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Protocol Update Version 6.032 Updated January 20, 2006 Created by Central Mass EMS Corp. (Region II EMS) Visit us! www.cmemsc.org Overview General Changes Specific Protocol Changes New Protocols Appendix Changes

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protocol update

Protocol Update

Version 6.032

Updated January 20, 2006

Created by

Central Mass EMS Corp. (Region II EMS)

Visit us! www.cmemsc.org

overview
Overview
  • General Changes
  • Specific Protocol Changes
  • New Protocols
  • Appendix Changes
  • Administrative Requirements and Advisories released since last protocol update
  • Conclusion
general changes4
General Changes
  • New Format (redundancy eliminated)
  • Preamble updated (see #13)
  • Generic names for all medications; also bold typed
  • Drug Reference edited to include only those medications on Medications List (see Appendix A)
general changes continued
General Changes, continued
  • Use of nasal Naloxone wherever Naloxone allowed
  • Blood glucose threshold changed in all pertinent protocols from 100 to 70
general changes continued6
General Changes, continued
  • Reference to “Follow AED Protocol” replaced in all pertinent protocols with:

“Use AED according to the standards of the American Heart Association or as otherwise noted in these protocols and other advisories”.

asystole cardiac arrest 1 1
Asystole/Cardiac Arrest (1.1)

Paramedic Standing Orders:

Administer a250cc bolus of IV Normal Saline if warranted

atrial fibrillation 1 2 and atrial flutter 1 3
Atrial Fibrillation (1.2) andAtrial Flutter (1.3)
  • NOTE: For rate control in adult patients currently prescribed a beta-blocker

Paramedic Medical Control:

  • Administer Metoprolol Bolus 2.5mg-5mg slow IV Push over 2 minutes
  • Repeat dosing in 5 minute intervals to a max of 15mg
atrial fibrillation 1 2 and atrial flutter 1 3 continued
Atrial Fibrillation (1.2) andAtrial Flutter (1.3), continued

CAUTION:

Do not mix IV Metoprolol with IV Ca blockers

chest pain 1 5
Chest Pain (1.5)
  • Name changed to Acute Coronary Syndrome
  • Paramedic Standing Orders: Morphine dose 2.0-4.0 mg
  • Medical Control: Lidocaine and repeat bolus removed
post resuscitation 1 6
Post Resuscitation (1.6)

Paramedic Standing Orders:

Dopamine 10.0mcg/kg per minute if BP is < 80 systolic after fluid bolus

vtach with pulses 1 11
VTach with Pulses (1.11)
  • Paramedic Standing Orders: Amiodarone 150mg in 10cc normal saline IV over 8-10 minutesadded
  • Medical Control: Amiodarone 150mg-300mg in 10ml Normal Saline IV over 8-10 minutes (changed from 1-2 minutes)
hypothermia 2 4
Hypothermia (2.4)

Paramedic Standing orders:

Thiamine administration removed

nerve agent exposure 2 6
Nerve Agent Exposure (2.6)

First Responders may administer nerve agent antidotes (Mark-1 kits) to fellow authorized public employees

(This change was initially released as an OEMS Advisory on January 18, 2005)

abdominal pain 3 1
Abdominal Pain (3.1)

Medical Control:

Patients with severe pain and a BP > 110 systolic may be considered for pain management under Adult Pain Management Protocol (3.14)

allergic reaction anaphylaxis 3 2 and pediatric anaphylaxis 5 2
Allergic Reaction/Anaphylaxis (3.2) and Pediatric Anaphylaxis(5.2)
  • “NOTE” section deleted referring to authorized EPI course.
  • All EPI training should now be completed within the Initial EMT course.
  • Further “refresher” training of EPI may be done through continuing education.
chf pulmonary edema 3 5
CHF/Pulmonary Edema (3.5)

Paramedic Standing Orders:

Dobutamine infusion deleted

chf pulmonary edema 3 5 and hypertensive emergencies 3 7
CHF/Pulmonary Edema (3.5) and Hypertensive Emergencies (3.7)

Nitrate note changed to:

Do not administer Nitroglycerin if patient (male or female) has taken any medication in the phosphodiesterase-type-5 inhibitor category within the last 48 hours.

obstetrical emergencies 3 8
Obstetrical Emergencies (3.8)
  • Pitocin (Oxytocin) removed
  • Eclamptic Seizures:
    • Lorazepam 2-4mg slow IV Push or IM -OR-
    • Diazepam 5-10mg slow IV Push or IM
seizures 3 9
Seizures (3.9)
  • Paramedic Standing Orders: Lorazepam 2-4mg slow IV Push or IM over 2-3 minutes
  • CAUTION note added: In patients with head injury or hypotension, the use of Diazepam or Lorazepam may be contraindicated
shock hypotension 3 10
Shock/Hypotension (3.10)

Medical Control Options deleted:

  • Second IV of NS/LR
  • Dobutamine Infusion 2-20µg/kg/minute (duplication)
  • Norepinephrine Infusion
acute stroke 3 11
Acute Stroke (3.11)

Edited for consistency with current Stroke POE guidelines

  • Reference to Massachusetts Stroke Scale (MASS)
  • Reference to Thrombolytic Checklist included in Basic Procedures
spinal injury 4 7
Spinal Injury (4.7)

Paramedic Medical Control Option deleted:

  • Methylprednisolone (Solumedrol) IV infusion over 30 minutes
newborn resuscitation 5 1
Newborn Resuscitation (5.1)

