Transcript Slide 1

Buncombe/Madison/Yancey EMS System
2012 Protocol Changes
Keith Owens, Ned Fowler, Jamie Judd, Stace Horine, DO
April 2013
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• NCCEP now allows agencies to modify protocols to reflect
local practice
– Medications listed in protocols match those in our local Drug List
– Local agencies now have greater ownership of protocols
• Changes in Table of Content
– 13 Categories compared to 4 previous categories
– Each category has specific color around the border
• New appearance of each protocol
-Protocol is on one page, Pearls are located on second page
including local comments in purple section
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• Previous “Legend” block has been removed
– Color coding has changed per level
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White with no lettering – Medical Responder
White with “B” – EMT-Basic
Yellow with “I” – Intermediate
Blue with “P” – Paramedic
Information
Boxes
Hexagon
illustrates
Assessment or
Decision points
Terminator Oval
exits to another
protocol
Procedures / Actions
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• GENERAL SECTION – Black Border
– Protocol #1: Universal Patient Care
• No significant changes
• ADULT GENERAL SECTION – Light Green
– Protocol #3: Adult, Failed Airway
• Ventilatory rate 8-10 breaths/minute
• Addition of Gum Elastic Bougie (refer to procedure #7)
– Protocol #4: Rapid Sequence Intubation (name change)
• New medications – Ketamine, Rocuronium, Fentanyl
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT GENERAL SECTION – Light Green
– Protocol #6: Behavioral
• Excited Delirium Syndrome with treatment guidelines
– Protocol #7: Pain Control, Adult
• New medication – Fentanyl
– Protocol #8: Scene Rehabilitation (New Protocol)
• New Protocol to be utilized when ALS transport
agencies establish a formal rehab section
• Follows NFPA recommendations
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT CARDIAC SECTION – Dark Blue
– Protocol #13: Cardiac Arrest, Adult
• Emphasis on continuous CPR compressions
• Breathing / Airway management after 2nd shock and/or
2 rounds of compressions
• Do not interrupt compressions to place endotracheal
tube, consider BIAD first to limit interruptions
– Protocol #11: Adult Asystole / PEA
• Previous separate protocols
• Atropine has been removed
• TCP removed unless advised by Medical Control
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT CARDIAC SECTION – Dark Blue
– Protocol #14: Chest Pain, Cardiac and STEMI
• Scene time ≤ 10 minutes
• New Medications – NTG SL with BP > 100, NTG Paste with
guidelines, Fentanyl
• Normal Saline Bolus – Maximum 2 liters
• If N&V presents, continue utilizing anti-emetics (protocol #35)
– Protocol #15: CHF / Pulmonary Edema
• New Medications – NTG SL with BP > 100, NTG Paste with
guidelines, Dopamine in Cardiogenic Shock
• Consider Furosemide with transport time > 30 minutes
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT CARDIAC SECTION – Dark Blue
– Protocol #16: Adult Tachycardia, Narrow Complex
• Note extensive Pearls list
– Protocol #17: Adult Tachycardia, Wide Complex
• Three options for stable patients
• New Medications – Adenosine, Mag. Sulfate
• Note extensive Pearls list
– Protocol #18: Vent. Fib / Pulseless Vent. Tach
• Amiodarone -vs- Lidocaine
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT CARDIAC SECTION – Dark Blue
– Protocol #19: Post Resuscitation
• Consider Sedation / Paralysis with definitive airway in place
– Protocol #20: Induced Hypothermia
• New Medications – Etomidate, Fentanyl
• New Target Temp. – 91.4F (33C)
– Protocol #21: Team Focused CPR (New Protocol)
• To be implemented as agencies complete training
