for External pacing to be right next to

external pacing

• Many of the protocols have such small grammatical

and organizational changes

• This one is the most significant

Medical

• M411 – Toxicological

• Removed Charcoal

• Rarely used – no longer recommended

• Can aspirate and have bad outcome

• Cyanide

• Treatment should occur when both of the following are

present

• Decreased Level of Consciousness

• Hypotension

• There are no absolute contraindications

• Treatment may temporarily turn the victim’s skin orange

Medical

• M411 – Toxicological

• Naloxone

• EMT may now give IN or Auto Injector

• Intranasal (IN)

• Do not use more than 1 ml of medication per nostril (0.2 to

0.3 is the ideal volume). If a higher volume is required, apply

it in two separate doses allowing a few minutes between for

the previous dose to absorb.

• Always deliver half the medication dose up each nostril. This

doubles the available mucosal surface area (over a single

nostril) for drug absorption and increases rate and amount of

absorption.

Medical

• M411 – Toxicological

• Naloxone

• Auto Injector

• Follow manufacturer recommendations

• The FDA has approved Evzio (naloxone) a $600 (as of

2014) naloxone auto-injector for treating suspected opioid

overdose, analogous to an epinephrine pen for

analphylaxis. Evzio comes in a kit with two 0.4 mg auto-

injectors and a “trainer” device that also has voice

guidance. The standard 0.4 mg injectable dose of

naloxone, which can be given intranasally, costs about $20

Medical

• M416 – OTC Meds

• New Protocol

• The patient expressly requests treatment for a minor

medical concern by a specific over-the-counter (OTC)

medication.

• No sign or symptom of a significant medical condition

exists.

• The paramedic has access to the official

manufacturer’s list of indications, contraindications,

and administration instructions.

Medical

• M416 – OTC Meds

• This protocol is not intended for use with patients being

transported to the hospital, but instead for patients seeking

care at “special events” where paramedics are stationed or

for emergency personnel on critical scene assignments.

• We do not need to put OTC meds on our drug license

Surgical

• S500 Hemorrhagic shock

• Immobilize per T704 added

Surgical

• S501 Head or Spinal Trauma

• Added lots of things to comply with national brain injury

guidelines

• Changed protocol to 95% sat

• Normal Ventilation

• Maintain RR 14-16

• End tidal CO2 35-40

Surgical

• S501 Head or Spinal Trauma

• If pupils >1mm difference and comotose

• Hyperventilate to end tidal CO2 of 30

• Consider 3% saline

• Stop if pupils normalize

• Decided not to do mannitol for variety of reasons

Surgical

• S503 Imminent Delivery (Child Birth)• Changed Viability to 24 weeks

• Gave more detailed instructions on delivery

• Where to clamp umbilical cord

• Meconium staining

• infants with meconium-stained amniotic fluid should no longer routinely receive intrapartum suctioning. If the newborn is vigorous, defined as having strong respiratory efforts, good muscle tone, and a heart rate greater than 100 beats per minute, there is no evidence that tracheal suctioning is necessary. Injury to the vocal cords is more likely to occur when attempting to intubate a vigorous newborn.

• If meconium is present and the newborn is depressed, refer to P600 Pediatric Newborn Resuscitation.

• Take mom and baby to same hospital

Surgical

• S506 Tranexamic Acid (TXA)

• Brand new protocol

• Not yet for Peds

• Active research and you may see some other

protocols out there with AirCare or other higher level

care providers

• Presentations on Protocol Website

Surgical

Tranexamic acid (TXA) Checklist

Administration of TXA is indicated if all of the following criteria are present

1) Age 16

2) Evidence of significant blunt or penetrating traumatic injury

(MVC with ejection, rollover MVC, fall > 20 ft, pedestrian struck, penetrating injury to head,

neck, torso, etc.)

3) Evidence of or concern for severe internal or external hemorrhage

(bleeding requiring a tourniquet, unstable pelvic fracture, two or more proximal long-bone

fractures,

flail chest etc.)

4) Sustained Systolic BP < 90mmHg (or < 100mmHg if older than 55 yo)

5) Sustained heart rate > 110 bpm

6) Time since the initial injury is known to be < 3 hours

To administer TXA: Mix 1g of TXA in 100ml of 0.9% Normal Saline or Lactated Ringers & infuse over 10

minutes IV or IO. (If given as an IV push, may cause hypotension) Use dedicated IV/IO line if possible and Do NOT

administer in the same IV or IO line as blood products, factor VIIa, or Penicillin

Pediatric

• P615 Pediatric Submersion Injury

• Brand new protocol

• Ice visible on water

Pediatric

• P615 Pediatric Submersion Injury

• If there are obvious signs of ice on the water,

ensure ALS back-up and proceed with the cardiac

arrest protocols P601 or P602 depending on whether

their initial presentation is VF/VT or PEA/asystole.

