Transcript Snohomish County Protocol Update

Snohomish County Protocol
Update
July 2006
Ron Brown, MD, FACEP
Effective Date
These protocols will go into effect
September 01, 2006
 If your protocols do not say “effective
09/01/06” discard them
 The most current copy of the protocols
can always be found at

http://www.snocountyems.org/emshome.html
Process

Thank you all for being patient
The Protocol Committee was started by
Dr. Cozzetto
 Those protocols were finished by
committee and adopted in early 2005
 Various changes were needed, to
provide internal consistency and to stay
abreast with prehospital medical care

Process
Protocol Committee reconvened 2006
 Since then we’ve been working through
the entire document
 The new 2006 AHA guidelines came out
and those were integrated immediately
to be concurrent with recertification
training (you all should be working off the
new standard already)

Implementation

It is required of ALL providers in Snohomish
County to review the new protocols during the
months of July and August
 This PowerPoint reviews some of the changes
 ALL providers must take a protocol test
BEFORE September 30, 2006
 Failure to pass the exam may result in inability
to practice medicine in Snohomish County
Implementation
A passing score of 80% must be
achieved
 If less, the provider must retake the
exam
 ALL providers must have a passing
score by December 1, 2006

Future Updates

Updates to the protocols will happen yearly
unless more immediate changes are needed
 If the protocols are changed a copy of that
Section will be sent out along with the Table of
Contents and Index
 These sections will reflect a “revised date” in
the footer
 A short explanation of the changes will
accompany the document
Errors

Please notify me of any errors in the
protocols (including typographical) via
email ([email protected]) or
through the Snohomish County EMS
Office (425) 259-4172
Section 1
Introduction
Introduction
No major changes in this section
Section 2
EMS System
Transfer of Care Responsibility and
Delegation

The assessment and decision for transfer of
care shall be documented



If an ALS provider performs an exam (at any level)
and determines BLS transport is appropriate,
documentation of their assessment must be
completed
This is not to say that if a paramedic is on scene
acting in a supporting role (taking VS, etc) that they
must document their presence
Rather this is to ensure if an ALS assessment is
performed, that assessment is clearly documented
on the MIR
Section 3
EMS Protocols
EMS Protocols

No major changes
Section 4
Cardiac Emergencies – Adult
Order
Most of the protocols are alphabetic by
section
 This did not flow well in either the adult
or pediatric cardiac sections
 The protocols have been re-ordered to
make better sense

Cardiac Chest Pain

Designation of Condition
As a system we are still having cardiac
chest pain patients sent in BLS
 While not every chest pain requires ALS
transport the following line was added:


Providers should recognize that there are many
types of chest pain and it may be difficult to
distinguish between cardiac chest pain and other
forms. Caution should be given and err on the
side of cardiac in origin
Cardiac Chest Pain

BLS Providers


This is not new but a reminder that EMTBasic should give Aspirin to a patient
suspected of having cardiac chest pain
ALS Providers
Medical Control must be contacted for use
of nitro paste (only in long transport
situations)
 Metoprolol cannot be used in inferior MI’s

Cardiac Arrest – Universal Algorithm
This was a new protocol created with the
new AHA changes
 If down time is less than 4 minutes then
CPR should be performed only until AED
is applied and ready to analyze


The goal is this situation is rapid
defibrillation
Cardiac Arrest – Universal Algorithm

If down time is greater than 4 minutes 2
minutes of CPR (30:2) should be
performed without interruption
The goal is to perfuse the heart and attempt
to rectify the acidic environment
 During this time ILS/ALS personnel can be
establishing IV/IO access

Asystole

Vasopressin was added to reflect current
ACLS guidelines
PEA
The algorithm was changed to highlight
the causes
 Vasopressin was added to reflect current
ACLS guidelines

