Protocol Modification 10/2014

Protocol Changes

• Effective October 1st, 2014 the following protocol modifications will take effect:– Midazolam dose changes and physician order’s

required for repeat dosing

– Lactated Ringers added for Trauma and Burn patients

– Updated Selective Spinal Immobilization protocol• Further training will be sent out October 1st (waiting for

clarification from the State)

MIDAZOLAM• Adults:

• OLD protocols included dose ranges from 0.5 mg to 2.5 mg and option to repeat up to 5 mg on standing orders

• NEW protocols have specific dose of 1 mg, 2 mg, or 4 mg based on patient’s age and route of administration. After initial administration, physician orders are REQUIRED for any further dose.

• Pediatrics:• OLD protocols included dose range of .01 mg/kg to .02 mg/kg and

repeat on standing orders.• NEW protocols have specific dose of .02 mg/kg and physician

order’s are REQUIRED for any further dosing.

Protocol 2- Airway• Original: Midazolam 2.5mg

IV/IO, may repeat in 5minutes if needed.

• CAUTIONCAUTION: Use only with definitive airway in place.

• Update: Midazolam 2 mg IV/IO/IN. Contact Medical Control for Additional dosing

Protocol 6: Behavioral• Original Midazolam 1-2.5mg

IV/IO/IN

• 5mg IM, Age =/> 65 0.5mg-1mg IV/IN 2.5 mg IM, May repeat Maximum 5mg

• Update: Midazolam 2mg IV/IO/IN or 4mg IM, Age =/> 65 1mg IV/IO/IN or 2mg IM, Contact Medical Control for additional dosing

Protocol 6 Behavioral Con’t

• Original: Midazolam 2.5mg IV/IN 5mg IM, Age =/> 65 1-2.5mg IV/IN 2.5mg IM, Repeat every 2-3 minutes as needed

• Update: Midazolam 2mg IV/IO/IN or 4mg IM, Age =/> 1mg IV/IO/IN or 2mg IM. Contact Medical Control for additional dosing

Protocol 12: Bradycardia Pulse Present

• Original: Midazolam 0.5mg to 2.5mg IV/IO, may repeat as needed, Maximum dose 5mg

• Update: Midazolam 2mg IV/IO/IN, Contact Medical Control for additional dosing

Protocol 16 Adult Tachycardia; Narrow

Complex• Original: Midazolam

0-2.5 IV/IO, May repeat if needed, Maximum 5mg

• Update: Midazolam 2mg IV/IO/IN Contact Medical Control for additional dosing

Protocol 17Adult Tachycardia; Wide Complex

• Original: Midazolam 0-2.5mg IV/IO, may repeat if needed, Maximum 5mg

• Update: Midazolam 2mg IV/IO/IN, Contact Medical Control for additional dosing

Protocol 19Post Resuscitation

• Original Versed 2.5mg IV/IO, May repeat in 5 minutes if needed.

• Update: Midazolam 2mg IV/IO/IN, Contact Medical Control for additional dosing

Protocol 32 Seizure

• Original: Midazolam 0.5mg-2.5mg IV/IO, 5mg IM or 2mg IN if no IV/IO access, May repeat every 3-5 minutes as needed, Maximum 10mg

• Update: Midazolam 2mg IV/IO/IN or 4mg IM if no IV/IO access. Contact medical Control for additional dosing

Protocol 39 Obstetrical Emergency

• Original: Midazolam 2.5mg IV/IO, May repeat every 3-5 minutes as needed, Midazolam 5mg IM or 2mg IN, if no IV/IO access, Maximum 10mg

• Update: Midazolam 2mg IV/IO/IN or 4mg IM if no IV/IO access, Contact Medical Control for additional dosing

Protocol 44Pediatric Airway

• Original: Midazolam 0.1-0.2mg/kg IV/IO, May repeat in 5 minutes if needed, Use only with definitive airway in place

• Update: Midazolam 0.2mg/kg IV/IO, Contact Medical Control for additional dosing. Use ONLY with definitive airway in place.

Protocol 52 Pediatric Tachycardia

• Original: Midazolam 0.1-0.2mg/kg IV/IO, may repeat if needed, Maximum 5mg, 0.2mg/kg IN maximum 2mg.

