Transcript Medical Control

2006 Protocol Update
Central Shenandoah EMS Council
1
Summary of Major AHA Changes
2006 Protocol Update
2
Advanced Life Support - Adults
• Recommended use of endotracheal (ET)
intubation is limited to providers with
adequate training and opportunities to practice
or perform intubations.
• Confirmation of ET tube placement requires
both clinical assessment and use of a device
(e.g. exhaled CO2 detector, esophageal
detector device). Use of a device is part of
primary confirmation of tube placement and is
no longer characterized as secondary
confirmation.
3
Advanced Life Support - Adults
• Intravenous or intraosseous (IO) drug
administration is preferred to endotracheal
administration.
• Implementation of the EZ-IO
– More on this later…
4
Advanced Life Support - Adults
• General concepts of treating pulseless arrest
– BLS skills, including effective chest compressions with
minimal interruptions, are the priority skills and
interventions for cardiac arrest.
– Insertion of an advanced airway may not be a high
priority.
– Organize care to minimize interruptions in chest
compressions for rhythm check, shock delivery,
advanced airway insertion or vascular access.
5
Advanced Life Support - Adults
• Treatment of VF or pulseless VT
– One shock followed immediately by CPR
(beginning with chest compressions).
– Manufacturer’s recommendations for energy
settings.
– Do not attempt to palpate a pulse or check the
rhythm after shock delivery.
– After about two minutes of CPR if an organized
rhythm is apparent during rhythm check, the
provider checks a pulse.
6
Advanced Life Support - Adults
• Treatment of VF or pulseless VT
– Deliver drugs during CPR.
– Prepare drug doses before they are needed.
– If rhythm check shows VF/VT, the vasopressor
or antiarrhythmic should be administered as
soon as possible after the rhythm check.
• It can be administered during the CPR that precedes
or follows the shock delivery.
7
Advanced Life Support - Adults
• Treatment of VF or pulseless VT
– The timing of drug delivery is less important
than is the need to minimize interruptions in
chest compressions.
8
Advanced Life Support - Adults
• Treatment of VF or pulseless VT
– Vasopressin is administered when an IV/IO line
is in place, if VF or pulseless VT persists after
the first shock.
– Vasopressin replaces the first and second doses
of epinephrine.
– Amiodarone is administered after
the dose of vasopressin.
– Amiodarone has replaced lidocaine.
9
Advanced Life Support - Adults
• Treatment of asystole/PEA:
– Vasopressin replaces the first and second doses of
epinephrine.
• Treatment of symptomatic bradycardia:
– The atropine dose is now 0.5 mg IV, which may be
repeated to a total of 3 mg.
10
Advanced Life Support - Adults
• Therapy for acute coronary syndrome (ACS):
– Emphasis on 12-lead ECG acquisition by EMT-Bs and all
ALS providers.
11
Advanced Life Support - Pediatric
• Apply health-care provider “child” CPR guidelines
to victims from one year of age to the onset of
puberty.
• No endotracheal intubation <8 years of age.
• IO placement is an acceptable alternative for
vascular access in children of all ages.
• Timing of one shock, CPR and drug administration
during pulseless arrest has changed and now is
identical to that for ACLS.
12
Advanced Life Support - Pediatric
• No vasopressin for pediatric cardiac arrest.
• Amiodarone is considered the drug of choice for
shock-refractory VF/pulseless VT.
13
Learn More…
• www.americanheart.org
• Click on…
– CPR & ECC  AHA Guidelines for CPR & ECC
14
2006 ALS Protocol Review
CSEMS Council
15
Adult Dysrhythmia Management
2006 Protocol Update
16
Asystole/PEA
15
More…
17
15
Asystole/
PEA
18
VF and Pulseless VT
15
More…
19
17
VF and
Pulseless VT
20
19
Bradycardia
21
Bradycardia
20
• Key Points
– Severely symptomatic patients should receive
immediate pacing.
– Atropine may be used for nausea in a severely
symptomatic patient. Titrate atropine to a maximum of
3 mg over 15 minutes.
– Toxicological etiology  follow the appropriate
toxicology protocol.
– Sedation with midazolam.
• 2.5 mg slow IVP titrated to effect. May repeat dose every 5
minutes if needed.
• Sedation should not delay pacing in the severely symptomatic
patient.
22
Narrow QRS Tachycardia
21
More…
23
Narrow QRS Tachycardia
21
24
Narrow QRS Tachycardia
22
• Give adenosine rapidly over 1 to 3 seconds through a large
(e.g., antecubital) vein
• followed by a 10 mL saline flush and elevation of the arm.
