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Paramedic Protocol Update 2009 Westchester Regional Emergency Medical Services Council Introduction Each agency will be provided with CD containing the protocol roll-out training materials.

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paramedic protocol update 2009

Paramedic Protocol Update2009

Westchester Regional Emergency Medical Services Council

Westchester Paramedic Protocol Update 5/09 - Overview

introduction
Introduction
  • Each agency will be provided with CD containing the protocol roll-out training materials.
  • Protocol roll-out presentations cover all changes by section (Adult Medical, Pediatric Medical, Trauma, etc.).
  • Agencies are expected to deliver content to affiliated paramedics. Agency Medical Director should approve delivery mechanism (i.e., classroom session, computer delivery, follow-up quiz ??)

Westchester Paramedic Protocol Update 5/09 - Overview

introduction3
Introduction
  • Protocols also included on CD in PDF format. Will also be posted on WREMSCO website. *No field guides initially as additional changes are expected.
  • Protocol implementation date – July 1, 2009
  • Agency Medical Director must affirm that affiliated paramedics have received training (affirmation form included on CD).

Westchester Paramedic Protocol Update 5/09 - Overview

overview
Overview
  • New Format indicating STANDING ORDERS, MEDICAL CONTROL OPTIONS, and NOTATIONS.
  • Each protocol initiates with M1.0-Routine Medical Care or T1.0-Routine Trauma Care.
  • To be carried out in conjunction with appropriate policies, procedures, and advisories.
  • Separate Interfacility Transport Protocols under development

Westchester Paramedic Protocol Update 5/09 - Overview

new format
New Format

Westchester Paramedic Protocol Update 5/09 - Overview

trauma protocols

Trauma Protocols

Westchester Regional Paramedic Protocol Update 2009

Westchester Paramedic Protocol Update 5/09 - Overview

routine trauma care t1 0
Routine Trauma Care T1.0

Replaces old trauma protocols

Consolidated: Routine Medical Care, airway, transport consideration, fluid resuscitation for shock, analgesics for pain management, and CPR/rapid transport for Traumatic arrest.

Added: Directs provider to Airway Management Protocols, Trauma Transport Algorithm, and Pain Management Protocol.

Westchester Paramedic Protocol Update 5/09 - Overview

trauma report appendix 2 3
Trauma Report Appendix 2.3

Westchester Paramedic Protocol Update 5/09 - Overview

adult medical protocols

Adult Medical Protocols

Westchester Regional Paramedic Protocol Update 2009

Westchester Paramedic Protocol Update 5/09 - Overview

adult medical protocols10
Adult Medical Protocols
  • New Standard Operating Procedures for Advanced Airway Management, Tension Pneumothorax, and Intravenous Access (separate document)
  • Endotracheal drug administration has been removed from all protocols
  • Pediatric protocols now in separate pediatric section

Westchester Paramedic Protocol Update 5/09 - Overview

adult medical protocols11
Adult Medical Protocols
  • Routine Medical Care M1.0 - Pulse Oximetry now a Standing Order
  • Airway Management M2.0 - Etomidate now a standing order.
    • If patient needs facilitated advanced airway management:
    • Consider ETOMIDATE 0.3 mg/kg IV or IO, perform ENDOTRACHEAL INTUBATION, and
    • CONTACT MEDICAL CONTROL
  • Bronchospasm/Asthma/COPD M3.0 - Methylprednisolone and Magnesium Sulfate now Standing Orders. Terbutaline now administered IM route.

Westchester Paramedic Protocol Update 5/09 - Overview

adult medical protocols12
Adult Medical Protocols
  • Cardiac M4.0 - Refers to appropriate sub-protocol. 12 lead ECG added.
  • Acute Coronary Syndrome M4.1 -NITROGLYCERIN should be given with caution to patients taking erectile dysfunction (ED) medications (i.e., Viagra, Cialis, Levitra), or suspected inferior wall or right ventricle (RV) myocardial infarctions (MI)
  • Acute Pulmonary Edema Congestive Heart Failure M4.2 -Administer CPAP if available. Medical Control Option for Lasix changed from 40-80 mg to 80-120 mg