VF/Pulseless VT

Updated to reflect current ACLS
guidelines
Bradycardia – Symptomatic

Atropine dose 0.5 mg

Decreased from previous
Anti-Emetic Use
This protocol was removed
 Use anti-emetics in chest pain patients
that are vomiting, as needed

Cardiac Arrest – NonTraumatic/Medical Origin

Removed
Cardiac Emergencies

Removed
Section 5
Cardiac Emergencies – Pediatric
General

These were updated to reflect new AHA
standards
Section 6
Medical Emergencies
Allergic Reaction and Anaphylaxis

Epinephrine drip (2-10 mcg/min) is now
the preferred vasopressor in
anaphylactic shock for refractory
hypotension instead of Dopamine
Carbon Monoxide Poisoning
Somehow or other oxygen therapy was
being based off pulse oximetry
saturation?!
 Obviously, pulse oximetry is ineffective
during CO poisoning

Cerebrovascular Accident (CVA)

The goal is rapid transport to a facility with a
CT scanner
 This may be sent BLS
 If symptoms are less than 2 hours, emergent
(Code Red) transport should be initiated
 ALS Providers


Dextrose administration was reduced to 12.5 GM
increments
Clarification of EtCO2 numbers were added for
intubated patients
Chemical/Substance Abuse
Removed
 Addressed under
psychological/behavioral section

Croup/Epiglottitis
Epiglottitis was removed
 This protocol now only addresses croup

Fainting/Syncope
Reference to fainting removed
 ALS providers


Cardiac monitoring should be performed on
all syncopal patients
Hyperthermia

Changed to “Heat Related Illnesses”
Increased Intracranial Pressure
Removed
 It was felt this issue was addressed in
each individual protocol (CVA, TBI, etc)
and was not required

Toxic Substance Exposure

Removed
Tricyclic Antidepressant Overdose

ALS Providers

Indications for Sodium Bicarbonate have
changed

Heart rate as an indication is removed
Section 7
Obstetric & Gynecologic
Emergencies
General

This section has been re-organized to
achieve better flow
Neonatal Resuscitation
Do not stop delivery to suction the baby
in the perineum if meconium stained
 Instead deliver the entire baby and then
suction for meconium

Vaginal Hemorrhage – Post Delivery
One dose and indication for Oxytocin (20
units/1000 ml wide open)
 Don’t forget fundal massage

Spontaneous Rupture of
Membranes

Removed
Section 8
Psychological/Behavioral
General
Revised this entire section
 Please review entire section thoroughly

General

Main issues addressed:
Use of restraints-verbal, physical, chemical
 Evaluating patients to screen for “excited
delerium” or Sudden Unexpected Death
Syndrome while in Law Enforcement
custody

Section 9
Trauma
Trauma (Blunt and Penetrating)

Removed and replaced with a Shock
protocol
Spinal Motion Restriction
Simplified
 ALL EMS providers are now able to NOT
backboard patients under certain
conditions
 Old protocols allowed only ALS providers
to do this
 This is an important protocol
 Please review thoroughly!

Spinal Motion Restriction
The concept is that as long as the patient
is c/a/o without distracting injuries or
significant MOI they do not have to be
backboarded
 When evaluating the next for pain
remember it is only POSTERIOR CSPINE pain that counts

Spinal Motion Restriction
Lateral neck pain (not directly over the cspine) does not warrant LSB use
 SMR is not a benign procedure
 I will inform the local hospitals so you are
not questioned by the ED staff for not
having a patient backboarded with lateral
neck pain (make sure you document
your assessment well)

Trauma Triage Criteria
Replaced this protocol with Trauma
Team Activation Criteria
 Please review

Section 10
Communication & Notification
Issues
General
Keep reports brief
 When to speak to a physician

Giving report in special situations
 Requesting medical control

Section 11
Appendix A – Procedures
General
This section was significantly revamped
 Please review entire section closely
 Main emphasis on Low Frequency-High
Risk procedures

