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PROTOCOL UPDATE ALABAMA EMS PROTOCOLS. EDITION 5 JUNE, 2009 UPDATE . PROTOCOL UPDATE. IF YOU IDENTIFY MISTAKES IN THE PROTOCOLS OR IF YOU HAVE SUGGESTIONS FOR PROTOCOL CHANGES EMAIL: [email protected] PURPOSE OF PROTOCOLS . IMPROVE PATIENT CARE

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protocol update alabama ems protocols

PROTOCOL UPDATEALABAMA EMS PROTOCOLS

EDITION 5

JUNE, 2009 UPDATE

protocol update
PROTOCOL UPDATE
  • IF YOU IDENTIFY MISTAKES IN THE PROTOCOLS OR IF YOU HAVE SUGGESTIONS FOR PROTOCOL CHANGES EMAIL: [email protected]
purpose of protocols
PURPOSE OF PROTOCOLS
  • IMPROVE PATIENT CARE
  • PROVIDE OFF-LINE MEDICAL DIRECTION
  • REPRESENT STANDARD OF CARE
  • PROVIDE QI STANDARDS
  • PROVIDE EDUCATION STANDARDS
general change
GENERAL CHANGE
  • CHANGED THE WORD “DRUG” TO “MEDICATION” THROUGHOUT THE PROTOCOLS
title page table of contents
TITLE PAGE & TABLE OF CONTENTS
  • CHANGED TO 5TH EDITION
  • TABLE OF CONTENTS UPDATED WITH CHANGES
    • Has been alphabetized and renumbered (except General Patient Care and Communications were left as 4.1 & 4.2
    • Deleted Coma, 4.15 and combined it with Altered Mental Status, 4.5
    • No new Patient Care Protocols added
      • Two protocols were extensively rewritten
    • Added one new medication (Ondansetron)
preface
PREFACE
  • Dr. Campbell’s email address corrected
  • Clarified the EMT’s responsibility to refuse to accept orders that are not in his/her scope of privilege
  • Added that a pediatric patient is defined as someone aged 15 years or younger unless otherwise noted in the protocols
  • Noted that anything referring to a pediatric patient will be in Tahoma font, in bold, and colored green
section 2 patients rights
SECTION 2PATIENTS RIGHTS
  • #6:Corrected to explain that families of patients do not have the same rights as the patients themselves. While as a general rule the EMT should take the patient to the hospital the patient’s family wants, if the hospital is inappropriate or is on diversion, OLMD must be called and his/her orders followed
section 2 patients rights8
SECTION 2PATIENTS RIGHTS
  • #7: Added that, while an ambulance service does not have to take a patient out of town if it leaves the community without ambulance service, that is not a license to ignore the trauma system and always take the trauma patient to the local hospital.
    • If the ambulance service is unable to comply with the regional trauma plan, the service must contact the office of EMS & Trauma to develop a plan to correct this.
section 3 3 physician medical direction
SECTION 3.3PHYSICIAN MEDICAL DIRECTION
  • Clarifies that medication orders may be signed by an OLMD physician or by the service’s medical director.
section 3 4 medication and procedure classification
SECTION 3.4MEDICATION AND PROCEDURE CLASSIFICATION
  • Added list of pediatric Category A and Category B medications since they are not the same as the adult Category A and Category B medications
section 3 4 medication and procedure classification11
SECTION 3.4MEDICATION AND PROCEDURE CLASSIFICATION
  • Added Hemostatic Agents, CPAP, and Ondansetron to the list of required medications and procedures.
    • All are Category A
    • CPAP is optional for ALS nontransport services
section 3 5 optional medications and procedures
SECTION 3.5OPTIONAL MEDICATIONS AND PROCEDURES
  • Removed CPAP and Hemostatic Agents from the list of optional medications and procedures
    • CPAP remains optional to ALS nontransport services
section 4

