2016 EMS PROTOCOLINSTRUCTOR UPDATE

How We Got Here

• Year long project

• Team approach

• Frequent Team meetings 2 times a month since January 4 to 5 hours per meeting

• Emailed every section to the Medical Director and Specialists for comment and approval

Protocol Team

• Dominic Silvestro, Paramedic, EMSI

• Todd Kulina, Paramedic, EMSI

• Bill Bernhard, Paramedic, EMSI

• Scott Wildenheim, Paramedic, EMSI 341 Pages74808 Words

11251 Editing Mins4.5 MB File

New Protocol Goals • Fresh new look, unique to UH• Improve ease of use• Add safety features• Format Pediatric section same as adult• Streamline treatment pathways• Match prehospital care with care provided in the ED• Group interventions as they would be actually undertaken in field• Review / Update clinical care to meet current research and studies• Assure inexperienced providers have clear, understandable, treatment

pathways with little room for misunderstanding• Allow experienced providers the room to practice good prehospital

medicine

Creation and Approval Process

New Order of Protocol Sections

Unique New Look

Sections Color Coded Blue – AdultPink – PedsPurple – OB

Gray- Reference

Edge Tabs for Easy of Use as Printed DocumentBlue tab is current section

Gray tabs are other sections in document

Safety Features Added to Protocol Tree

New Bold Colors & Rounded Boxes

Transport - “CONTACT MECDICAL CONTROL” box reworded to actual order of events

Legend moved to bottom of page

Hyperlinked Protocol

• Single file adobe .pdf• Downloadable• Multi-platform (Anything

that supports adobe .pdf)• Hyperlinks within the .pdf

(Over 3500 Hyperlinks)• Internet connection not

required for hyperlinks• Hyperlinks will be

explained later in this PowerPoint.

Built In Safety Features Stops / Cautions

• Stops – Brings critical contraindications to the treatment tree

• Cautions – Reminds provider of pertinent decision making issues during treatment

Grouped Interventions

• This new layout “Blocks” interventions in groups as they are actually performed

• However most will usually be done concurrently by multiple providers

PROCEDURE CHANGES, ADDITIONS, AND

UPDATES

EMT Scope of Practice Change“Patient Assisted” Meds

• In the State EMT Scope of Practice there are Two Meanings for Patient Assist as it relates to Medication administration– Can assist with patient’s Prescription upon patient request and with

written protocol - OR– Can Provide supplied medications with verbal medical direction

• This Protocol will adopt this definition for EMT’s• Off line Meds – EPI PEN, ASA, Narcan

Working Cardiac Arrest on Scene

• Survival odds decrease when patients are transported This is a Suggestion only, each situation should be judged individually every situation is unique. Use common sense.

• The best option for patients who do not have special resuscitation circumstances (hypothermia, electrocution, etc.) is to attempt to gain ROSC on scene.

• ALS only• Adult only• Transport once ROSC is achieved

Sedation in Airway• Pre Intervention if patient

responds to pain • Post Intervention if patient

awakens• Use Midazolam or

Lorazepam as available• STOP for head injured

patients• THIS IS NOT RSI

Sedation in Airway• Expectations with Ativan

and Versed– These Drugs are NOT

Paralytics– Your patient will not fall

motionless on your cot– These meds provide amnestic

effects as well as sedation (they won’t remember)

• Apnic Oxygenation– Assures the patients pulse ox

stays up during intubation attempts

Respiratory Distress - Stridor

• Added column for Severe Distress with STRIDOR adults

• Nebulized epinephrine for treatment of upper airway constriction

• Differentiated from lower airway with hashed background

• Lower airway issues are treated per the left column (not pictured here) and the middle column “Moderate / Servere Distress” as shown on this slide

Half Amp Dextrose• Change recommended by UH endocrine

specialists

• BGL < 40 – Full Amp (25 Grams) of D50

• BGL > 40 up to 70 Treat with Half Amp (12.5 grams) of D50

(With signs and symptoms as stated in the Key Point of this protocol)

• Repeat as necessary

• Recent research reveals that treating acute CVS’s with D50 should only be done if the glucose level is below 60 as hyperglycemia may injure the punumbra.