“NOTE” section referring to AED use removed from Basic and Intermediate procedures

pediatric seizures 5 7
Pediatric Seizures (5.7)
  • Paramedic Standing Orders:
    • Cardiac Monitor 12 lead ECG-manage dysrhythmias removed
    • Naloxone HCL removed
    • Diazepam 0.25mg/kg IV/IO to max 5-10mg or Rectal Diazepam 0.5mg/kg -OR-
    • Lorazepam 0.05-0.1mg/kg IV/IO (dilute 1:1 NS) or IM to max 2mg
pediatric seizures continued
Pediatric Seizures, continued
  • Medical Control Note:

Reference to seizure activity changed from 30 minutes to 10 minutes

pediatric vfib pulseless vtach 5 12
Pediatric VFib/Pulseless VTach (5.12)

Paramedic Standing Orders: Epinephrine doses reformatted

  • Initial dose: IV/IO: 0.01mg/kg; ET: 0.1mg/kg(1:10,000, 0.1mL/kg)
  • Subsequent doses: same
  • May repeat every 3-5 minutes
  • IV/IO doses up to 0.02mg/kg of 1:10,000 may be effective
adult upper airway obstruction 3 15
Adult Upper Airway Obstruction (3.15)
  • Modeled after Pediatric Upper Airway Obstruction (5.11)
  • Provides guidance for Tracheostomy tube obstruction management in the adult
diabetic emergencies 3 16
Diabetic Emergencies (3.16)
  • Referenced in Altered Mental Status Protocol (3.3)
  • Hypoglycemia threshold changed from 100 to 70
appendix a medication list
Appendix A: Medication List

Additional Nerve Agent Antidotes added to the Optional Medication List

appendix c cessation of resuscitation
Appendix C: Cessation of Resuscitation
  • Refer to AR 5-515 (2/1/05)
  • Current valid DNR
  • Trauma inconsistent with survival
  • Body condition clearly indicates biological death
appendix d rescue airway
Appendix D: Rescue Airway
  • Name changed to Emergent Advanced Airway
  • Paramedic Medical Control Option: Sedative medications may be allowed
appendix d continued
Appendix D, continued
  • If intubation unsuccessful, insert LMA, Combi-Tube, or other approved rescue device
  • “Grading Airway” figuresadded
appendix n inter facility transfers
Appendix N: Inter-facility Transfers

Updated version to be released soon

appendix q mass
Appendix Q: MASS
  • Massachusetts Stroke Scale
    • Facial Droop
    • Arm Weakness
    • Speech Disturbance
slide39
Administrative Requirements

and

OEMS Advisories Review

administrative requirements 2005
Administrative Requirements 2005
  • AR 5-610 Responding to Scenes Involving Minors Refusing Treatment or Transport
    • Refers to minors that have an emergency medical condition (or potential for one)
    • Use reasonable judgment in determining if patient is minor (<18) or emancipated
ars 2005 continued
ARs 2005, continued
  • AR 5-610 (Minors), continued
    • Refusal for <18 must be made by parent or legal guardian
    • Document in detail: findings, actions and reasons
    • Services should also develop policies with own legal counsel to establish guidelines
ars 2005 continued42
ARs 2005, continued
  • AR 5-520 Requirements for Basic & Intermediate EMT Use of Glucose Monitoring
    • Optionalskill for EMT-B and I
    • Requires agreement for medical director oversight
    • Service must provide appropriate training & associated records
ars 2005 continued43
ARs 2005, continued
  • AR 5-520(Glucometer) continued
    • QA/QI program in place that includes yearly training review
    • Glucose results must be documented
    • Blood borne pathogen policies must be adhered to
    • Glucose monitoring device must meet department requirements
ars 2005 continued44
ARs 2005, continued
  • AR 5-520(Glucometer) continued
    • Manufacturer’s instructions for control runs, use, care & cleaning must be followed
    • CLIA (Clinical Laboratories Improvement Amendments) waiver must be obtained
ars 2005 continued45
ARs 2005, continued
  • AR 5-615 Cancellation of ALS
    • Affiliate hospital and/or service medical director must establish written guidelines
    • BLS must complete assessment and treatment according to state protocols
    • Careful documentation by BLS and ALS
ars 2005 continued46
ARs 2005, continued
  • AR 5-620 ALS Transfer of Calls to BLS
    • If patient contact established by ALS, must complete assessment & treatment according to state protocols
    • If ALS intervention initiated, must attend to patient during transport
    • May transfer care to BLS if ALS intervention is not needed or anticipated
    • Documentation of encounter required
ars 2005 continued47
ARs 2005, continued
  • AR 2-360 Dept. Assessment of Info Reported by EMS Personnel per 105 CMR 170.937
    • EMTs/EFRs must file written report with both DPH/OEMS and own service within 5 days of:
      • any conviction of misdemeanor or felony
      • loss or suspension of driver’s license
advisories 2004
Advisories 2004
  • Administration of Medications by Paramedics to Persons Not Being Transported
    • Don’t do it
  • On-Line CPR Training
    • Not valid unless it also includes practical skills evaluation
advisories 2005
Advisories 2005
  • Ventricular Assist Devices:
    • Do not do chest compressions
    • Use in accordance with manufacturer’s instructions
  • AED Use for ages 1-8
    • Adult AED allowed if pediatric AED is not available
advisories 2005 continued
Advisories 2005, continued
  • Paramedic Medical Control Option: Allows bypass of closest facility to transport to PCI (aka: angioplasty) facility for patients with:
      • ST elevation AND
      • Cardiogenic shock or CHF or contraindications to thrombolysis
conclusion
Conclusion
  • Summary
  • Verbal Assessment
  • Online Resources:
    • Regional Office
      • www.cmemsc.org
    • OEMS
      • www.mass.gov/dph/oems