• Maintain airway and administer oxygen.

• Initiate transport to Cincinnati Children’s Burnet Campus,

which is capable of performing pediatric extracorporeal

membrane oxygenation (ECMO).

• Notify Cincinnati Children’s.

Pediatric

• P615 Pediatric Submersion Injury

• If there are NO obvious signs of ice, and the patient

has been submerged for 30 minutes or longer, the

evidence suggests the patient is unlikely to survive.

Ensure ALS back-up and proceed with the cardiac

arrest protocols P601 or P602 depending on whether

their initial presentation is VF/VT or PEA/asystole.

Contact medical control to discuss CPR limits. If

patient is transported, transport to the closest

emergency department while performing CPR.

Pediatric

• P615 Pediatric Submersion Injury

• If there are NO signs of ice, and the patient has been

submerged for less than 30 minutes or the time is

unknown, ensure ALS back-up and proceed with the

cardiac arrest protocols P601 or P602 depending on

whether their initial presentation is VF/VT or

PEA/asystole). Transport to the closest emergency

department while performing CPR. Notify receiving

hospital.

Procedures

• T704 Spinal Immobilization

• Major rewrite

• Strengthened statement re who to put in immobilization -

only

• Altered mental status (anything less than a GCS of 15 and

normal alertness)

• Suspicion of intoxication (any substance, including pain

medications)

• Distraction (either painful distracting injury or psychosocial

distraction)

• Midline spinal tenderness (careful palpation exam required)

• Focal neurologic deficit (anything less than a full and

symmetric motor and sensory exam in all limbs)

Procedures

• T705 Airway

• Change “rescue airway” to “supraglottic airway”

• Added to basic technique

• Immobilization of a patient with a compromised airway

using a c-collar and backboard should only be considered

/ performed in the trauma patient. Utilizing the reverse

Trendelenburg position by elevating the head of the cot /

backboard 20 degrees has shown benefits to both

patients with a compromised airway and during intubation

by facilitating better laryngeal exposure during direct

laryngoscopy and reducing atelectatic collapse of the

posterior lungs.

Procedures

• T705 Airway

• Defined basic airway failure

• (chest rise and/or audible bilateral breath sounds),

• The decision to utilize orotracheal intubation and/or a

Supraglottic Airway (King Airway etc) as the preferred

advanced airway shall be the decision of the EMS service

and its medical director. Regular training in each airway

skill shall be conducted and documented and available for

review during the Academy of Medicine Compliance and

Inspection Committee Site Visit Review.

Procedures

• T705 Airway

• Removed old reference to nasal intubation

• No more than 2 attempts at intubation

• Question regarding S502 burn management

• Recommends intubation if patient has

• Respiratory distress

• Unconscious

• Re-did flow diagram

Procedures

Procedures

• T706 Orotracheal intubation

• Removed “hyper” oxygenate

• Pre-oxygenate the patient if time allows, studies have

shown that use of oxygen by nasal cannula at 15 lpm

during intubation and insertion of an SGA aid in the pre

oxygenation of the patient. Pre oxygenation using a nasal

cannula with BVM ventilations also increases the

oropharyngeal FiO2 (fraction of inspired oxygen).

• Added not to stop chest compressions

• Added 20 degree head up

• Removed cricoid pressure, left in BURP

Procedures

• T710 Hemorrhage Control

• New Protocol

• Replaces Tourniquet protocol

• Tools to control hemorrhage

• Tourniquet

• Wound packing

• Hemostatic Guaze

• TXA

Medications

• Added

• Hypertonic Saline

• Evzio

• Lactated Ringers

• Tranexamic Acid (TXA)

Medications

• Removed

• Lasix

• M404 CHF

• Dopamine

• P609Anaphylaxis

• M411 toxicology

• M409 Anaphylaxix

• M401 Cardiogenic Shock

• M400 Acute coronary syndrome

• C307 ROSC

• C302 Bradycardia

Medications

• Not needed to be added

• Hemostatic Guaze

• Over the counter medications

• New Drug list for EMT Basic

• Asprin

• EpiPen

• Narcan – Evzio

• Oxygen

• Duodote

• Sterile water for irrigation

Drug License

• Current drug license extended until 3-31-15

• Go to State Pharmacy Board website to renew

• Upload 2015 protocols, drug list, personnel list

• Protocol and drug list must be notarized

• Instructions on State website and will get letter soon

• Call Todd Owens of Reading with any questions

• 733-5537

Final Approval

• 2015 Protocols posted on Academy of Medicine

Website on October 1st. academyofmedicine.org

• Open for comments until December 1st

• Please find all of our typo’s and mistakes

• Send your comments to Dr. Lempert

hlempert9@gmail.com

• Updated Protocols will be posted on Academy of

Medicine website the last week of December for

implementation January 1st, 2015