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT MEDICAL SECTION – Light Blue
– Protocol #23: Abdominal Pain
• New formatting, treatment guidelines similar
– Protocol #24: Allergic Reaction
• Three new categories (Mild, Moderate & Severe)
• (Intermediate Level) Epi 1:1000 IM dosage may be
repeated in 5 minutes without contacting MC
– Protocol #25: Altered Mental Status
• Assessment leads to specific protocols for treatment
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT MEDICAL SECTION – Light Blue
– Protocol #26: Adult COPD / Asthma
• Title change from previous “Respiratory Distress “
• New Medication – Magnesium Sulfate
– Protocol #27: Diabetic; Adult
• New Protocol from previous “Altered Mental Status”
• Normal Saline Bolus – Maximum 2 liters
• Additional information in Pearls
– Protocol #28: Dialysis / Renal Failure
• New Protocol
• Normal Saline Bolus – Maximum “1” liter
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT MEDICAL SECTION – Light Blue
– Protocol #29: Hypertension
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Systolic BP 220 or greater
Diastolic BP 120 or greater
New Medication – Labetalol after contacting MC
Assessment leads to specific protocols for treatment
– Protocol #30: Hypotension / Shock
• Four New Categories (Hypovolemic, Cardiogenic, Distributive
& Obstructive)
• Complex to read
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT MEDICAL SECTION – Light Blue
– Protocol #31: Overdose / Toxic Ingestion
• Five New Categories (Beta Blocker / Ca Channel Blocker,
Tricyclic Antidepressant, Organophosphate & Cyanide / Carbon
Monoxide OD)
• New Medications - Glucagon, Calcium Chloride &
Dopamine
• New Acronym – D.U.M.B.B.E.L.S
– Protocol #32: Seizure
• New Medication – Magnesium Sulfate
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT MEDICAL SECTION – Light Blue
– Protocol #33: Suspected Stroke
• New Medication – Labetalol after contacting MC
– Todd’s Paralysis
– Protocol #34: Syncope
• Assessment leads to specific protocols for treatment
– Protocol #35: Vomiting and Diarrhea
• Assessment leads to specific protocols for treatment
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT OBSTETRICAL SECTION – Purple
– Protocol #37: Childbirth / Labor
• Two New Categories (Prolapsed Cord / Shoulder Dystocia &
Breech Birth)
• New Information Box (Unable to Deliver)
– Protocol #38: Newly Born
• New formatting, treatment guidelines similar
• Normal Saline Bolus – 10ml/kg, may repeat x 1
• Additional information in Pearls
– Protocol #39: Obstetrical Emergency
• New formatting, treatment guidelines similar
• Additional information in Pearls
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT TRAUMA and BURN SECTION – Red
– Protocol #40: Adult Thermal Burn
• Refers to New Carbon Monoxide / Cyanide Protocol
• Additional Information in Pearls
– Protocol #41: Head Trauma
• New Information Boxes (Do Not Hyperventilate), (Brain
Herniation)
– Protocol #42: Multiple Trauma
• New formatting, treatment guidelines similar
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• PEDIATRIC GENERAL SECTION – Olive Green
– Protocol #44: Pediatric Airway
• New Procedure (Chest Decompression)
– Protocol #45: Pediatric Failed Airway
• SP02 saturation ≥ 90%
– Protocol #46: Pediatric Pain Control
• New Medication – Ketorolac & Fentanyl
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• PEDIATRIC CARDIAC SECTION – Dark Blue
– Protocol #48: Pediatric Asystole / PEA
• New Protocol
– Protocol #49: Pediatric Bradycardia
• New formatting, treatment guidelines similar
– Protocol #50: Pediatric Pulmonary Edema / CHF
• New Protocol
– Protocol #51: Pediatric Pulseless Arrest
• Assessment leads to specific protocols for treatment
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• PEDIATRIC CARDIAC SECTION – Dark Blue
