2019 EMS Policy Updates

1. 2019 EMS Policy Updates Overview of Significant Updates to EMS Policies and Base Hospital Orders Formulary Additions include: Vasopressor Doses of Epinephrine Fentanyl Citrate Tranexamic Acid (TXA)

2. Policy #601 Universal Reminder of Protocol Format • In all protocols - standing orders are listed for each provider level • BLS – EMT • BLS Elective Skills – Select EMTs • ALS - Paramedics Base Hospital Orders • Any treatment listed in “Base Hospital Orders” section: • CAN be ordered by MICN • Defer to department policy and physician consultation if needed • Standing orders after communication failure • Physician Consult for any treatments needed (determined on patient need) that are not listed in Base Hospital Orders

3. Vasopressor Doses of Epinephrine Push-dose Epinephrine and Epinephrine drips August 1st, 2019 Fluid refractory Shock ROSC - Cardiac Arrest (non-traumatic) Cardiogenic shock Refractory Bradycardia Neurogenic shock

4. Prehospital Vasopressor Options • Push-Dose (PD) epinephrine – started June 1st • Epinephrine Drips – starting August 1st • Dopamine – will be removed August 1st • Paramedics may still administer and monitor dopamine drips started by hospital staff Vasopressors are not “standing orders” for paramedics • Base Hospital Orders or Physician Consult are required Note – Levophed (norepinephrine) is not in the paramedic scope of practice in the state of California

5. Indications for Use of Pressor Doses of Epinephrine An epinephrine drip OR Push-Dose epi are appropriate for hypotensive shock that is NOT caused by hypovolemia: • Hypotension refractory to IV fluids • Potential hypovolemia should be corrected before administering vasopressors • ALS Providers may request early orders to administer vasopressors if: • Pulmonary edema is present • ROSC with deteriorating vital signs • Critical hypotension, impending cardiovascular collapse • Mean Arterial Pressure (MAP) is <45 mmHg • Consider for bradycardia refractory to other causes • Consider reversible causes of bradycardia

6. Protocol #619 - Shock • Undifferentiated Shock • First-line treatment should focus on IV fluids • Estimated only 34% of patients are given proper fluid challenge prior to administration of vasopressors* • Vasopressors refractory to fluids • Hypovolemic Shock • Treatment should focus on fluid replacement • Septic Shock • First-line treatment – aggressive fluid replacement (consult base as needed) • Vasopressors for critical hypotension or shock refractory to fluids • Cardiogenic Shock • Vasopressors may be considered early * Holden, D. PharmD, et al. Safety Considerations and Guideline-Based Safe Use Recommendations for “Bolus-Dose” Vasopressors in the Emergency Department. Annals of Emergency Medicine, 2017

7. Protocol #619 - Shock • Physician Consult • Vasopressor doses of epinephrine may be indicated for pediatrics, and other conditions (severe anaphylaxis) • MICN can consider giving orders listed in Base Hospital Orders section • Physician Consult may be requested as needed • Pediatric considerations • Wide array of differential diagnoses for pediatric shock – most common is hypovolemia • Order requires Physician Consult • During communication failure prehospital treatment should focus on fluid boluses * Holden, D. PharmD, et al. Safety Considerations and Guideline-Based Safe Use Recommendations for “Bolus-Dose” Vasopressors in the Emergency Department. Annals of Emergency Medicine, 2017

8. Protocol #641Cardiac Arrest (atraumatic) ROSC with Persistent Hypotension • Consider vasopressors for persistent hypotension • Consider giving orders early for severe hypotension • Consider giving pre-emptive orders if vital signs appear to be deteriorating Pediatric Considerations • Indications are the same as adult (age appropriate signs of perfusion) • 1 mcg/kg is appropriate starting dose (max of 10 mcg/min) • Dosing only needs to be adjusted if patient <10 kg • PD epi – 0.1 mL/kg • Epi drip – 1 mcg/kg

9. Protocol #644Bradycardia • Atropine - First-line treatment for most unstable bradycardias • Consider other reversible causes (i.e. CaCl for hyperkalemia) • Vasopressors – refractory to atropine • Consider early orders for epinephrine in unstable high-degree heart blocks • High-degree heart blocks may not respond well to Atropine • 2nd Degree II AVB or Mobitz II • 3rd Degree AVB or Complete Heart Block

10. Optional references for Push-Dose Epi Detailed information and instructions for PD epi • SLO EMSA Provider Training Page • PD Epi Dilution Demo from Inland Counties EMS Agency

11. Policy #611 Allergic reaction ALS Standing Orders • Diphenhydramine (50 mg IV/IM) standing orders for stable allergic reactions and for anaphylaxis • Was previously a base hospital order for stable reactions Base Hospital Orders • Base Physician Orders may be considered for vasopressor doses of epinephrine (PD epi or Epi drip) instead of IV bolus of epi

12. Policy #641 Cardiac Arrest (atraumatic) Minor changes in standing orders: • Emphasis placed on resuscitation of pediatricpatients prior to transport • Providers should attempt to stay on-scene while: • Establishing vascular access • Managing airway (BLS) • Administering first dose of epinephrine • HPCPR throughout

13. Protocol #641Cardiac Arrest (atraumatic) Upon ROSC • Field providers should prioritize optimization of: • Ventilations, oxygenation, perfusion, and identification of STEMI • ALS providers may request orders for vasopressor doses of epinephrine to optimize perfusion • Push-Dose epinephrine may be quicker and easier for rapidly deteriorating or unstable patients • Epinephrine drip may be preferable over long transport or to optimize dosing • Early orders for vasopressors may be appropriate if vital signs are unstable or deteriorating * *American Heart Association, ECC- Algorithm for Care in ROSC (2015)