• Update: Midazolam 0.2mg/kg IV/IO/IN, Contact Medical Control for additional dosing

Protocol 54Pediatric Post Resuscitation

• Original: Versed 0.1-0.2mg/kg IV/IO, may repeat in 3-5 minutes as needed.

• Update: Midazolam 0.2mg/kg IV/IO, Contact Medical Control for additional dosing

Protocol 62Pediatric Seizure

• Original: Midazolam 0.1-0.2 mg/kg IV/IM/IO maximum 2mg, Midazolam 0.2mg/kg IN maximum 2mg.

• Update: Midazolam 0.2mg/kg IV/IO/IN/IM Contact Medical Control for additional dosing

Protocol 78Bites and Envenomations

• Orignial: Medazolam 0.5-2mg IV/IO over 2-3 minutes, Midazolam 1 to 2mg IN, Midazolam 5mg IM, Maximum 5mg.

• PED: Midazolam 0.1-0.2mg/kg IV/IO over 2-3 minutes, Midazolam 0.2mg/kg IN

Protocol 78 Continued

• Update: Midazolam 2mg IV/IO over 2-3 minutes OR 2mg IN OR 4mg IM. PED: Midazolam 0.2mg/kg IV/IO over 2-3 minutes OR Midazolam 0.2mg/kg IN. Contact medical control for additional dosing

Protocol 88Crush Syndrome Trauma

• Original: Midazolam 0.5-2mg IV/IO, 1-2mg IN, Maximum 5mg. Peds: 0.1-0.2mg/kg IV/IO, 0.2mg/kg IN, Maximum 2mg.

• Slowly over 2-3 minutes

Protocol 88Crush Syndrome Continued

• Update: Midazolam 2mg IV/IO/IN, Peds 0.2mg/kg IV/IO/IN

• Slowly by over 2-3 minutes as needed. Contact Medical Control for additional dosing

Lactated Ringers

• Lactated Ringer’s (LR) will be added to all of the units October 1st, 2014.

• The exact amount and location will be announced prior to being placed on the units.

• LR has been added to CCFEMS Protocols ONLY for Trauma and Burn patients.

Lactated Ringers Continued

• Isotonic crystalloid used to treat hypovolemia due to burns and loss of blood volume.

• Invented in the early 1880s by Sydney Ringer and is also known as Hartmann's solution. Lactated Ringers contain 130 mEq of Sodium, 109 mEq of Chloride, 28 mEq of Lactate, 4 mEq of Potassium, and 3 mEq of Calcium per liter with a pH of 6.5. In comparison, Normal Saline contains 154 mEq of Sodium and 154 mEq of Chloride and has pH of 5.5.

Lactated Ringers Continued

• Lactated Ringers use is contraindicated with a known hypersensitivity to sodium lactate. It should be used with caution in patients with conditions that may predispose them to hyperkalemia such as renal failure as the potassium may worsen this condition.

Lactated Ringers Continued• LR is the fluid replacement of choice in the

treatment of significant burns and should be administered according to protocol using the percentage of burn and weight based formula in the protocol (Parkland formula).

• Some studies indicate LR maybe superior to normal saline for fluid replacement of the trauma patient. Boluses for the hypotensive patient should be the same as with normal saline. LR is compatible with all pre-hospital drugs.

Protocol 42Multiple Trauma

• Original: Normal Saline Bolus 500mL IV/IO Repeat to effect SBP =/> 90, Maximum 2 Liters

• Update: Normal Saline OR Lactated Ringers Bolus 500mL IV/IO Repeated to effect SBP =/> 90 Maximum 2 Liters

Protocol 66Pediatric Multiple Trauma

• Original: Normal Saline Bolus 20mL/kg IV/IO, Repeat to effect age appropriate SBP =/> 70 + 2x age, Maximum 60mL/kg

• Update: Normal Saline or Lactated Ringers Bolus 20mL/kg IV/IO, Repeat to effect age appropriate SBP =/> 70 + 2x age, Maximum 60 mL/kg

Selective Spinal Immobilization

• Replace Selective Spinal Immobilization 2012 with Selective Spinal Immobilization revised 4/16/14

Contact Capt. Dicaprio for further questions.