SECTION 4

TREATMENT PROTOCOLS

general patient care 4 1
GENERAL PATIENT CARE 4.1
  • Clarified that when filling out the ePCR, the General Patient Care protocol can be listed if there is no specific protocol for use in treating the patient
communitcations 4 2
COMMUNITCATIONS 4.2
  • For stable patients and patients only requiring Cat. A treatment, added that the EMT may notify the nurse or paramedic at the receiving hospital
    • Some hospitals have paramedics answer the phone
altered mental status 4 5
ALTERED MENTAL STATUS 4.5
  • Combined COMA 4.15 with this protocol
  • You should review this entire protocol as there are so many changes
burns 4 7
BURNS 4.7
  • For burn patients with wheezing, changed albuterol to Category A for adults
cardiac arrest 4 8
CARDIAC ARREST 4.8
  • Added that if the patient is in cardiac arrest, and has a venous port, you may access the port if you have been trained and have the proper equipment
    • This requires your medical director to see what type of ports are being used in your area and see that you are trained how to access that particular port
    • Some ports require special needles to access
quick reference to cardiac medications 4 9
QUICK REFERENCE TO CARDIAC MEDICATIONS 4.9
  • INFANTS AND CHILDREN (Age one month t 8 years)
    • Under Sodium Bicarbonate changed “Dilute 50% with D5W” to “Dilute 50% with NS”
    • Also changed dose from 1 mEq/dose to 1mEq/kg initial dose
cardiac symptoms acute coronary syndrome 4 10
CARDIAC SYMPTOMS/ACUTE CORONARY SYNDROME 4.10
  • Added note that this protocol is for adults only. you should contact OLMD for chest pain in pediatric patients (age 15 or less).
  • Aspirin to be given to adults unless 324mg or more has already been given in the last 24 hours
    • If the patient has only had a baby aspirin (81 mg) you should give another four baby aspirin
  • Aspirin is almost never given to pediatric patients (CAT. B) because of danger of Reye’s syndrome
pediatric bradycardia 4 11
PEDIATRIC BRADYCARDIA 4.11
  • Added that epinephrine and atropine are CAT A
    • Epinephrine may be repeated every 3-5 minutes until heart rate is 80 or above
    • Atropine may be repeated once in 5 minutes if heart rate is not 80 or above (maximum total dose of 1 mg)
  • Added that external pacing is for age 14 and above and is CAT B
childbirth 4 12
CHILDBIRTH 4.12
  • Changed the order of clamping and cutting the cord to the correct place in the sequence of care
    • It was originally listed after wrapping the baby in a blanket and taking the vital signs
congestive heart failure 4 14
CONGESTIVEHEART FAILURE 4.14
  • Added that the patient should be put in the upright sitting position
  • Made nitroglycerin and CPAP Cat. A
  • Kept lasix and morphine as CAT. B
    • This was to bring our protocols in line with current treatment of CHF
coma 4 15
COMA 4.15
  • Deleted this protocol and combined its content with ALTERED MENTAL STATUS 4.5
near drowning 4 22
NEAR DROWNING 4.22
  • Added near drowning as a CAT. A indication for use of CPAP
poisons and overdoses 4 23
POISONS AND OVERDOSES 4.23
  • Since paramedics no longer carry syrup of ipecac, deleted the list of conditions in which you should not induce vomiting
  • The protocol now simply states “DO NOT INDUCE VOMITING”
respiratory distress 4 25
RESPIRATORY DISTRESS 4.25
  • Added that for pulmonary edema, nitroglycerin and CPAP are CAT. A and all other treatments (lasix and morphine) are CAT B.
    • This reflects current treatment of pulmonary edema
seizures 4 26
SEIZURES 4.26
  • Protocol has been changed to allow either diazepam or lorazepam for treatment of seizures
    • Some doctors prefer lorazepam
    • The only drawback to lorazepam is that it has only a 60-day unrefrigerated shelf-life
shock 4 27
SHOCK 4.27
  • Added that if external bleeding from an extremity cannot be controlled by pressure, application of a tourniquet is the reasonable next step in hemorrhage control
    • This reflects current treatment and current National Registry testing
shock 4 2730
SHOCK 4.27
  • Added to use a hemostatic agent if unable to stop severe bleeding with pressure or a tourniquet
  • Added that if the patient is in hypovolemic shock and the patient has a venous port, you may access the port if you have been trained and have the proper equipment
stroke 4 28
STROKE 4.28
  • Protocol has been rewritten to reflect the current national guidelines for diagnosis and treatment of the stroke patient
  • You should review the entire protocol since so many changes have been made
vomiting 4 32
VOMITING 4.32
  • Deleted “NAUSEA”
  • Changed treatment of vomiting from diphenhydramine to ondansetron (Zofran)
    • The cost of injectable ondansetron is now reasonable
section 5

SECTION 5

MEDICATIONS

albuterol 5 3
ALBUTEROL 5.3
  • Added burns and CHF as adult CAT. A use of albuterol
    • Still CAT B for pediatric burns with wheezing
aspirin 5 5
ASPIRIN 5.5
  • Added that aspirin is CAT. B for pediatric patients because it may be associated with Reye’s syndrome
diphenhydramine 5 10
DIPHENHYDRAMINE 5.10
  • Changed diphenhydramine to a secondary medication for treating vomiting
furosemide 5 13
FUROSEMIDE 5.13
  • Added a pediatric dose (CAT. B)
    • 0.5 to 1mg/kg IV given slowly over 2 minutes
lorazepam 5 17
LORAZEPAM 5.17
  • Added that lorazepam may be used in place of diazepam
    • Rather than only if you can’t get diazepam
      • Lorazepam was originally added to the protocols because for a time diazepam was unavailable
magnesium sulfate 5 18
MAGNESIUM SULFATE 5.18
  • added pediatric dose for treating torsade (CAT. B)
    • 25 to 50mg/kg IV or IO Maximum dose is 2 grams
nitroglycerin 5 21
NITROGLYCERIN 5.21
  • Added that nitroglycerin is contraindicated for pediatric patients in the EMS setting
nitrous oxide 5 22
NITROUS OXIDE 5.22
  • Added that use of nitrous oxide is CAT. B for pediatric patients
ondansetron 5 24
ONDANSETRON 5.24
  • Added new medication, ondansetron (Zofran) for treatment of vomiting
    • Ondansetron is non-sedating but has been too expensive to use in the past
      • It is now generic and inexpensive
sodium bicarbonate 5 26
SODIUM BICARBONATE 5.26
  • Added that for children between the ages of one month and 8 years of age the sodium bicarbonate should be diluted 50% with NS
thiamine 5 27
THIAMINE 5.27
  • Added that there is almost no indication for thiamine (CAT. B) use in a child
    • Only use is for treatment of Beriberi, a disease caused by a lack of thiamine (not an emergency condition)
vasopressin 5 28
VASOPRESSIN 5.28
  • Added that vasopressin use is contraindicated for pediatric cardiac arrest
section 6