• Sedation with midazolam.
• Synchronized cardioversion
– Use the device-specific doses for synchronized cardioversion, as
recommended by the monitor manufacturer, if different from
protocol-recommended energies.
• Unable to synchronize?
– Use high-energy unsynchronized shocks.
• If the 360 J shock does not convert a dysrhythmia, contact
[Medical Control] for direction.
25
Wide QRS Tachycardia
22
More…
26
Wide QRS Tachycardia
22
27
Wide QRS Tachycardia
22
• If cardioversion and amiodarone do not terminate
wide complex tachycardia, contact [Medical
Control].
28
Pediatric Dysrhythmia
Management
2006 Protocol Update
29
Asystole/PEA
27
30
VF and Pulseless VT
29
More…
31
VF and Pulseless VT
29
32
31
Bradycardia
More…
33
Bradycardia
31
34
33
Narrow QRS
Tachycardia
35
35
Wide QRS
Tachycardia
36
Medical & Trauma Protocols
2006 Protocol Update
37
Anaphylaxis
38
• Essentially unchanged.
• Note that methylprednisolone is not included as a
STT/E level drug according to the state drug
schedule.
– Regional medical director will be addressing the regional
inclusion with the state medical direction committee.
38
Chest Pain (Non-traumatic)
43
• Nitroglycerin to a total of 3 doses.
• Emphasis on 12-lead acquisition.
– Notification of hospital.
– Patient disposition.
39
Environmental (Hyperthermia)
45
• Essentially unchanged.
40
Environmental (Hypothermia)
47
• If the patient does not respond to 1 shock, further
defibrillation attempts should be deferred.
• Give initial cardiovascular drugs based on
presenting rhythm. If the patient fails to respond
to the initial drug therapy, defer additional boluses
of medication.
41
Hyperglycemia
50
• New protocol.
• IV of normal saline for glucose  300 mg/dL.
• Fluid for signs and symptoms of shock.
42
Hypoglycemia
51
• “New protocol.”
• D50 and D25 only.
– 1 g/kg up to 25 g of dextrose.
43
Obstetrics – Newborn Resuscitation
56
• Meconium suctioning permitted.
– Vigorous newborn = standard suctioning.
– If the newborn is NOT vigorous (poor or absent
respiratory effort, flaccid, lethargic), consider immediate
meconium aspiration via endotracheal suctioning.
44
Obstetrics – Newborn Resuscitation
56
• Review…
• Respirations adequate, HR >100, centrally cyanotic:
– Blow-by oxygen.
– No response in 30 seconds  BVM 40 to 60 breaths per minute.
• Respirations inadequate or HR <100:
– Ventilation with a BVM.
– Continue until HR >100.
• HR <60 after 30 seconds of BVM:
– Chest compressions at a rate of 120/min.
– Compression to ventilation ratio of 3:1.
– Continue until HR >60.
45
Obstetrics – Newborn Resuscitation
57
• HR <60 despite BVM chest compressions for 30
seconds:
–
–
–
–
–
Establish IV/IO access.
Give epinephrine 1:10,000 0.01 mg/kg IV/IO.
Repeat every 3 to 5 minutes if HR remains <60.
Dextrose 12.5% 1 g/kg (8 mL/kg).
10 mL/kg normal saline. Administer fluid bolus using a
syringe and a three-way stopcock.
46
Obstetrics – Newborn Resuscitation
57
• When administering a fluid bolus of normal saline,
consider the volume of fluid given with Dextrose
12.5% and adjust accordingly.
• If a diaphragmatic hernia is suspected, place an
orogastric tube and apply low, intermittent
suction.
47
Respiratory – Airway Obstruction
61
• In addition to BLS maneuvers previously
discussed…
– Direct visualization of the airway via laryngoscopy.
– Cricothyrotomy.
48
Respiratory – Asthma
62
• Essentially unchanged.
– Capnography
• More on this later…
49
Respiratory – Pulmonary Edema
67
• SBP  100
– SBP >180: Give nitroglycerin, 2 tablets, 0.4 mg SL and
2 inches of nitropaste 2%. If respiratory distress
persists and SPB >180 and HR 60 bpm, repeat
nitroglycerin, 2 tablets SL every 3 minutes.
– SBP 100 – 180: Give nitroglycerin, 1 tablet, 0.4 mg SL
and 1 inch of nitropaste 2%. If respiratory distress
persists and SPB 100 and HR 60 bpm, repeat
nitroglycerin, 1 tablet SL every 5 minutes.