Westchester Paramedic Protocol Update 5/09 - Overview

adult medical protocols13
Adult Medical Protocols
  • Bradycardia M4.3 - TCP now before atropine. Dopamine under Medical Control Options now 2-10 mcg/kg/min
  • Supraventricular Tachycardia– Divided into two new protocols
  • Narrow Complex Tachycardia Unstable M4.4 - Fluid challenge now Standing Order. Doses of energy for Cardioversion depend on the underlying rhythm. Diltiazem added as Medical Control Option
  • Narrow Complex Tachycardia Stable M4.5 -Diltiazem 15-25mg as Standing Order for ATRIAL FLUTTER, ATRIAL FIBRILLATION or MULTIFOCAL ATRIAL TACHYCARDIA unless patient has a known history of Wolff-Parkinson-White Syndrome (WPW)

Westchester Paramedic Protocol Update 5/09 - Overview

adult medical protocols14
Adult Medical Protocols
  • Wide Complex Tachycardia Unstable M4.6 - Doses of energy for Cardioversion depend on the underlying rhythm. Total maximum dose of Amiodarone in Standing Orders is now 2.2gm/24 hrs.
  • Wide Complex TachycardiaStable M4.7 - Standing Order of Amiodarone to 150 mg/100 ml of D5W. Repeat if VT persists. Max 2.2 gm/24 hrs.Procainamide now Medical Control Option only.

Westchester Paramedic Protocol Update 5/09 - Overview

adult medical protocols15
Adult Medical Protocols
  • Cardiac (Arrest) Non-Traumatic Cardiopulmonary Arrest M5.0 - This protocol directs the EMS provider to two new protocols:

M5.1 – Shockable Rhythm

M5.2 – Non-Shockable Rhythm

  • Notes for consideration of the following medications for all Cardiac Arrests have been added:
    • SODIUM BICARBONATE 1 mEq/kg IVP or IO with suspected hyperkalemia, profound acidosis, tricyclic antidepressant, cocaine, or diphenhydramine overdoses. Dose may be repeated at 0.5 mEq/kg every 10 minutes.
    • DEXTROSE 50% IVP or IO if clinically indicated; may be repeated once.
    • NALOXONE 2 mg IV or IO if clinically indicated.
    • DOPAMINE 400 mg in 250 ml 0.9% Normal Saline; initiate drip at 5 - 10 mcg/kg/min.
    • CALCIUM CHLORIDE 250 – 500 mg IVP or IO; may be repeated to a maximum of 1 gm. Only indicated with hyperkalemia, hypocalcemia, or calcium channel blocker toxicity.

Westchester Paramedic Protocol Update 5/09 - Overview

adult medical protocols16
Adult Medical Protocols
  • Cardiac Arrest Shockable Rhythm (VF or Pulseless VT) M5.1 – Follows latest CPR guidelines; single shocks, CPR @ 2 min. intervals. Precordial thump removed. Standing Order added for Magnesium Sulfate for known Hypomagnesemia or Torsades.
  • Cardiac Arrest Non-Shockable Rhythm M5.2 – Prompt to Search for and treat for contributing factors; address as appropriate. Vasopressin now a Standing Order but under review.

Westchester Paramedic Protocol Update 5/09 - Overview

adult medical protocols17
Adult Medical Protocols
  • Field Termination of Resuscitation Efforts M5.3– Grief counseling removed.
  • Altered Mental Status M6.0– Naloxone dose now 0.4 mg IV, IN, or IM, may be repeated up to 8 mg.
  • Anaphylactic Reaction M7.0 - Standing Orders now for Methylprednisolone, rapid fluid infusion, and Albuterol. Epinephrine is indicated as follows:
    • Cardiovascular collapse present, 1:10,000 1 mg IVP
    • Mild reaction, 1:1,000 0.3 ml IM
    • If patient is taking beta-blockers, also administer GLUCAGON 1 mg IM or IV.

Westchester Paramedic Protocol Update 5/09 - Overview

adult medical protocols18
Adult Medical Protocols
  • Toxic Exposure / Poisoning M8.0– For Carbon Monoxide (CO) exposure with history and signs/symptoms - Monitor CO levels (if available) - 100% oxygen therapy
  • Non-Traumatic Shock M9.0 – Dobutamine added as a Medical Control Option
        • 400mg/250 ml NS ,initiate drip at 5 – 10 mcg/kg/min.
        • May be titrated in increments of 5 mcg/kg/min until desired therapeutic effect is reached (max dose of 25 mcg/kg/min)
  • Post Partum Hemorrhage M10.0 - Oxytocin now a Standing Order “after delivery of placenta”

Westchester Paramedic Protocol Update 5/09 - Overview

adult medical protocols19
Adult Medical Protocols
  • Obstetrical Toxemia of Pregnancy M11.0– PRE-ECLAMPSIA now defined as – combination of BP 140/90 or greater, peripheral edema, and symptoms: headache, visual disturbances, upper abdominal pain. Magnesium Sulfate 4 gm/250 ml NS over 20 minutes now a Standing Order for Pre-Eclampsia and Eclampsia.
  • Seizures M12.0– “measure serum glucose”, and treat hypoglycemia after initiating Routine Medical Care. Standing Order now for “a Benzodiazepine”(Diazepam, Lorezapam, or Midazolam).