– Protocol #52: Pediatric Tachycardia
• New Protocol
– Protocol #53: Pediatric VF / Pulseless VT
• New Protocol
– Protocol #54: Pediatric Post Resuscitation
• New Protocol
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• PEDIATRIC MEDICAL SECTION – Light Blue
– Protocol #56: Pediatric Allergic Reaction
• New Protocol
– Protocol #57: Pediatric Altered Mental Status
• New Protocol
– Protocol #58: Pediatric Diabetic
• New Protocol
– Protocol #59: Pediatric Hypotension / Shock
• Four New Categories (Hypovolemic, Cardiogenic,
Distributive & Obstructive)
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• PEDIATRIC MEDICAL SECTION – Light Blue
– Protocol #60: Pediatric Overdose / Toxic Ingestion
• New Protocol
– Protocol #61: Pediatric Respiratory Distress
• EMT-I’s, Epi 1:1000 IM administered prior to
contacting MC
– Protocol #62: Pediatric Seizure
• Lorazepam preferred first-line medication
• Refer to Protocol #72 Fever/Infection Control
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• PEDIATRIC MEDICAL SECTION – Light Blue
– Protocol #63: Pediatric Vomiting / Diarrhea
• New Protocol
• PEDIATRIC TRAUMA and BURN SECTION – Brown
– Protocol #65: Pediatric Head Trauma
• Assessment leads to specific protocols for treatment
• Additional information in Pearls
– Protocol #66: Pediatric Multiple Trauma
• New formatting, treatment guidelines similar
• Additional information in Pearls
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• PEDIATRIC TRAUMA and BURN SECTION – Brown
– Protocol #67: Pediatric Thermal Burn
• New Protocol
• ADULT / PEDIATRIC GENERAL SECTION – Green
– Protocol #69: Triage
• New Protocol
– Protocol #70: Dental Problems
• New formatting, treatment guidelines similar
– Protocol #71: Epistaxis
• Ice Packs no longer recommended
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT / PEDIATRIC GENERAL SECTION – Green
– Protocol #72: Fever / Infection Control
• New formatting, treatment guidelines similar
– Protocol #73: Police Custody
• No Change
– Protocol #74: Emergencies Involving Indwelling
Central Lines
• New Protocol
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT / PEDIATRIC GENERAL SECTION – Green
– Protocol #75: Respiratory Distress With a
Tracheostomy Tube
• New Protocol
• Refer to Procedure #18, Tracheostomy Tube Change
– Protocol #76: Emergencies Involving Ventilators
• New Protocol
• Refer to Procedure #19, Ventilator Operation
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT / PEDIATRIC ENVIRONMEMTAL
SECTION – Salmon
– Protocol # 78: Bites and Envenomations
• Assessment leads to other protocols for some
treatment
• Three new categories (Spider/Bee, Snake, Dog/Cat/Human)
• New medication Midazolam for Spider/Bee
– Protocol # 79: Carbon Monoxide/Cyanide
• New Protocol
• New Medication – Hydroxocobalamin (CyanoKit)
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT / PEDIATRIC ENVIRONMEMTAL SECTION –
Salmon
– Protocol # 80: Drowning / Submersion Injury
• Three new categories (Awake/Alert, Awake/AMS, Unresponsive)
– Protocol # 81: Hyperthermia
• Three new categories (Heat Cramps, Heat Stroke, Heat Exhaustion)
• Note description of cooling measures on page 2
– Protocol # 82: Hypothermia / Frostbite
• Three new categories (Localized Cold Injury, Awake, Unresponsive)
• Note description of warming measures on page 2
• Note CPR guidelines in PEARLS (<86 degrees F/30 degrees C)
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT / PEDIATRIC ENVIRONMEMTAL
SECTION – Salmon
– Protocol # 83: Marine Envenomations / Injury
• New Protocol
• Calcium Chloride
– Protocol # 84: WMD Nerve Agent
• Three new categories (Asymptomatic, Minor, Major)
• Pralidoxime now prior to contact with Medical Control
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT / PEDIATRIC TRAUMA and BURN – Red