– Administer CPAP with 10 cmH20 PEEP.
50
Seizures
69
• Essentially unchanged.
• Initial…
– Diazepam IV/PR or midazolam IM.
• Refractory to diazepam…
– Midazolam.
51
Shock – Non-hypovolemia
73
• Cardiogenic shock
• Essentially unchanged.
52
Toxicology
79-80
• 4.25.2 – ALCOHOL INTOXICATION/WITHDRAWAL
– Essentially unchanged.
• 4.25.3 – NARCOTICS / OPIATES
– “New” protocol. No longer in coma/altered LOC.
• 4.25.4 – ORAL HYPOGLYCEMIC AGENTS
– Essentially unchanged.
53
Toxicology
81
• 4.25.5 – TRICYCLIC ANTIDEPRESSANTS
– Sodium bicarbonate 50 mEq IV over 2 minutes. Repeat
in 15 minutes if no improvement.
– Consider magnesium sulfate 2 g over 5 minutes.
• Reserved for VT unresponsive to alkalization.
• 4.25.6 – CHOLINERGICS
– Essentially unchanged.
54
Toxicology
82
• 4.25.7 – CALCIUM CHANNEL BLOCKERS
– Essentially unchanged.
• 4.25.8 – COCAINE / METHAMPHETAMINE
– Follow seizure protocol.
55
Procedures
2006 Protocol Update
56
CPAP
90
• CPAP guidelines for agencies electing to use
device.
• Generic procedure.
• Agency-based device-specific training.
57
Cricothyrotomy, Melker
91
• Expanded procedure descriptions including
illustrations.
58
Cricothyrotomy, Surgical
93
• Expanded procedure description.
• Includes option for using gum elastic bougie.
59
Capnography
95
• Indications
– Confirmation, monitoring and documentation of
endotracheal and Combitube intubation.
– Assessment, monitoring and documentation of the
respiratory status of the non-intubated patient
experiencing respiratory distress including but not
limited to asthma and COPD.
• Agency-based device-specific training.
• CSEMS will incorporate capnography into CE
program.
60
Capnography
95
• Quick overview
– Normal ETCO2 values: 35 – 45 mmHg
61
Colormetric ETCO2 Detection
97
• Expanded procedure.
62
Esophageal Detector Device
100
• New procedure.
• Use as needed in addition to a colormetric endtidal CO2 detector.
63
Gastric Decompression
101
• Indication expanded to include un-intubated
patients undergoing positive-pressure ventilation.
– Especially pediatrics
64
Intraosseous
103-110
• OMDs will require use of Vidacare’s EZ-IO
intraosseous system.
• Procedures for Jamshidi/Cook style devices and
the F.A.S.T.1 device remain in the procedures.
– Transitional period.
65
Intraosseous
103-110
• CSEMS Council will…
– Provide train-the-trainer programs for agencies.
– Seek and 100% RSAF grant to defer costs.
– Dollar-for-dollar credit for F.A.S.T.1 devices has been
negotiated.
66
Intubation, Nasotracheal
111
• Expanded procedure description.
67
Intubation, Orotracheal
112
• Expanded procedure description.
• Maximum of 2 attempts.
– Place Combitube.
• Continue with procedure restricted to patients
aged 8 years and older.
– OMDs will reconsider pediatric intubation after one year
of experience with capnography in adult intubations.
68
Intubation, Orotracheal
112
• Ventilation
– During CPR:
• Deliver 8 to 10 breaths per minute. Deliver each breath over
about 1 second while chest compressions are delivered at a rate
of 100 per minute, and do not attempt to synchronize the
compressions with the ventilations.
– Patients with a perfusing rhythm:
• Deliver approximately 10 to 12 breaths per minute (1 breath
every 6 to 7 seconds). Deliver these breaths over 1 second.
69
PVAD Access
115
• Pre-existing vascular access device.
• Expanded procedure description.
70
Suctioning, Meconium
118
• New procedure.
• Cardiac, Intermediate, and Paramedic levels.
71
Transcutaneous Pacing
124
• Expanded procedure description.
• Adult… rate = 80 bpm
• Pediatric… rate = 100 bpm
72
Vein Cannulation, Peripheral
126
• New procedure.
• EMTs transporting patients with INTs addressed in
this section.
73
Pharmacology
2006 Protocol Update
74
General Pharmacology
128
• Lidocaine removed… Amiodarone added.