•

• Large Glucose molecules draw fluid. High and low swings in glucose levels streese the body systems

Alcohol Related Emergencies

• New Protocol

• Addresses Mild Symptoms, Severely Combative, Obtunded, and Alcohol Withdrawal Patients

• This is a protocol that takes several existing treatments and puts them in one protocol / location

• When using Oral Zofran remember that this is a soft tablet that dissolves rapidly DO NOT try to push it through the package as it may crumble

• In this case the Benzo’s (Ativan / Versed) are for sedation and only given by Medics

CPR Device

• There have been documented cases across the country of cardiac arrest patients waking up during CPR device chest compressions ie: LUCUS CPR ever though they are still in a non-life sustaining rhythm.

• If CPR device yields Consciousness, pain management with fentanyl (sublimaze) is indicated.

Bleeding / Hemorrhage Control Procedure

• One general procedure covers– Tourniquet– iT Clamp– Hemostatic Gauze– BLS – Gauze Bandage, Direct

Pressure, Pressure Points, Etc.

• Remember to either keep product packaging or refer to the protocol for removal procedures as some receiving facilities may not be familiar with some of these products (iT Clamp)

Active Shooter / Direct Threat

• Outlines basic scene care for “warm zone” casualties of violent events

• Standard EMS care to resume after patient extricated from scene

Double Sequential Defibrillation• For VFIB / VTACH refractory to 360 J and medications• 720 J – Requires 2 Defibrillators

– This is a LAST RESORT for refractory VFIB / VTACH patients– Do not waste time acquiring a second device if device not already on site

• Medical control contact required for DSD consideration (Red Box)• 1 set of Pads Anterior / Posterior • 1 Set of Pads Apex / Sternum• Charge both monitors to 360 J and press Shock at the same time

Induced Hypothermia

• Passive cooling only• AHA No longer

recommends Chilled Saline for induced hypothermia

• Use Cooling Collar• Cold Packs• No target temp, EMS

Induced Hypothermia is designed to start the cooling process as soon as possible

Peds Dosing Charts

• Pre-Calculated • Follows Broslow Colors• Error Reduction• Includes all protocol

medications • Hyperlinked from med

pages (shown in upcoming slide)

• We are currently working to standardize the drug boxes across the system. Until then, double check the concentration to make sure it matches these charts. (Early 2016)

Dialysis / Renal Patient• EKG examples provided for

hyperkalemia• Addresses multiple topics

pertinent to dialysis patients• Covers Respiratory issues,

Cardiac changes, Hypertension, Hypotension, Chest Pain, and Bleeding catheters

• Albuterol and Calcium for Peaked T waves

• Calcium and Bicarbonate for Sine Wave

(see next slide)

Dialysis / Renal Patient

• Peaked T waves should be narrow and higher than the QRS in this setting

• Albuterol is easy and fast and should be done rapidly

• Calcium is safe and should be given SLOWLY over 2-3 minutes in a good IV /IO line

• Once you see Sine Wave there is only minutes until cardiac arrest and you must treat aggressively with Calcium and Sodium Bicarbonate

• Flush IV before CALCIUM and before SODIUM BICARBOANTE

Narcan • Everyone seems to have a

different thought process on how much to give

• Need to standardize for teaching / simplicity reasons

• We took a middle of the road approach

• Give at least 1 mg IV / IO• 2 mg IN• Now found in the Toxic

Ingestion Protocol • Also Per AHA Narcan can be

given in Cardiac Arrest when you suspect Opiate overdose as the cause.

Severe Pain Management

• The Severe Pain Management has been reworked as well

• Some dosages have been changed to meet current standards as well as an update of indications and contraindication based on current research and current accepted ED treatment

• Added Hydromorphone (Dilaudid) to your pain management options

Severe Pain ManagementHydromorphone (Dilaudid)

•8-10 x Potency Morphine, Longer lasting•Preferred for unremitting / intractable pain•Supplied 1 mg / ml, 1 ml Carpuject •Dose 0.5mg – 1.0mg IV/IO/IM May repeat to a Max 2.0mg (Half Dose >65 yrs old, Liver or Renal disease)

Fentanyl (Sublimaze)•Preferred for hemodynamic instability, trauma, procedural pain management, Can be given IN, Shorter acting•New Dose 25 – 100mcg IV/IO/IM/IN 100mcg MAX•Small chance of chest wall ridgity (only happens if pushed to fast remember to push slowly

Morphine•Still available, mostly for peds / ACS•New Dose 2.5 – 5.0mg IV/IO/IM – MAX 10mg

Toradol• Dosage change due to recent literature that finds

more than 15mg IV /IO does nothing more for pain and increases risk of bleeding.