– Protocol # 86: Blast Injury / Incident
• New Protocol
– Protocol # 87: Chemical and Electrical Burn
• Three categories (Minor, Serious, Critical)
• New formatting, treatment guidelines similar
– Protocol # 88: Crush Syndrome
• New Protocol
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• ADULT / PEDIATRIC TRAUMA and BURN – Red
– Protocol # 89: Extremity Trauma
• New formatting, treatment guidelines similar
• New box for open fracture with exposed bone
– Protocol # 90: Selective Spinal Immobilization
• New title: Former Protocol 12 – Spinal Immobilization
Clearance
– Protocol # 91 Radiation Incident
• New Protocol
• Extensive information
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• Drug List
– Atropine
• No longer indicated in Asystole
– Calcium Chloride
• New protocols: Dialysis/Renal Failure, Marine
Envenomation, Crush Injury
– Dextrose 10%
• Now only in Peds Diabetic protocol (still indicated CBG <60)
– Dextrose 50%
• Now only in Adult Diabetic protocol (still indicated CBG <60)
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• Drug List
– Diltiazem (Cardizem)
• New Adult dosing guidelines
• 20 mg IV/IO over 2 min, repeat 25 mg in 15 min if needed
• If age ≥ 60 reduce dosage according to protocol
– Diphenhydramine (Benadryl)
• New Adult dosing guidelines 25 – 50 mg IV/IO/IM/PO
– Epi 1:1000
• Now IM route only
– Epi 1:10,000
• Maximum Pediatric dose now 1 mg
– Fentanyl (Sublimaze)– New Medication
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Narcotic analgesic, with vasodilatation
Avoid in BP < 110
50-75 mcg IM/IV/IO Adult, repeat 25 mcg every 20 min, Max 200 mcg
1 mcg/kg IM/IV/IO Peds, repeat 0.5 mcg/kg every 5 min, Max 2 mcg/kg
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• Drug List
– Furosemide (Lasix)
• New Adult dose 40 mg IV or equal to patient normal PO
dose
– Glucagon
• Now in fewer protocols (still indicated CBG <60)
– Hydroxocobalamin (CyanoKit) – New Medication
• 70 mg/kg IV/IO – Requires reconstitution – Max 5 grams
– Ketamine (Ketalar) – New Medication
• Sedative in RSI if Etomidate not available
• 1.5 mg/kg IV/IO
• Do not use if suspected coronary ischemia
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• Drug List
– Ketorolac (Toradol)
• Adult Dose 30 mg IV/IO, 60 mg IM
• Peds dose 0.5 mg/kg IV/IO/IM, Max 30 mg
– Labetalol (Normodyne) – New Medication
• Persistent Symptomatic High BP (<220 systolic or 120 diastolic)
• Requires online order from Med Control
• 10 mg IV/IO
– Lorazepam (Ativan)
• New adult dose 1 -2 mg IV/IM, May repeat every 5 min until seizure
controlled
– Magnesium Sulfate
• New adult dosing guideline spelling out how fast to push
• Over 10 min in Resp Distress, Over 2 – 3 min in OB Seizures
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• Drug List
– Midazolam (Versed)
• Usual Adult Dose 2.5 – 5 mg IV/IO/IM (Max single dose 5 mg)
• May repeat as needed (No total maximum dose in Adult)
• Usual Peds Total Dose 0.1 - 0.2 mg/kg IV/IO/IM
– Normal Saline
• Adult Fluid Bolus 500 mL, may repeat up to 2 Liters per individual protocol
• Peds Fluid Bolus 20mL/Kg, may repeat up to 60 mL/kg (except Cardiogenic
Shock)
• Infant <28 days Fluid Bolus 10 mL/kg, may repeat X1
– Nitroglycerin
• No longer used in Hypertensive Crisis
• Paste dosing guideline
– BP >100 = 1 Inch
– BP >150 = 1.5 inches
– BP >200 = 2 inches
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• Drug List
– Odansetron (Zofran)
• Added IO, PO and ODT (Oral Dissolving Tablet) routes
– Pralidoxime (2-Pam)
• Adult dosing increases with major symptoms from 600 mg to 1800
mg over 30 minutes
– Promethazine (Phenergan)
• Adult Dose 12.5 mg, May repeat X1, ≥ 60 yoa give ½ dose
– Rocuronium – New medication