Westchester Paramedic Protocol Update 5/09 - Overview

pediatric medical protocols

Pediatric Medical Protocols

Westchester Regional Paramedic Protocol Update 2009

Westchester Paramedic Protocol Update 5/09 - Overview

pediatric medical protocols21
Pediatric Medical Protocols
  • Endotracheal drug administration has been removed from all protocols
  • 14 years or youngerfor pediatric patient

Westchester Paramedic Protocol Update 5/09 - Overview

pediatric medical protocols22
Pediatric Medical Protocols
  • Pediatric Airway Management P1.0– Etomidate dose 0.3 mg/kg IV or IO now a Medical Control Option for all Paramedics. Continuous EKG, pulse oximetry and wave-form capnography added.
  • Bronchospasm / Asthma P2.0 –Separated from Croup/Epiglottitis in old protocol. Albuterol 2.5 mg plus one unit dose of Ipratropium 0.5 mg via nebulizer may be repeatedonce if needed under standing orders. Dexamethasone 0.6 mg/kg IM added as a Medical Control Option.

Westchester Paramedic Protocol Update 5/09 - Overview

pediatric medical protocols23
Pediatric Medical Protocols
  • Croup/Epiglottitis P3.0– Nebulized Epinephrine or Racemic Epinephrine now a Standing Order. Dexamethasone 0.6 mg/kg IM added as a Medical Control Option
  • Cardiac P4.0 – Refers to appropriate sub-protocol. 12 lead ECG added.
  • Bradycardia P4.1 - Now states “ If increased vagal tone, or primary AV Block, administer Atropine 0.02 mg/kg IV or IO – minimum dose 0.1mg; maximum single dose:
    • 0.5 mg for children
    • 1 mg for adolescents.
    • If inadequate response, may repeat once”

Westchester Paramedic Protocol Update 5/09 - Overview

pediatric medical protocols24
Pediatric Medical Protocols
  • Narrow Complex Tachycardia P4.2– If Sinus Rhythm, consider Fluid Challenge of 0.9% Normal Saline (10-20 ml/kg rapid infusion) if indicated; search for and treat any causes found as appropriate
  • Wide Complex Tachycardia P4.3 –New protocol. Apply cardiac monitor to determine rhythm.
  • If patient is Unstable:
    • If it does not delay CARDIOVERSION, administer ADENOSINE 0.1 mg/kg IV or IO first to determine if the rhythm is SVT with aberrant conduction.
    • SYNCHRONOUS CARDIOVERSION 0.5 J/kg – 1 J/kg; if no change, repeat at 2 J/kg (c);consider sedation / analgesia, CONTACT MEDICAL CONTROL.
    • If rhythm FAILS TO COVERT after 2nd CARDIOVERSION to a supraventricular rhythm, CONTACT MEDICAL CONTROL

Westchester Paramedic Protocol Update 5/09 - Overview

pediatric medical protocols25
Pediatric Medical Protocols
  • Cardiac (Arrest) Non-Traumatic Cardiopulmonary Arrest P5.0–This protocol directs the EMS provider to two new protocols:

P5.1 – Shockable Rhythm

P5.2 – Non-Shockable Rhythm

  • Cardiac Arrest Shockable Rhythm (VF or Pulseless VT) P5.1 – Follows latest CPR guidelines; single shocks, CPR @ 2 min. intervals. Precordial thump removed. “In the event of return of spontaneous circulation (ROSC), CONTACT MEDICAL CONTROL for post-resuscitation care.”

Westchester Paramedic Protocol Update 5/09 - Overview

pediatric medical protocols26
Pediatric Medical Protocols
  • Cardiac Arrest Non-Shockable Rhythm P5.2– Search for and treat for contributing factors; address as appropriate.
  • Altered Mental Status P6.0 – For documented or suspected hypoglycemia:
    • Administer DEXTROSE 1g/kg IV or IO:
      • For patients 40 kg or less, DEXTROSE 25% 4 ml/kg
      • For patients 40 kg or more, DEXTROSE 50% 2 ml/kg
    • if no response in 5 minutes, repeat the same dose.