• Dose - 15 mg IV / IO, 30 mg IM – 1 DOSE LIMIT

• Has many Contraindications (list below)

Peds Severe Pain Management

Morphine• For IV / IO / IM

administration

Fentanyl (Sublimaze)• IN use ONLY

ACS Pain Management

• You now have two options for pain management in the Acute Coronary Syndrome Patient

• Morphine Sulfate or Fentanyl (Sublimaze)– Fentanyl will not drop BP and gives you an IN option– Note Dose Changes

Narrow Complex – Rate Control

• Metoprolol (Lopressor) now red boxed

• Concerned about incorrect use, many contraindications

• If Capnography is in normal range there is no need to change the rate

• Not for physiological tachycardias, cocaine use

• Cocaine is a sympathetic alpha and beta stimulant. A beta blocker only will leave unopposed alpha and the blood pressure may actually rise

Behavioral / Psych Emergencies• New Columns

– Agitation – Non Combative

– Combative – Physical Restraint

– Combative – Chemical Restraint

• While Benzo’s and Benadryl are Advanced EMT Drugs (Green Box) in this protocol it is a Medic only (Blue box) because they are being used for sedation with Haldol and to treat EPS (Benadryl) caused by the administration of the Haldol and should only be given by a Paramedic in this instance.

Hypertensive Emergencies

• New Protocol• Primarily a direction

finding protocol– Use Critical Thinking. It is

important to find an underlying cause if present.

– This protocol is used to remind you of the possible causes and direct you to the specific protocol.

(Hyperlinked in the electronic version)

Stroke / MEND

• Addition of MEND to stroke protocol

• MEND is not done on scene. Conduct the MEND while enroute to the receiving facility.

• May be able to detect strokes NOT evident from The Cincinnati Stroke Scale

Neonatal Resuscitation• Ventilate with ROOM AIR in the first 30 seconds at 40

– 60 BPM• Low Pulse Ox is a normal finding as it may take up to

10 minutes for the neonate to be in the 90% range

Med Pages• Pregnancy Class

– A – No Risk in controlled human studies

– B – No risk in other studies– C – Risk not ruled out– D Positive evidence of risk– X – Contraindicated in

pregnancy• Adult Dose• Peds Dose• Color coded for level of care• Peds dosing weights

hyperlinked to dose charts in .pdf version shown earlier in this Lecture.

Special Operations

Procedures• Nitrous Oxide

Administration• Tasered Patient• Active Shooter / Direct

Threat Protocol• Patient Decontamination• Nerve Agent Exposure Kit• Blood Collection for

Evidence

Medications• Ciprofloxicin (Cipro)• Clopidrogril (Plavix)• Vobramycin (Doxycycline)• Duo-Dote• Etomidate (Amidate)• Hydroxocobalmin (Cyanokit)• Ketamine• Nitrous Oxide• Succinylcholine (Anectine)• Tenecteplase (TNKase)

Altered Level of Consciousness

• There are many causes for Altered Level of Consciousness

• Identifying the cause will ensure rapid care

• This is a Direction finding protocol each possible cause will be hyperlinked to the appropriate protocols listed in the .pdf version

Croup

• New Peds Protocol• Upper airway is

separate protocol from lower

• Stridor at rest – Aerosolize Epinephrine 1:1000

• Nebulized saline otherwise

Peds Aerosols

• Lower airway• Rainbow added Duoneb

this year in Severe Column

• Albuterol first, then transition to Duoneb for Mild / Moderate

Peds Toxic Ingestion / Exposure / OD

• Rainbow approved dosing for Calcium Chlorine in Calcium Channel Blocker OD

• 10 mg / kg IV/IO MAX 1 gram

• Narcotic OD moved here same as adult protocol

What's Hyperlinked?

Section Tabs

What's Hyperlinked? Table of Contents

What's Hyperlinked? Procedures

What's Hyperlinked? Medications

What's Hyperlinked? Medication Indication

Click on the indication and you will be taken to that protocol

What's Hyperlinked? Pediatric Dosing

Rollout

• System wide Protocol Rollout Education throughout the month of December

• Hard Copy Protocols will be given to each department for each Ambulance in their fleet.

• Electronic .pdf complete with all hyperlinks will go live on our website on January 1, 2016

• You will be able to download this .pdf to any computer, tablet, smart phone, etc. that supports Adobe .pdf.

• We encourage you to put this on every computer in your station and fleet.

Protocol Email

• Established email for protocol suggestions / corrections

• uhemsprotocols@uhhospitals.org

• Seen by all team members

Questions

?