14. Protocol #660General Trauma In the presence of suspected neurogenic shock ALS Providers can request vasopressor doses of epinephrine (PD epi or epi drip) • First-line treatment should focus on IV fluids • Vasopressors for persistent or severe hypotension refractory to fluids • Field providers are reminded that MOST hypotension after trauma is caused by hemorrhage • Should be treated with permissive hypotension and fluids, NOT with vasopressors

15. Policy #661 Traumatic Cardiac arrest First responders do not need to initiate resuscitation, or may discontinue resuscitation in cases of traumatic arrest where patient is found to have arrested prior to responders arrival If trauma patient arrests while responders are providing care responders should start resuscitation and consult with trauma center regarding: • Continued resuscitation versus termination • Destination decision • Trauma center may direct transport to nearest hospital if appropriate due to time difference

16. Policy #603 Pain Management Policy #640 Cardiac Chest Pain 2019 Updates Pain Management and Fentanyl

17. Fentanyl Citrate Morphine will be replaced with Fentanyl – August 1st 2019 Morphine will be removed from protocols, and will not be stocked by field provider agencies Morphine will remain in the paramedic formulary and remains in the paramedic’s basic state scope of practice Morphine could be stocked and placed into use in the future if severe drug shortages make fentanyl unavailable

18. Morphine vs. Fentanyl • Fentanyl has been reported to have fewer adverse effects than morphine in a prehospital environment ** • Total incidence of adverse effects - 6.6% for fentanyl vs. 9.9% for morphine • Nausea was estimated to occur in half as many patients compared with morphine • Less risk of hypotension and other cardiovascular adverse effects Fentanyl’s rapid onset and low incidence of adverse effects (compared to morphine) make it an ideal choice for prehospital patients *Pandharipande MD, McGrane MD. Pain control in the critically ill adult patient – table 4 Intravenous sedative and analgesic dosing regimens for managing pain, agitation, and delirium in the intensive care unit. Post TW, ed. UpToDate. Waltham, MA **Fleischman, R., et al. (2010) Effectiveness and Safety of Fentanyl Compared With Morphine for Out-of-Hospital Analgesia, Annals of Emergency Medicine, Vol 56-3

19. Fentanyl Formulary Contraindications in the prehospital formulary may include some “relative” contraindications ALS providers may call requesting orders for pain patients where fentanyl is contraindicated in prehospital protocols (e.g. hypotension) Consider giving orders if fentanyl administration seems safe for circumstances described during consult

20. Fentanyl may be considered for ANY moderate or severe pain that was not relieved by BLS measures Standing orders Acute pain without contraindications to Fentanyl Use base contact for patients needing pain management not covered by standing orders

21. Adult Administration • IV route is first-line route for prehospital fentanyl administration • ALS providers should attempt to titrate dose to minimal amount needed to obtain safe analgesia • IN and IM dosing are appropriate options if difficulty is encountered obtaining an IV Low dose (down to 25 mcg) should be considered in: Elderly patients Maintenance dosing after adequate initial analgesia was established Patients with precautions to fentanyl administration

22. Pediatric Administration • IN route is first-line route for prehospital fentanyl administration to pediatrics • IN route is well-established in pediatrics • Analgesia should not be delayed because of difficulty obtaining an IV in a pediatric • IM route may be considered • IV route should be used if vascular access already established

23. Tranexamic Acid (TXA) State EMS Authority approved Local Optional Scope of Practice

24. ALS providers may administer TXA to trauma patients, age ≥15 with: • Blunt or penetrating injury with SBP ≤90 • Significant blood loss/bleeding not controlled by BLS measures • Base physician orders may be used to order administration for other life-threatening bleeding: • Early signs of hemorrhagic shock • GI/GU bleeding • other TXA Summary

25. Blunt or penetrating traumatic injury with SBP ≤90 • Significant blood loss with ongoing bleeding not controlled by direct pressure, hemostatic agents, or tourniquet application • External bleeding should be managed with the methods listed above • TXA is given only if these measures are not successful • Base hospital consultation and orders • Unclear on indications • Other causes of life-threatening hemorrhage • i.e. GI bleeding, vaginal bleeding, ENT post-op, etc • TXA is currently a “local optional scope of practice” (LOSOP) for ALS providers in California • Indications for use under “standing orders” are narrowly defined by the State Prehospital Indications

26. Patients less than 15 years old • Greater than 3 hours post injury • Isolated Traumatic Brain Injury • Isolated spinal shock • Spinal injury with motor signs and hypotension • Isolated extremity hemorrhage when bleeding has been controlled • Contraindications to prehospital administration have been kept strict while the State evaluates whether or not TXA should be added to standard scope of practice • Age restrictions are required by State Prehospital Contraindications

27. Base contact, consultations, and destination for patients receiving TXA should be a trauma center • SVRMC or MRMC • SLO County Policy #121 • Patient will likely require: • Massive Transfusion Protocols (MTP) • Repeat doses of TXA • Surgical interventions • Other interventions Transport to a Trauma Center

28. CRASH2 trial (2010): • If given within three hours of injury, TXA reduces the risk of death due to bleeding by about a third • http://www.crash2.lshtm.ac.uk/ MATTERS trial (2011): • Marked improvement in survival in most severely injured compared to those who did not receive it • https://jamanetwork.com/journals/jamasurgery/fullarticle/1107351 CalPAT Trial (2017) California Prehospital Antithrombolytic Trial: • TXA reduced 30-day mortality from 8.3% to 3.6% • Mortality benefit greater in more seriously injured patients References, Clinical Trials