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Used in RSI when Succinylcholine is not available
Onset longer than Succinylcholine – up to 3 minutes
Patient will not defasciculate
1 mg/kg IV/IO
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• Drug List
– Sodium Bicarbonate
• Repeat dose requires order from Medical Control
– Succinylcholine
• No Adult IM dose
– Vecuronium
• Now included in Post Resuscitation and Induced
Hypothermia protocols
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• Procedures
– New Procedures
• ET Tube Introducer – Procedure 7
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• Procedures
– Modified Procedures
• Procedure 1 – 12 Lead ECG
– Label ECG and provide hospital with patient full name and DOB
• Procedure 5 – Airway CPAP
– Modified from 2009
• Procedure 6 – Airway Cricothyrotomy - Surgical
– Clarified incision technique
– 1” vertical through skin, ½” horizontal through Cric membrane
• Procedure 12 – Nasotracheal Intubation
– No longer included in system protocol
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• Procedures
– Modified Procedures
• Procedure 28 - CPR
– Follows current AHA guidelines
• Procedure 29 – Cardioversion
– Note energy settings based on individual protocol
• Procedure 30 – Chest Decompression
– Note catheter sizes for Adult and Pediatric (<12 yoa)
• Procedure 35 and 36 – Defibrillation
– Emphasis on minimal interruption of chest compressions
– Note energy settings for Manual Defibrillation
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• Procedures
– Modified Procedures
• Procedure 37 – Gastric Tube Insertion
– No longer included in system protocol
• Procedure 46 – Temperature Measurement
– Format change only, procedure similar
• Procedure 50 – Venous Access: Existing Catheter
– Do not attempt to access hemodialysis catheters (Perma Cath)
– Added verbiage regarding use of non-coring needle for implanted
ports
• Procedure 54 – Venous Access: Intraosseous
– Procedure re-written to reflect EZ-IO and Manual IO devices
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• Procedures
– Modified Procedures
• Procedure 55 Venous Access: Swan-Ganz Catheter
Maintenance
– No longer included in system protocol
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• Policies
– New Policies
• Policy 21 – Rapid Sequence Intubation
– New policy mandated by state
– Requires Waveform Capnography and Pulse Oximetry
– Establishes mandatory Airway Evaluation Form procedures
• Ventricular Assist Devices Policy 31
– Provides guidance for assessment and treatment of patients
with VAD
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• Policies
– Modified Policies
• Policy 1 – Air Transport
– Added estimated weight to minimal information to provide
• Policy 6 – Discontinuation of Prehospital Resuscitation
– Policy modified to reflect current practice
• Policy 7 – Disposition (Patient Instructions)
– Added two items clarifying patient refusal practices
• Policy 12 – EMS Back In Service Time
– Within 30 minutes (Previously 45 minutes) 90% of time
• Policy 13 – EMS Dispatch Center Time
– Less than 90 seconds (Previously 120 seconds) 90% of time
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• Policies
– Modified Policies
• Policy 14 – Wheels Rolling (Turn-out) Time
– Less than 90 seconds (Previously 3 minutes) 90% of time
• Policy 22 – Care on Minors
– Renumbered (Previously Policy 21)
• Policy 23 – Communications (Previously Policy 22)
– Significant Revision
• Policy 24 – Conditions For Direction
– Renumbered (Previously Policy 23)
Buncombe/Madison/Yancey EMS
2012 Protocol Changes
• Interfacility Transport Medications
– No change
• Appendices
– Age reference
• Clarifies age guidelines for procedures
– Approved Medical Abbreviations
• Modified to remove non approved abbreviations