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Protocol Update - PowerPoint PPT Presentation

Jims
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Protocol Update

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  1. Protocol Update Version 6.032 Updated January 20, 2006 Created by Central Mass EMS Corp. (Region II EMS) Visit us! www.cmemsc.org

  2. Overview • General Changes • Specific Protocol Changes • New Protocols • Appendix Changes • Administrative Requirements and Advisories released since last protocol update • Conclusion

  3. General Changes

  4. 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)

  5. General Changes, continued • Use of nasal Naloxone wherever Naloxone allowed • Blood glucose threshold changed in all pertinent protocols from 100 to 70

  6. 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”.

  7. Specific Protocol Changes

  8. Asystole/Cardiac Arrest (1.1) Paramedic Standing Orders: Administer a250cc bolus of IV Normal Saline if warranted

  9. 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

  10. Atrial Fibrillation (1.2) andAtrial Flutter (1.3), continued CAUTION: Do not mix IV Metoprolol with IV Ca blockers

  11. 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

  12. Post Resuscitation (1.6) Paramedic Standing Orders: Dopamine 10.0mcg/kg per minute if BP is < 80 systolic after fluid bolus

  13. 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)

  14. Hypothermia (2.4) Paramedic Standing orders: Thiamine administration removed

  15. 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)

  16. 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)

  17. 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.

  18. CHF/Pulmonary Edema (3.5) Paramedic Standing Orders: Dobutamine infusion deleted

  19. 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.

  20. 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

  21. 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

  22. Shock/Hypotension (3.10) Medical Control Options deleted: • Second IV of NS/LR • Dobutamine Infusion 2-20µg/kg/minute (duplication) • Norepinephrine Infusion

  23. 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

  24. Spinal Injury (4.7) Paramedic Medical Control Option deleted: • Methylprednisolone (Solumedrol) IV infusion over 30 minutes

  25. Newborn Resuscitation (5.1) “NOTE” section referring to AED use removed from Basic and Intermediate procedures

  26. 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

  27. Pediatric Seizures, continued • Medical Control Note: Reference to seizure activity changed from 30 minutes to 10 minutes

  28. 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

  29. New Protocols

  30. Adult Upper Airway Obstruction (3.15) • Modeled after Pediatric Upper Airway Obstruction (5.11) • Provides guidance for Tracheostomy tube obstruction management in the adult

  31. Diabetic Emergencies (3.16) • Referenced in Altered Mental Status Protocol (3.3) • Hypoglycemia threshold changed from 100 to 70

  32. Appendix Changes

  33. Appendix A: Medication List Additional Nerve Agent Antidotes added to the Optional Medication List

  34. 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

  35. Appendix D: Rescue Airway • Name changed to Emergent Advanced Airway • Paramedic Medical Control Option: Sedative medications may be allowed

  36. Appendix D, continued • If intubation unsuccessful, insert LMA, Combi-Tube, or other approved rescue device • “Grading Airway” figuresadded

  37. Appendix N: Inter-facility Transfers Updated version to be released soon

  38. Appendix Q: MASS • Massachusetts Stroke Scale • Facial Droop • Arm Weakness • Speech Disturbance

  39. Administrative Requirements and OEMS Advisories Review

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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

  45. 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

  46. 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

  47. 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

  48. 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

  49. 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

  50. 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