SECTION 6

PROCEDURES

continuous positive airway pressure cpap 6 3
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) 6.3
  • Added near drowning as an indication for use of CPAP
  • Added a note that CPAP is not used in children under the age of 12 because of lack of complete development of their respiratory system
endotracheal intubation 6 5
ENDOTRACHEAL INTUBATION 6.5
  • Added that orotracheal intubation is CAT. B for children and nasotracheal intubation is contraindicated in children
section 8

SECTION 8

ADMINISTRATIVE PROTOCOLS

documentaton of care 8 2
DOCUMENTATON OF CARE 8.2
  • Added that ePCRs must be completed and transmitted to the office of EMS & Trauma within 168 hours (one week) of the provided medical care
trauma system protocol 8 5
TRAUMA SYSTEM PROTOCOL 8.5
  • Changed the protocol to reflect suggestions made by the pediatric workgroup and the State Trauma Advisory Council
  • Physiologic Criteria
    • Added that a BP of <90mmHg refers to an adult or a child 6 years of age or older
trauma system protocol 8 552
TRAUMA SYSTEM PROTOCOL 8.5
  • Physiologic Criteria (cont.)
    • Added that respiratory distress rates in children are:
      • <20 or >60 in a newborn
      • < 20 or > 40 in a child three years or younger
      • <12 or >29 in a child four years or older
    • Added that head trauma with any neurologic changes in a child 5 years or younger puts the child in the trauma system
section 9

SECTION 9

ACCEPTABLE EMS EQUIPMENT AND DEVICES

bougie for difficult intubations 9 2
BOUGIE FOR DIFFICULT INTUBATIONS 9.2
  • Added this optional equipment to the list of acceptable equipment
    • Bougie, Endotracheal Tube Introducer
      • 15 French by 60-70cm for 6.0 to 11.0 ET tubes
devices to perform chest decompression 9 4
DEVICES TO PERFORM CHEST DECOMPRESSION 9.4
  • Added: Becton Dickinson Angiocath 14 gauge by 3.25 inches long
hemostatic agents 9 5
HEMOSTATIC AGENTS 9.5
  • Added QuikClot Combat Gauze
    • Kaolin based
    • Currently being used by military in combat in Iraq
  • Added WoundStat
    • Granular combination of smectite and polymer
request to be taken to a hospital on diversion 10 2
REQUEST TO BE TAKEN TO A HOSPITAL ON DIVERSION 10.2
  • Removed “the patient’s family” as being able to sign to take the patient to a hospital on diversion
stroke checklist 10 4
STROKE CHECKLIST 10.4
  • Rewrote stroke checklist to reflect the new Stroke Protocol
alert before using new prtotocols
ALERT! BEFORE USING NEW PRTOTOCOLS:
  • EACH SERVICE MUST NOTIFY AND PROVIDE YOUR SERVICE OFF-LINE MEDICAL DIRECTOR A COPY OF THE 5TH EDITION PROTOCOLS (June 09 edition) AND A COPY OF THIS UPDATE PRESENTATION
    • It is OK for the medical director to download the material instead
  • EACH SERVICE MUST BE SURE THE ON-LINE MEDICAL DIRECTORS AT YOUR MEDICAL DIRECTION HOSPITALS ARE AWARE THAT THE PROTOCOLS HAVE BEEN UPDATED AND WHERE TO GET THE MATERIAL
    • The service is not responsible for furnishing copies of the protocols or update slide presentation
new protocols can be used
NEW PROTOCOLS CAN BE USED
  • WHEN EVERYONE IN A SERVICE HAS BEEN UPDATED
    • TURNED ON SERVICE BY SERVICE NOT INDIVIDUAL BY INDIVIDUAL
    • TURN IN ROSTER TO REGIONAL EMS AGENCY NOT TO OFFICE OF EMS & TRAUMA
      • Also acknowledge that you have updated your off-line medical director and provided copy of protocols
    • REGIONAL EMS AGENCY WILL NOTIFY YOU WHEN YOU CAN START USING NEW PROTOCOLS
    • EVERY SERVICE MUST BE UPDATED BY OCTOBER 1ST, 2009
ad