Westchester Paramedic Protocol Update 5/09 - Overview

pediatric medical protocols27
Pediatric Medical Protocols
  • Anaphylactic Reaction P7.0– Standing Orders for Methylprednisolone, Albuterol, and rapid fluid infusion added. Prior to initiating Routine Medical Care, Epinephrine is indicated as follows:
    • Cardiovascular collapse present, 1:1,000 0.01 mg/kg (max dose 0.3mg) IM
    • Post RMC, if patient still manifests Cardiovascular collapse, administer Epinephrine 1:10,000 0.01 mg/kg IV or IO
  • Toxic Exposure / Poisoning P8.0 – For Carbon Monoxide (CO) exposure with history and signs/symptoms - Monitor CO levels (if available) - 100% oxygen therapy

Westchester Paramedic Protocol Update 5/09 - Overview

pediatric medical protocols28
Pediatric Medical Protocols
  • Non-Traumatic Shock P9.0– Fluid Challenge 0.9% Normal Saline IV or IO 5-10 ml/kg, rapid infusion; may be repeated as needed. Avoid in the presence of pulmonary edema
  • Note: PALS recommends giving smaller volumes if myocardial dysfunction or distributive shock is present of suspected but more rapid infusion boluses may be needed to correct hypotensive or septic shock.
  • REMAC contends that infusion volumes of 20 ml/kg may be necessary. Plans to appeal to SEMAC.

Westchester Paramedic Protocol Update 5/09 - Overview

pediatric medical protocols29
Pediatric Medical Protocols
  • Neonatal Resuscitation P10.0– Now states: If thick meconium is observed in amniotic fluid AND the newborn demonstrates absent or depressed respirations, heart rate under 100 per minute, or poor muscle tone:
    • Clear the airway using endotracheal intubation and directly suction the endotracheal tube.
    • Repeat the procedure until the endotracheal tube is clear of thick meconium up to a maximum of three (3) times.
    • DO NOT re-intubate once the airway has been cleared of thick meconium unless the newborn still meets the criteria in STEP 2.

Westchester Paramedic Protocol Update 5/09 - Overview

pediatric medical protocols30
Pediatric Medical Protocols
  • Seizures P11.0– After initiating Routine Medical Care, “measure serum glucose”, for hypoglycemia administer:
      • DEXTROSE 1g/kg IV or IO:
        • For patients 40 kg or less, DEXTROSE 25% 4 ml/kg
        • For patients 40 kg or more, DEXTROSE 50% 2 ml/kg
          • If no response in 5 minutes, repeat the same dose.
      • GLUCAGON 0.1 mg/kg IM if IV or IO route is not available, up to a maximum dose of 1 mg.
  • Standing Order now for “a Benzodiazepine”(Diazepam, Lorezapam, or Midazolam).

Westchester Paramedic Protocol Update 5/09 - Overview

special protocols

Special Protocols

Westchester Regional Paramedic Protocol Update 2009

Westchester Paramedic Protocol Update 5/09 - Overview

pain management s1 0
Pain Management S1.0

Replaces old protocols 31 and 31a

Changed: For patients presenting with need for pain management (a) with a SBP greater than 110 mmHg:

MORPHINE 0.1 mg/kg IV or IO (maximum 5 mg) (b); For continued pain, repeat once (maximum total dose 10 mg)

Contact Medical Control

Westchester Paramedic Protocol Update 5/09 - Overview

pain management s1 033
Pain Management S1.0

Replaces old protocols 31 and 31a

Added: Notes a & b.

a. Pain management is CONTRAINDICATED for patients presenting with (including but not limited to):

Altered Mental Status, Moderate or Severe Head Trauma, Overdoses, or Hypotension

b. If HYPOVENTILATION develops:

in the ADULT PATIENT, administer NALOXONE up to 2 mg IV, IO or IN.

in the PEDIATRIC PATIENT, administer NALOXONE 0.1 mg/kg IV, IM, IO or IN

Westchester Paramedic Protocol Update 5/09 - Overview

rapid sequence intubation s2 0
Rapid Sequence Intubation S2.0

Replaces old protocol S-1

Added: Note b. Once medication is used to facilitate intubation, whether or not it is successful, the patient’s respiratory effort MUST be monitored with CONTINUOUS WAVEFORM CAPNOGRAPHY.

