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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: John.Campbell@adph.state.al.us. PURPOSE OF PROTOCOLS . IMPROVE PATIENT CARE

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Protocol update alabama ems protocols l.jpg

PROTOCOL UPDATEALABAMA EMS PROTOCOLS

EDITION 5

JUNE, 2009 UPDATE


Protocol update l.jpg
PROTOCOL UPDATE

  • IF YOU IDENTIFY MISTAKES IN THE PROTOCOLS OR IF YOU HAVE SUGGESTIONS FOR PROTOCOL CHANGES EMAIL: John.Campbell@adph.state.al.us


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PURPOSE OF PROTOCOLS

  • IMPROVE PATIENT CARE

  • PROVIDE OFF-LINE MEDICAL DIRECTION

  • REPRESENT STANDARD OF CARE

  • PROVIDE QI STANDARDS

  • PROVIDE EDUCATION STANDARDS


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GENERAL CHANGE

  • CHANGED THE WORD “DRUG” TO “MEDICATION” THROUGHOUT THE PROTOCOLS


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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)


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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


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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


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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.


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SECTION 3.3PHYSICIAN MEDICAL DIRECTION

  • Clarifies that medication orders may be signed by an OLMD physician or by the service’s medical director.


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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


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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


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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


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SECTION 4

TREATMENT PROTOCOLS


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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


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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


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ALTERED MENTAL STATUS 4.5

  • Combined COMA 4.15 with this protocol

  • You should review this entire protocol as there are so many changes


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BURNS 4.7

  • For burn patients with wheezing, changed albuterol to Category A for adults


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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


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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


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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


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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


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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


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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


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COMA 4.15

  • Deleted this protocol and combined its content with ALTERED MENTAL STATUS 4.5


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NEAR DROWNING 4.22

  • Added near drowning as a CAT. A indication for use of CPAP


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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”


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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


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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


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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


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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


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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


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VOMITING 4.32

  • Deleted “NAUSEA”

  • Changed treatment of vomiting from diphenhydramine to ondansetron (Zofran)

    • The cost of injectable ondansetron is now reasonable


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SECTION 5

MEDICATIONS


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ALBUTEROL 5.3

  • Added burns and CHF as adult CAT. A use of albuterol

    • Still CAT B for pediatric burns with wheezing


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ASPIRIN 5.5

  • Added that aspirin is CAT. B for pediatric patients because it may be associated with Reye’s syndrome


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DIPHENHYDRAMINE 5.10

  • Changed diphenhydramine to a secondary medication for treating vomiting


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FUROSEMIDE 5.13

  • Added a pediatric dose (CAT. B)

    • 0.5 to 1mg/kg IV given slowly over 2 minutes


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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


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MAGNESIUM SULFATE 5.18

  • added pediatric dose for treating torsade (CAT. B)

    • 25 to 50mg/kg IV or IO Maximum dose is 2 grams


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NITROGLYCERIN 5.21

  • Added that nitroglycerin is contraindicated for pediatric patients in the EMS setting


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NITROUS OXIDE 5.22

  • Added that use of nitrous oxide is CAT. B for pediatric patients


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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


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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


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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)


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VASOPRESSIN 5.28

  • Added that vasopressin use is contraindicated for pediatric cardiac arrest


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SECTION 6

PROCEDURES


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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


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ENDOTRACHEAL INTUBATION 6.5

  • Added that orotracheal intubation is CAT. B for children and nasotracheal intubation is contraindicated in children


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SECTION 8

ADMINISTRATIVE PROTOCOLS


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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


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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


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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


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SECTION 9

ACCEPTABLE EMS EQUIPMENT AND DEVICES


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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



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DEVICES TO PERFORM CHEST DECOMPRESSION 9.4

  • Added: Becton Dickinson Angiocath 14 gauge by 3.25 inches long


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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


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SECTION 10

FORMS


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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


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STROKE CHECKLIST 10.4

  • Rewrote stroke checklist to reflect the new Stroke Protocol


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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


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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



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