• All drug listings have been revised.
– Some have revised action descriptions.
– Added chemical class, pharmacokinetics, etc.
• We will review significant modifications or
changes.
75
Drugs Essentially Unchanged
•
•
•
•
•
•
•
Adenosine
Albuterol
Calcium Chloride 10%
Diphenhydramine
Dopamine
Epinephrine 1:1,000
Epinephrine 1:10,000
•
•
•
•
•
•
Furosemide
Glucagon
Ipratropium
Methylprednisolone
Naloxone
Promethazine
76
Amiodarone
130
77
Amiodarone
130
78
Amiodarone
130
79
Amiodarone
130
• Pharmacies will begin stocking amiodarone on
July 1, 2006.
• Check the “date packed” so that you know what
is in your drug box.
• Will have a period of time where either lidocaine
or amiodarone is used.
– Follow appropriate guidelines.
80
Atropine
132
• Adult:
– Bradycardia: 0.5 mg, repeat every 5 minutes to a total
dose of 3 mg.
– Asystole/PEA: 1 mg, repeat every 3 to 5 min (up to 3
doses).
– Cholinergic Toxicity: 2 mg IV, repeat every 5
minutes.
– ET route de-emphasized.
• Pediatric:
– Bradycardia: 0.02 mg/kg, repeat once in 3 to 5
minutes.
– Not indicated for asystole.
81
Dextrose
134
• Adult:
– Give dextrose 50% 1 g/kg up to 25 g IV. Repeat once
in 2 minutes if GCS remains 12.
• Pediatric:
– Give dextrose 25% 1 g/kg up to 25 g IV. Repeat once
in 2 minutes if GCS remains 12.
• Neonate:
– Give dextrose 12.5% 1 g/kg (8 mL/kg)..
82
Diazepam
135
• Adult:
– Give 0.25 mg/kg up to 5 mg slow IV push, titrated to
effect. Repeat dose in 5 minutes if seizure persists.
• Pediatric:
– IV: Give 0.25 mg/kg up to 5 mg slow IV push, titrated
to effect. Repeat dose in 5 minutes if seizure persists.
– PR: Give 0.25 mg/kg up to 5 mg PR.
• Medical Control not required for repeat dose.
83
Magnesium Sulfate
144
• 20% solution.
– 2 g dose, mix 2 g (4 mL) with 6 mL of normal saline.
• Pulseless:
– 2 g (20% solution) IV over 1 to 2 minutes.
• With Pulse:
– 2 g (20% solution) IV over 5 minutes. Repeat dose if
needed.
• Pediatric
– Pulseless: Give 25 mg/kg up to 2 g IV/IO, for torsades
de pointes.
84
Metoprolol
147
• Indications
– Irregular narrow-complex tachycardia.
– Regular narrow-complex tachycardia that does not
covert following administration of adenosine.
– Stable wide-complex tachycardia [Medical Control].
– Acute myocardial infarction [Medical Control].
• Administration
– Give 5 mg IV over 2 minutes. Repeat every 5 minutes if
needed to a total dose of 15 mg.
85
Midazolam
148
• Administration - Adult
– 2.5 mg slow IV titrated to effect. May repeat dose
every 5 minutes if needed.
– 5 mg IM if unable to readily establish IV access.
• Administration - Pediatric
– 0.1 mg/kg slow IV, titrated to effect. May repeat every
5 minutes as needed [Medical Control].
– 0.1 mg/kg IM if unable to readily establish IV access
[Medical Control].
86
Morphine
149
• New indication
– Acute abdominal pain [Medical Control].
87
Nitroglycerin
152
• Sublingual
– Chest Pain: Give 0.4 mg SL. Repeat every 5 minutes,
if needed, up to 3 doses.
– Pulmonary Edema (SBP >180): Give 2 tablets, 0.4
mg SL. Repeat 2 tablets every 3 minutes if needed.
– Pulmonary Edema (SBP 100–180): Give 1 tablet,
0.4 mg SL. Repeat 1 tablet every 5 minutes if needed.
88
Sodium Bicarbonate
156
• Cardiac arrest unchanged.
• TCA overdose
– No longer administer drip infusion.
– 50 mEq IV over 2 minutes. Repeat in 15 minutes if
needed.
89
Vasopressin
157
• First-line vasopressor for all cardiac arrest.
• One dose of vasopressin is substituted for the first
and second doses of epinephrine 1:10,000.
90
Drug by Weight Chart
166
91
IV Infusion
Chart
168
92
Questions
93