Westchester Paramedic Protocol Update 5/09 - Overview

nerve agent antidotes s3 0
Nerve Agent Antidotes S3.0

Replaces old protocol S-2

Added: Commercially available DuoDoteTM auto-injectors, or the previously manufactured Mark I kits, may be possessed / used by a paramedic only under the following conditions…

Changed: Directs provider to Adult Administration Protocol (S3.1) and Pediatric Administration Protocol (S3.2)

(Continued on Next Slide)

Westchester Paramedic Protocol Update 5/09 - Overview

nerve agent antidote adult s3 1
Nerve Agent Antidote-Adult S3.1

Changed: Standing Orders now:

MILD - 1 MARK I KIT /1 DUODOTETM KIT or ATROPINE 2 mg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 1 g IV, IM or IO over 10 minutes

MODERATE - 2 MARK I KITS / 2 DUODOTETM KITS or ATROPINE 4 mg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 2 g IV, IM or IO over 10 minutes

SEVERE - 3 MARK I KITS /3 DUODOTETM KITS or ATROPINE 6 mg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 2 g IV, IM or IO over 10 minutes

(Continued on Next Slide)

Westchester Paramedic Protocol Update 5/09 - Overview

nerve agent antidote pediatric s3 2
Nerve Agent Antidote-Pediatric S3.2

Changed: Standing Orders now:

MODERATE - 2 MARK I KITS / 2 DUODOTE KITS or ATROPINE 0.02 mg/kg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 40 mg/kg IV, IM or IO over 10 minutes

SEVERE- 3 MARK I KITS /3 DUODOTE KITS or ATROPINE 0.04 mg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 40 mg/kg IV, IM or IO over 10 minutes

If the patient is presenting with MILD exposure symptoms, CONTACT MEDICAL CONTROL.

1 MARK I KIT /1 DUODOTE KIT or ATROPINE 0.02 mg/kg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 40 mg/kg IV, IM or IO over 10 minutes

Westchester Paramedic Protocol Update 5/09 - Overview

standard operating procedures

Standard Operating Procedures

Westchester Regional Paramedic Protocol Update 2009

Westchester Paramedic Protocol Update 5/09 - Overview

standard operating procedures39
Standard Operating Procedures
  • Three new procedures:
    • Advanced Airway Management
    • Tension Pneumothorax
    • Intravenous Access

Westchester Paramedic Protocol Update 5/09 - Overview

advanced airway management
Advanced Airway Management

Includes:

  • Endotracheal Intubation (ETT)
  • Laryngeal Mask Airway (LMA)
  • Multi-lumen Airway (i.e. Combitube)
  • Foreign Body Airway Removal via direct Laryngoscopy
  • Needle Cricothyrotomy
  • Tracheal Suctioning (including meconium aspiration)
  • Gastric Decompression
  • Needle Decompression
  • Rapid Sequence Intubation (RSI)*

*May only be performed by with approval of WREMAC

Westchester Paramedic Protocol Update 5/09 - Overview

advanced airway management41
Advanced Airway Management

Must document PRIMARY confirmation of ETT placement using:

  • Qualitative Methods
    • Colormetric end-tidal CO2 detectors
  • Quantitative Methods
    • Digital end-tidal CO2 detectors
    • Wave form capnography

Westchester Paramedic Protocol Update 5/09 - Overview

advanced airway management42
Advanced Airway Management
  • Document secondary confirmation using accepted clinical parameters per ACLS guidelines.
  • Continuous Waveform Capnography must be monitored if medication is used to facilitate intubation.

Westchester Paramedic Protocol Update 5/09 - Overview

slide43

Tension Pneumothorax

Evidence of respiratory/cardiovascular compromise and two of the following:

- Absent/decreased breath sounds on affected side- Tracheal deviation- Subcutaneous emphysema

Pleural decompression is indicated using a large bore over the needle catheter or other REMAC approved device.

Procedure may be repeated if signs and symptoms recur.

Westchester Paramedic Protocol Update 5/09 - Overview

slide44

Intravenous Access

IV KVO of NS or IV lock unless fluid challenge is required.

  • IV NS with large bore (18ga or larger) catheter for patients requiring rapid volume replacement.
  • Peripheral veins (not external jugular) should be used as primary access site.
  • IO may be used only if other sites are not accessible.
  • IO med administration is preferred over ETT if no IV.
  • Blood drawing as indicated. Before med administration.

Westchester Paramedic Protocol Update 5/09 - Overview

slide45

Future SOPs

Additional SOPs will be added as needed

Westchester Paramedic Protocol Update 5/09 - Overview

questions
Questions
  • WREMSCO Office
    • 914-231-1616

Westchester Paramedic Protocol Update 5/09 - Overview

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