PROTOCOL UPDATE ALABAMA EMS PROTOCOLS

1. PROTOCOL UPDATEALABAMA EMS PROTOCOLS EDITION 5 JUNE, 2009 UPDATE

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

3. PURPOSE OF PROTOCOLS • IMPROVE PATIENT CARE • PROVIDE OFF-LINE MEDICAL DIRECTION • REPRESENT STANDARD OF CARE • PROVIDE QI STANDARDS • PROVIDE EDUCATION STANDARDS

4. GENERAL CHANGE • CHANGED THE WORD “DRUG” TO “MEDICATION” THROUGHOUT THE PROTOCOLS

5. 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)

6. 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

7. 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

8. 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.

9. SECTION 3.3PHYSICIAN MEDICAL DIRECTION • Clarifies that medication orders may be signed by an OLMD physician or by the service’s medical director.

10. 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

11. 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

12. 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

13. SECTION 4 TREATMENT PROTOCOLS

14. 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

15. 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

16. ALTERED MENTAL STATUS 4.5 • Combined COMA 4.15 with this protocol • You should review this entire protocol as there are so many changes

17. BURNS 4.7 • For burn patients with wheezing, changed albuterol to Category A for adults

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. COMA 4.15 • Deleted this protocol and combined its content with ALTERED MENTAL STATUS 4.5

25. NEAR DROWNING 4.22 • Added near drowning as a CAT. A indication for use of CPAP

26. 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”

27. 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

28. 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

29. 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

30. 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

31. 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

32. VOMITING 4.32 • Deleted “NAUSEA” • Changed treatment of vomiting from diphenhydramine to ondansetron (Zofran) • The cost of injectable ondansetron is now reasonable

33. SECTION 5 MEDICATIONS

34. ALBUTEROL 5.3 • Added burns and CHF as adult CAT. A use of albuterol • Still CAT B for pediatric burns with wheezing

35. ASPIRIN 5.5 • Added that aspirin is CAT. B for pediatric patients because it may be associated with Reye’s syndrome

36. DIPHENHYDRAMINE 5.10 • Changed diphenhydramine to a secondary medication for treating vomiting

37. FUROSEMIDE 5.13 • Added a pediatric dose (CAT. B) • 0.5 to 1mg/kg IV given slowly over 2 minutes

38. 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

39. MAGNESIUM SULFATE 5.18 • added pediatric dose for treating torsade (CAT. B) • 25 to 50mg/kg IV or IO Maximum dose is 2 grams

40. NITROGLYCERIN 5.21 • Added that nitroglycerin is contraindicated for pediatric patients in the EMS setting

41. NITROUS OXIDE 5.22 • Added that use of nitrous oxide is CAT. B for pediatric patients

42. 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

43. 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

44. 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)

45. VASOPRESSIN 5.28 • Added that vasopressin use is contraindicated for pediatric cardiac arrest

46. SECTION 6 PROCEDURES

47. 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

48. ENDOTRACHEAL INTUBATION 6.5 • Added that orotracheal intubation is CAT. B for children and nasotracheal intubation is contraindicated in children

49. SECTION 8 ADMINISTRATIVE PROTOCOLS

50. 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