Indications
 Contraindications

Airway Management
New protocols
 Includes

Recognizing approved management tools,
from All Provider maneuvers to advanced
ALS interventions
 Protocol on Drug-Assisted Intubation (DAI)

Sedation only
 Rapid Sequence Intubation

Airway Management

Includes
Difficult Airway Algorithm
 Failed Airway Algorithm


Note ALS Providers should avoid transporting a
patient with a failed airway using BVM
ventilation, particularly after failed DAI
Assisting with Medications
Removed
 Felt this was standard information and
did not need to be included

AED

Updated to reflect new AHA changes
Cardioversion
Removed
 It was felt this is common knowledge
(standard ACLS)

Central Venous Catheter

Added to clarify options available to ALS
providers
Accessing preexisting catheter
 Placing a new central line

CPAP
Condensed some information
 Note indications and contraindications

Cricothyrotomy

The vertical skin incision is the only
approved method for this procedure
Intraosseous Access

This is a new skill in Snohomish County
 There have been some concerns raised by
physicians about their use (started on patients
that had peripheral access, or did not have a
need for life-saving IVF/meds)
 Clarifies when IO access may be considered


First line in cardiac arrest only
Otherwise all other patients should have peripheral
access attempted first
Intraosseous Access

If you think of placing a central line, you
can think of placing an intraosseous line
Thoracostomy
New protocol, old procedure (chest
decompression)
 Outlines procedure


Note approach
Post Intubation Sedation…

This protocol was removed, felt to be
redundant
RSI

Incorporated into Airway Protocol
Transthoracic Pacing

Felt to be a basic ACLS skill and not
required in the protocols
Section 12
Special Situations
Blood Draws
Still up to each service
 I do not believe EMS should be drawing
blood
 Legal Blood draws by EMS in the field
are NOT currently allowed per protocol


I addressed this with Law Enforcement
countywide in 2005
Inter-Facility Transport
Patient should be stabilized by sending
facility prior to transport
 EMS crews may refuse to transport the
patient if they believe the patient has not
been adequately stabilized

Non-Transport and Refusals
These two protocols were revised and
combined
 Please review this protocol carefully!
 Not all Non-transports are refusals

EMS-initiated no-transports have much
higher liability
 Good documentation in necessary
 Each agency should maintain a release
form

Relationship Between ALS Team
and Private Physician
Addressed elsewhere
 Removed

Trauma Triage Tool
Washington State DOH Document
 Note the thrust of this document is to get
the patient to the highest level trauma
Center possible within thirty minutes
transport time
 This will occasionally mean ground
transport to Snohomish County hospitals

Section 13
Forms
General

This section completely removed
Section 14

Paramedic Drug Supplement
Required Drugs
Removed: Bretylium, Oxytocin,
Procainamide from Required Drugs
 Added Etomidate and Oxygen to
Required Drugs
 Removed all Required (Optional
Substitutions) other than
benzodiazepines

Allowed Drugs
Changed “Alcaine” to “Topical Ophthalmic
Drops (Proparacaine)”
 Removed Mannitol and Etomidate from
Allowed Drugs. Mannitol is gone.
 Added Oxytocin, Procainamide, Ipratroprium
Bromide, Metropolol, Terbutaline, and Fentanyl
to the Allowed Drugs.
 Made Dexamethasone and Metaclopramide
an optional substitution for Allowed Drugs.

Fentanyl
Dose increased to 0.3 mg/kg dose
 Both pediatric and adult dose are the
same

Protocols
That outlines some of the main changes
in the new versions
 This does not relieve you from reading
the entire protocols
 The tests will reflect your level of care
 Paramedics may also have questions
from the Drug Supplement Section
(doses, indications, contraindications,
etc)

Prehospital Care
Thank you for your dedication to caring
for the sick and injured in Snohomish
County
 Continue to strive to educate yourselves
and learn

Snohomish County EMS
Thanks!